Fracture of the distal radius including sequelae--shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study

[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Establishment and preliminary evaluation of CT-based classification for distal radius fracture

Establish a new classification system of distal radius fracture based on computed tomographic (CT), and evaluate its reliability and reproducibility preliminarily, and provide a new theoretical reference for clinicians to use the clinical classification system. The imaging data and clinical data of 204 inpatients with distal radius fracture during 6 years from January 1, 2014 to January 1, 2019 in orthopaedic department were analyzed retrospectively and classified based on CT. Three observers evaluated the image data of 48 randomly selected cases based on CT at different time nodes of T1 and T2. Cohen's kappa was used to calculate the consistency. At the last follow-up, patients' Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and VAS scores were collected. Among 204 cases, there were 12 cases of type 1, including 6 cases of type 1-D, 4 cases of type 1-V and 2 cases of type 1-R. There were 6 cases of type 2, including 2 cases of type 2-DV, 2 cases of type 2-DR and 2 cases of type 2-VR. There were 186 cases of type 3, including 32 cases of type 3-0, 127 cases of type 3-1 and 27 cases of type 3-2. There was no significant difference in DASH, PRWE and VAS scores among all types (P > 0.05). The results of interobserver reproducibility were kappa = 0.985, ICC = 0.984 in the first evaluation, kappa = 0.986, ICC = 0.986 in the second evaluation. The results of intraobserver reproducibility were O1 = 0.991, O2 = 0.991, O3 = 0.989 respectively. The new classification system of distal radius fracture based on CT has theoretical and practical significance for incision selection, fracture reduction and internal fixation. 123 classification system is clear, comprehensive, easy to understand and remember. Moreover, it has higher interobserver reliability and intraobserver reproducibility than other systems reported at present.

Distal radius fractures: Classifications concordance among orthopedic residents on a teaching hospital

BACKGROUND

Several classification systems have been developed to support orthopedic surgeons regarding diagnostic, treatment, or prognostic outcomes of distal radius fracture (DRF). However, the best classification system for this fracture remains controversial. We aimed to identify the reliability of three different DRF classifications among orthopedists in training (medical residents).

METHODS

Orthopedic residents (n = 22) evaluated thirty cases of DRF in anteroposterior and lateral projections in three different periods (0, 6, 12 months). Each radiography was sorted with three different classifications: Frykman, AO/OTA, and Jupiter-Fernandez. All assessments were blinded to the investigators. The inter- and intra-observer reliability was evaluated using the Cohen's kappa coefficient. An additional analysis was performed for a simpler sub-classification of the AO/OTA (27, 9, or 3 groups).

RESULTS

Inter-observer agreement for AO/OTA, Frykman, and Jupiter-Fernandez classifications was slight (k = 0.15), fair (k = 0.31), and fair (k = 0.30), respectively. Intra-observer agreement showed similar results: AO/OTA, k = 0.14; Frykman, k = 0.28; and Jupiter-Fernandez, k = 0.28. When the AO/OTA classification was simplified (9 or 3 descriptions), the inter-observer agreement improved from slight (k = 0.16) to fair (k = 0.21 and k = 0.30, respectively). A similar improvement from slight (k = 0.14) to fair (k = 0.32 and k = 0.21) was detected for intra-observer agreement.

CONCLUSIONS

The more complex the DRF classification system, the more complex is to reach reliable inter- and intra-observer agreements between orthopedic trainees. Senior residents did not necessarily show greater kappa values in DRF classifications.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex

PURPOSE

The purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament.

METHODS

Between March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant.

RESULT

The mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist.

CONCLUSION

In the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

Intraarticular Distal End Radius Fractures Treated with Volar Locking Plate Variations

Introduction

"Distal end radius fractures" account for almost 16% of all fractures and are the most common kind of upper limb fractures treated in hospital emergency departments. "Distal end radial fractures" occur more often in younger people due to high-energy trauma than in older people due to low-energy trauma. When comparing women and men of the same age, proximal end radii fracture are more prevalent in women than men owing to significant osteoporosis and a higher tendency for accidents in older women.

Methodology

This was a prospective interventional study in which participants were divided in to two groups.

Result and Conclusion

Both groups in the study had comparable range of motion, with the exception of the forearm", where the "variable angle volar locking plate" excelled. The risk of complications was low in both approaches. Thus we conclude that when it comes to treating "displaced intra-articular distal end radius" fractures, the variable angle volar locking plate is superior than the Ellis locking plate.

Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial

BACKGROUND

This study aimed to compare functional outcomes of a volar plate osteosynthesis for distal radius fractures (DRF) performed with either a standard volar approach (SVA), which required detachment of the pronator quadratus muscle, or a pronator-sparing approach (PqSA).

MATERIALS AND METHODS

This prospective randomized controlled study included 106 patients scheduled for volar plate osteosyntheses. Patients were allocated to either the SVA group (n = 53) or the PqSA group (n = 53). Patients were blinded to treatment until completion of the study. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcome parameters were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Modified Mayo Wrist Score (MMWS). Follow-up examinations were performed at 8 weeks and 3, 6, and 12 months postoperatively.

RESULTS

Overall, 91 patients were included in the final analysis: 48 in the SVA group and 43 in the PqSA group. The two cohorts were not significantly different in demographic characteristics, including age, sex, injuries on the dominant side, type of injury, and fracture classification. We found significant differences between groups at 6 months in the mean PRWE (SVA: 12.3 ± 10.4, PqSA: 18.9 ± 14.11 points) and in the mean DASH score (SVA: 12.3 ± 11.9, PqSA: 19.3 ± 16.7 points), which favoured the SVA. We found no significant differences between groups in the MMWS or in the PRWE and DASH scores at any other time points.

CONCLUSIONS

This randomized comparative clinical trial failed to demonstrate that a volar plate osteosynthesis performed with a PqSA could improve the outcome, compared to the SVA, in patients with DRF.

LEVEL OF EVIDENCE

II Trial registration Comparison of Two Volar Plating Systems for Distal Radius Fractures, ClinicalTrials.gov (NCT03474445), registered 22 March 2018, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03474445?cond=radius&cntry=AT&draw=2&rank=1.

Automatic classification of distal radius fracture using a two-stage ensemble deep learning framework

Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subdivided into intra- and extra-articular fractures. Compared with extra-articular DRFs which spare the joint surface, intra-articular DRFs extend to the articular surface and can be more difficult to treat. Identification of articular involvement can provide valuable information about the characteristics of fracture patterns. In this study, a two-stage ensemble deep learning framework was proposed to differentiate intra- and extra-articular DRFs automatically on posteroanterior (PA) view wrist X-rays. The framework firstly detects the distal radius region of interest (ROI) using an ensemble model of YOLOv5 networks, which imitates the clinicians' search pattern of zooming in on relevant regions to assess abnormalities. Secondly, an ensemble model of EfficientNet-B3 networks classifies the fractures in the detected ROIs into intra- and extra-articular. The framework achieved an area under the receiver operating characteristic curve of 0.82, an accuracy of 0.81, a true positive rate of 0.83 and a false positive rate of 0.27 (specificity of 0.73) for differentiating intra- from extra-articular DRFs. This study has demonstrated the potential in automatic DRF characterization using deep learning on clinically acquired wrist radiographs and can serve as a baseline for further research in incorporating multi-view information for fracture classification.

Casting Position for Distal Radius Fractures Changes Radiocarpal Joint Forces: A Cadaveric Study

PURPOSE

Nonsurgical distal radius fracture treatment requires immobilization and classical teaching suggests varying cast positions. We investigated the effect of cast position on the force and pressure experienced by the articular cartilage in the scaphoid and lunate fossae.

METHODS

Ten fresh-frozen cadaveric specimens were used. A standardized extra-articular distal radius fracture was made. Force sensors were affixed to the articular cartilage of the scaphoid and lunate fossae. Baseline data were obtained. Specimens were then placed into a short arm cast with the wrist either neutrally aligned or flexed and ulnarly deviated (FUD). Specimens had a standard load applied, and a force profile was obtained. The cast was removed and the other cast type was placed and measurements were repeated. Overall force and pressure values were compared between baseline data and the 2 cast types. Additionally, differences in volar and dorsal scaphoid and lunate fossa forces and pressures were compared pairwise within the 2 cast types. The relative force and pressure values across cast types were also compared.

RESULTS

Both cast types significantly reduced the median force and pressure experienced by the radiocarpal joint compared with no cast. In the FUD cast, the volar and dorsal lunate fossa experienced significantly greater force, and the dorsal lunate fossa experienced significantly greater pressure compared with the dorsal scaphoid fossa. There were no differences for any fossae in the neutral cast. When comparing between casts, the volar lunate fossa experienced a significantly greater relative force in the FUD cast compared with the neutral cast.

CONCLUSIONS

Casting a distal radius fracture decreases the forces and pressures in the radiocarpal joint. Placing the wrist in a FUD position results in greater forces and pressures on the lunate fossa compared with the scaphoid fossa.

CLINICAL RELEVANCE

When immobilization is needed, we advocate for the placement of patients in a relatively neutral short-arm cast with minimal FUD to avoid this increased pressure.

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study

INTRODUCTION

Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported.

MATERIALS AND METHODS

We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures.

RESULTS

The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%.

CONCLUSION

This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

Distal Radioulnar Joint Instability and Associated Injuries: A Literature Review

The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients’ lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extremity injuries, as well as an isolated pathology. Diagnosis of this injury requires the clinician to have a high index of suspicion and low threshold for clinical testing and further imaging of the DRUJ. The purpose of this article is to provide a review on DRUJ anatomy and biomechanics, to discuss common diagnostic and treatment modalities, and to identify common injuries associated with DRUJ instability.

Closed Reduction Techniques for Distal Radius Fractures and Appropriate Casting Methods

Distal radius fractures are one of the most common orthopedic injuries. After history, physical examination, and diagnostic imaging, treatment begins with closed reduction and immobilization to restore an upper extremity that has both acceptable alignment and stability. Whether for definitive nonoperative management or in preparation for surgical fixation, it is important to understand the principles of closed reduction and immobilization. This article presents a brief review of indications and a technical guide to successful closed reduction and casting for the orthopedic surgeon.

The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius

Background

Acute carpal tunnel syndrome (ACTS) is a known complication of distal radius fractures. This study aimed to document the demographics, range of presenting symptoms and risk factors of patients who develop ACTS following a fracture of the distal radius.

Methods

A retrospective review of 1189 patients with an acute distal radius fracture treated in the study centre over a one-year period were identified. Demographic and clinical variables were collected and compared between controls (did not develop ACTS) and those patients who did develop ACTS to identify factors associated with developing ACS.

Results

There were 51 (4.3%) distal radius fractures complicated by ACTS. The mean age of patients who developed ACTS was 56 years (range, 16–89) and 73% were female. The median time of onset post-injury was one week (range, 1–12). There was no association between patient background and comorbidities with the development of ACTS. AO-OTA Type C fractures had significantly increased rates of developing ACTS.

Conclusion

Four percent of distal radius fractures were complicated by ACTS. There was no association between patient background and comorbidities with the development of ACTS. AO-OTA type C complete articular fractures had a significantly higher rate of ACTS. A suggested treatment algorithm for patients presenting with ACTS has been presented.

Level of evidence:

III.

Functional Outcome of Distal Radial Fractures in Patients With a Mean Age of 75 Years at a Mean Follow-Up of 5.4 Years

Purpose

Distal radial fractures in the elderly are common and present in a wide spectrum of severity. Their management is varied. The aim of this retrospective case review is to evaluate the late functional outcome of surgically treated distal radial fractures in the elderly population.

Methods

Forty-two patients (36 female and six male) were surgically treated for an unstable distal radial fracture. The mean age of the patients was 75 years. Frykman classification was used to assess the severity of the injury. Surgical options used were reduction and K wires (19 patients) or open reduction and internal fixation (ORIF) using volar distal radial plate fixation (23 patients). At a mean follow-up of 5.4 years, a validated questionnaire (Patient Rated Wrist Evaluation-PRWE) of the functional ability was completed for each patient.

Results

The outcome in both groups was satisfactory (PRWE 40-50) with no significant statistical difference, however, a better functional outcome (<40 PRWE) was achieved in the K wire group compared to the ORIF group. Factors such as post injury fear from fall, weakness of grip, wrist pain, and other comorbidities altered the predicted functional outcome score.

Conclusion

In conclusion, surgically treated fractures in the elderly generally lead to good outcomes. However, confounding factors can contribute to unpredictable results despite good surgical reduction and fixation.

Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.

Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.

With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.

In elderly patients, non-operative treatment can be considered to be the gold standard.

Cite this article: EFORT Open Rev 2020;5:361-370. DOI: 10.1302/2058-5241.5.190060

Radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients

Background

To determine the radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients, we compared the radiographic parameters of the wrists between carpal tunnel syndrome patients and non-symptomatic controls.

Methods

We evaluated radiographic parameters of 94 wrists of 62 idiopathic carpal tunnel syndrome patients and 94 asymptomatic wrists of 94 controls. Carpal tunnel syndrome was diagnosed by clinical findings and nerve conduction studies. The lack of symptoms was confirmed with the medical records and interviews for the controls. X-ray images of the postero-anterior and lateral views of the wrist were taken. Using the obtained X-ray images, the indices of radial inclination, volar tilt, ulnar variance, and transverse and antero-posterior diameters of the wrists were measured. Two raters independently performed the measurement. One rater measured without information of clinical symptoms. Inter-rater reliabilities for each parameter were evaluated by the intra-class correlation coefficients. The averages of the measurements of two raters were compared between the carpal tunnel syndrome patients and the controls.

Results

The intra-class correlation coefficients were 0.58 for radial inclination, 0.77 for ulnar variance, 0.99 for transverse diameter, 0.60 for volar tilt, and 0.91 for antero-posterior diameter. Statistically significant correlations were found for all parameters (P < 0.01). The ulnar variance was significantly larger in the carpal tunnel syndrome patients compared to the controls (1.7 +/− 1.8 mm and 0.8 +/− 1.5 mm for the patients and controls, respectively P < 0.01). There were no significant differences in the other parameters.

Conclusions

Significant differences in the ulnar variance were observed between carpal tunnel syndrome patients and controls. This suggests that the imbalance of radioulnar bone length is one of the risk factors to develop carpal tunnel syndrome. The positive ulnar variance may be an index that needs attention to the development of carpal tunnel syndrome.

Level of evidence

level III, a case control study.

Percutaneous pinning for treating distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. This is an update of a Cochrane Review published in 2007.

OBJECTIVES

To assess the effects (benefits and harms) of percutaneous pinning versus cast immobilisation alone and of different methods and techniques of percutaneous pinning, modalities or duration of immobilisation after pinning, and methods or timing of pin or wire removal for treating fractures of the distal radius in adults. Our primary focus was on dorsally displaced fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registers, conference proceedings and reference lists of articles up to June 2019.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with non-surgical treatment or different aspects of percutaneous pinning. Our main outcomes were patient-reported function at the short term (up to three months), medium term (three up to 12 months) and long term (greater than 12 months); overall numbers of participants with complications requiring secondary treatment and any complication; grip strength and health-related quality of life at 12 months.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome.

MAIN RESULTS

We included 21 randomised controlled trials (RCTs) and five quasi-RCTs, involving 1946 generally older and female adults with dorsally displaced and potentially or evidently unstable distal radial fractures. Trial populations varied but the majority of studies reported mean ages in the sixth decade or older. All trials were at high risk of bias, invariably performance bias - which for most trials reflected the impracticality of blinding care providers or participants to treatment allocation - and often detection bias and selective reporting bias. Allocation concealment was secure in one trial only. All trials reported outcomes incompletely. The studies tested one of 10 comparisons. In the following, we report on those of the main outcomes for which evidence was available. No subgroup analysis, such as by pinning methods, was viable. Eleven heterogeneous trials involving 917 participants compared percutaneous pinning with plaster cast immobilisation after closed reduction of the fracture. The quality of the evidence was very low for all reported outcomes. Thus, we are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported function, measured using the DASH questionnaire, at six weeks or six months (incomplete data from one trial). Overall numbers of participants with complications were not reported. Redisplacement resulting in secondary treatment occurred on average in 12% (range 3.3% to 75%) of participants treated by cast alone (six trials) whereas pin tract infection requiring antibiotics and, often, early wire removal, occurred on average in 7.7% (range 0% to 15%) of pinning group participants (seven trials). We are uncertain whether pinning makes a difference to the incidence of complex regional pain syndrome, reported in four studies. Although two studies found finger stiffness after cast removal was less common after pinning (20% versus 36%), the treatment implications were not reported. Other reported complications were mainly surgery-related. Based on incomplete data or qualitative statements from only four studies, we are uncertain of the effects of pinning on grip strength at 12 months. We are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported quality of life at four months (one study). Five comparisons of different pinning methods were made by six trials in all. One of these trials, which reported results for 96 participants, compared Kapandji intrafocal pinning (2 or 3 wires) with early mobilisation versus trans-styloid fixation (2 wires) with six weeks cast immobilisation. We are uncertain whether Kapandji pinning slightly increases the risk of superficial radial nerve symptoms or complex regional pain syndrome, or whether it makes a difference in grip strength at 12 months (very low-quality evidence). Two small trials using two distinct pinning techniques compared biodegradable pins versus metal pins in 70 participants. Although very low-quality evidence, the extra demands at surgery of insertion of biodegradable pins and excess of serious complications (e.g. severe osteolytic reactions) associated with biodegradable material are important findings. Three poorly-reported trials involving 168 participants compared burying of wire ends versus leaving them exposed. We are uncertain whether burying of wires reduces the incidence of superficial infection (very low-quality evidence). There is low-quality evidence that burying of wires may be associated with a higher risk of requiring more invasive treatment for wire removal. Four small trials compared different types or duration of postoperative immobilisation. Very low-quality evidence of small between-group differences in individual complications and grip strength at 17 weeks, means we are uncertain of the effects of positioning the wrist in dorsiflexion versus palmar flexion during cast immobilisation following pinning of redisplaced fractures (one trial; 60 participants). Three small heterogeneous trials compared cast immobilisation for one week (early mobilisation) versus four or six weeks after percutaneous pinning in 170 people. Although we note one trial using Kapandji pinning reported more complications in the early group, the very low-quality evidence means there is uncertainty of the effects of early mobilisation on overall and individual complications, or grip strength at 12 months. No trials tested different methods for, or timing of, pin/wire removal.

AUTHORS' CONCLUSIONS

Overall, there is insufficient RCT evidence to inform on the role of percutaneous pinning versus cast immobilisation alone or associated treatment decisions such as method of pinning, burying or not of wire ends, wrist position and duration of immobilisation after pinning. Although very low-quality evidence, the serious complications associated with biodegradable materials is noteworthy. We advise waiting on the results of a large ongoing study comparing pinning with plaster cast treatment as these could help inform future research.

EVALUATION OF DISTAL FOREARM FRACTURES USING THE AO 2018 CLASSIFICATION

OBJECTIVE

Distal forearm fractures are among the most common upper limb fractures in all ages, and many classifications have been proposed to describe them. Recently, a new version of AO/OTA classification was proposed. The aim of this study is to use the AO/OTA 2018 classification to report the epidemiology of distal forearm fractures in adults treated at a single center.

METHODS

A retrospective analysis of the initial radiographs obtained from cases of distal forearm fractures in an orthopedic emergency room at a single tertiary hospital.

RESULTS

Three hundred twenty-two cases were studied, aged 50.35 ± 18.98 years, 55.3% were female and 44.7% were right-sided. Type 2R3A, 2R3B and 2R3C fractures corresponded to 32.3%, 18.0% and 48.4% of the cases, respectively. Distal ulnar fracture was present in 41.9%. There was a correlation between age and sex: 78.3% of the subjects aged under 30 years were male, and 80.6% of those aged over 60 years were female (p<0.001).

CONCLUSION

The most common type of radial fractures was 2R3C, and the most common type of ulna fracture was 2U3A1.1. There was a correlation between age and sex. Level of evidence IV, Case-series.

The effects of incremental ulnar styloid osteotomies on distal radioulnar joint stability: a biomechanical cadaveric study

The purpose of this study was to systematically quantify distal radioulnar joint stability with a cadaveric model, using radiographic and joint contact force measurements. Six fresh-frozen cadavers underwent sequential ulnar styloid osteotomies. Posteroanterior and lateral stress radiographs were obtained and joint contact forces and areas were measured. Posteroanterior radiographs showed a significant increase in the distal radioulnar joint gap after osteotomy of the base of the ulnar styloid. Contact force and contact area measurements were not significantly different. We conclude that fractures that involve the ulnar styloid base should be considered for operative fixation when carrying out open reduction and internal fixation of fractures of the distal radius.

Adult Monteggia Lesion with Ipsilateral Distal Radius Fracture: A Case Report and Review of the Literature

Introduction:

Monteggia lesion is a well-known injury that constitutes 0.7% of forearm fractures-dislocations. The combined presentation of Monteggia injury with ipsilateral distal radius fracture is an extremely rare lesion, especially in adults.

Case Report:

A 25-year-old woman fell from a chair, injuring her left forearm and wrist. On admission, plain roentgenograms of the left upper extremity revealed an anterior, Bado type-1 Monteggia fracture-dislocation associated with an ipsilateral distal radius fracture. The patient underwent surgical treatment of both injuries with a 3.5 limited contact dynamic compression plate for ulna and a 3.5 mm T-type buttress locking plate for distal radius. Intraoperative roentgenogram showed a spontaneous reduction of the ipsilateral dislocated radial head following osteosynthesis. An above, the elbow plaster cast was applied for 2 weeks because of the radial head dislocation. 10 weeks postoperatively the patient regained full range of motion of her wrist, elbow, and supination/pronation in her forearm. 4 months postoperatively she was returned to her previous daily activity after roentgenograms showed complete bone healing.

Conclusion:

In this rare case presentation with a review of the literature, we emphasize the mechanism of this lesion and we provide some risk factors for poor functional outcomes when treating such injuries. Both the review of the previous literature and our opinion support that rigid fixation of both fractures in such injuries is mandatory to achieve good functionality through early mobilization. Plain roentgenograms of the whole forearm including wrist and elbow are essential to avoid misdiagnosis.

The Radiographic Quality of Distal Radius Fracture Reduction Using Sedation Versus Hematoma Block

Introduction

Distal radius fractures (DRFs) are treated in the emergency department (ED) with a closed reduction in order to decrease neurovascular and soft tissue injury and as a first definitive step in conservative treatment. The type of anesthesia used may affect the ability to reduce the fracture and remains controversial.

Objective

The purpose of this study was to compare the quality of radiographic reduction achieved in the ED of DRF reduced using sedation anesthesia to those reduced with hematoma block anesthesia.

Methods

A retrospective case-control study of 240 DRF reductions, 30 treated with sedation and 210 with a hematoma block, was performed. Complications and time spent in the ED were documented. Pre- and postreduction radiographs were reviewed for volar tilt, radial angulation, radial height, and ulnar variance.

Results

Both groups were similar in gender, background illnesses, concomitant injuries, surgeon experience, and fracture radiographic classification. Postreduction values of volar tilt were better in the sedation group (P = .03). Volar tilt and ulnar variance improved more in the sedation group (P = .001). The sedation group spent more time in the ED (P = .001).

Discussion

Sedation seemed to be more efficient than hematoma block in supporting closed reduction of distal radius fractures in the ED. However, this method requires specialized personnel and more time spent in the ED.

Conclusion

We suggest using this method when the patient is planned to continue with conservative treatment.

Closed reduction of distal radius fractures: a systematic review and meta-analysis

Distal radius fractures (DRF) are a common injury, especially in the elderly.

Displaced fractures can be reduced by closed reduction through several techniques, two of which are compared in this systematic review and meta-analysis.

Closed reduction by finger-trap traction (FTT) seems to offer better correction of radial shortening. Additionally, there may be less pain and fewer complications associated with this technique.

Closed reduction by manual traction seems to offer better correction of the dorsal tilt.

Further research is needed to fully determine the optimal method of closed reduction.

Cite this article: EFORT Open Rev 2018;3:114-120.DOI: 10.1302/2058-5241.3.170063

Effects of Ulnar Styloid Fractures on Unstable Distal Radius Fracture Outcomes: A Systematic Review of Comparative Studies

Purpose  In this literature review, functional outcomes such as Disability of Arm, Shoulder and Hand (DASH) score and the visual analog scale (VAS) of pain along with clinical outcomes such as range of movement and grip strength of treated distal radius fractures (DRF) accompanied with ulnar styloid fractures (USF) will be compared with those with isolated DRF. Materials and Methods  We analyzed articles from MEDLINE, Embase, and CINAHL that met our predetermined inclusion and exclusion criteria as per the Preferred Reporting Items for Systematic Reviews and Meta-analysis statements. This resulted in the identification of 464 articles with 18 potentially eligible studies of which 6 were included at the full-text screening stage. The primary outcomes were wrist pain, range of motion, functional outcome and satisfaction, such as VAS, and the DASH questionnaire along with radiological assessment and incidence of complications. Results  These studies involved 796 participants with DRF and 806 wrists with DRF; 444 (55%) of DRF had an associated USF. Three studies did not report any statistically significant difference in DASH scores between the DRF patients with or without USF. Two studies reported worse DASH scores in the group with associated USF. Wrist pain was reported to be statistically significantly worse in patients with associated USF in two studies. Grip strength did not exhibit a statistically significant difference in any groups in four studies. On assessing the range of motion of the wrist and forearm, only one study reported a statistically significant difference in flexion at 2 years follow-up, with less flexion in patients with USF. Conclusion  This review suggests that there is no significant correlation between a USF and the functional and clinical outcomes of DRF treatment, albeit wrist pain and less flexion were reported in some studies to be associated with USF. There is a need for more robust evidence from large randomized controlled trials to specifically look at the effects of fixation versus nonfixation of USF on DRF, or large prospective cohort studies assessing DRF with and without USF, with a minimum of 12 months follow-up. Level of Evidence  Level II-therapeutic.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Classification systems for distal radius fractures

Background and purpose - The reliability of conventional radiography when classifying distal radius fractures (DRF) is fair to moderate. We investigated whether reliability increases when additional computed tomography scans (CT) are used. Patients and methods - In this prospective study, we performed pre- and postreduction posterior-anterior and lateral radiographs of 51 patients presenting with a displaced DRF. The case was included when there was a (questionable) indication for surgical treatment and an additional CT was conducted within 5 days. 4 observers assessed the cases using the Frykman, Fernández, Universal, and AO classification systems. The first 2 assessments were performed using conventional radiography alone; the following 2 assessments were performed with an additional CT. We used the intraclass correlation coefficient (ICC) to evaluate reliability. The CT was used as a reference standard to determine the accuracy. Results - The intraobserver ICC for conventional radiography alone versus radiography and an additional CT was: Frykman 0.57 vs. 0.51; Fernández 0.53 vs. 0.66; Universal 0.57 vs. 0.64; AO 0.59 vs. 0.71. The interobserver ICC was: Frykman: 0.45 vs. 0.28; Fernández: 0.38 vs. 0.44; Universal: 0.32 vs. 0.43; AO: 0.46 vs. 0.40. Interpretation - The intraobserver reliability of the classification systems was fair but improved when an additional CT was used, except for the Frykman classification. The interobserver reliability ranged from poor to fair and did not improve when using an additional CT. Additional CT scanning has implications for the accuracy of scoring the fracture types, especially for simple fracture types.

Does concomitant ulnar styloid fracture and distal radius fracture portend poorer outcomes? A meta-analysis of comparative studies

PURPOSE

An ulnar styloid fracture often occur in association with a distal radial fracture. Whether an ulnar styloid fracture interfere with the results of a distal radial fracture still remains controversial. The aim of this study was to analyse the effects of an accompanying ulnar styloid fracture on clinical outcomes in patients with distal radial fractures.

METHODS

A meta-analysis of published studies comparing outcomes of distal radial fractures with an ulnar styloid fracture versus isolated distal radial fractures was performed. Outcomes of function results, radiological evaluation, and patient reported scores were analyzed.

RESULTS

Ten studies including 1403 distal radius fractures were identified fitting inclusion criteria. There was no significant difference in wrist motion, grip strength, radial height, volar angle, ulnar variance, pain score, PRWE score, or SF-36 score for distal radial fractures associated with an ulnar styloid fracture versus isolated distal radial fractures. In final follow up, patients with associated an ulnar styloid fracture had lower radial inclination and higher DASH scores. But there was no significant clinical difference. In addition, we found there was no significant difference of outcomes between union and non-union ulnar styloid fractures.

CONCLUSIONS

Based on this meta-analysis, we suggest that an associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture and clinicians should be caution in electing operative treatment for patients with an ulnar styloid fracture.

[Distal radius fracture of the adult : Diagnostics and therapy]

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

Patient Reported Pain and Disability Following a Distal Radius Fracture: A Prospective Study

BACKGROUND

Fractures of the distal radius are common. Few studies investigating the extended long term outcomes of participants following a distal radius fracture (especially beyond 2 years) and they have relied on subjective measures or single objective tests to measure participant's final outcome.

OBJECTIVES

The objective of this study was to describe the pain and disability in long-term follow-up of participants after a distal radius fracture. Participants who had previously participated in a prospective study, where baseline and standardized one-year follow-up were performed, were contacted to volunteer to participate in this follow-up (FU) study. Sixty-five participants (17 males, 48 females) with an average age of 57 (SD 13) years at the time of injury and 67 (SD 13 years) at follow-up were evaluated at an average of 11(SD 6) years (range 2-20 years).

RESULTS

The majority of patients (85%) participants reported no change or had less pain and disability (PRWE) (<5 point difference) at their long-term follow-up compared to their one year PRWE scores. One year PRWE scores were found to be predictive (19.1%) of the variability in long term PRWE score (p=0.02). Age, gender, and mechanism of fall were not significant predictors of worsened outcome.

CONCLUSION

The majority of people that are experiencing no or low patient reported pain and disability one year following a DRF can expect to retain their positive outcome 10-20 years later. This study did not identify how to predict worsened outcome.

Acute Isolated Flexor Tendon Laceration Associated With a Distal Radius Fracture

BACKGROUND

Subacute rupture of the flexor tendons secondary to distal radius fractures is well documented. Recently, accounts of flexor tendon rupture following open reduction internal fixation have been associated with volar plate fixation. However, discovery of an occult traumatic flexor tendon laceration during fixation of an acute distal radius fracture is not well described. This case indicates the importance of careful preoperative and intraoperative examination of the flexor tendons in the setting of comminuted distal radius fractures.

METHODS

A forty-seven-year-old male sustained a comminuted, dorsally displaced distal radius fracture. Initial and post-reduction examinations revealed no gross functional abnormalities. Upon operative fixation of the fracture, laceration of the flexor digitorum profundus (FDP) tendon to the index finger was incidentally noted at the level of the fracture site.

RESULTS

Due to extensive dorsal comminution, shortening, and the presence of a lunate facet fragment, we performed volar fragment-specific and dorsal spanning bridge plate fixation. The proximal and distal ends of the FDP tendon were marked, but repair was deferred until implant removal. This allowed for proper informed consent and avoided potential compromise of the repair given the presence of a volar implant.

CONCLUSIONS

Acute flexor tendon rupture secondary to closed distal radius fractures may go unnoticed if a high index of suspicion is not maintained. Delayed diagnosis of these ruptures convolutes the mechanism of injury and disrupts the recovery process. Hand surgeons should be vigilant in examining flexor tendon function during the preoperative evaluation, especially in the setting of acute high-energy injury.

[The MEU classification system for distal radius fractures: Prognostic and therapeutic value of an independent assessment of various fracture parameters]

Distal radius fractures (DRF) are often complex injuries that can impact the radial metaphysis (M), the radial epiphysis (E) and the distal ulna (U). Each of these parameters can influence the outcome. In a given injury, these three DRF components are involved to a varying degree and are variably associated. The MEU classification independently analyzes the three main bone components of the fracture; thus, all possible combinations and each specific injury can be described. It accurately depicts the type and severity of the DRF. Our results show that this classification is useful for both prognosis and treatment. The criteria are simple and easy to determine, making the system reliable and reproducible. The classification system uses rigorous and validated criteria to define fracture instability: any fracture for which M>2 and/or E>2 (severe fracture) is more likely to be associated with secondary displacement, DRUJ pain, and patient dissatisfaction. Furthermore, a metaphyseal fracture entering the DRUJ (M') and the presence of a displaced ulnar fracture (U>1) affect the functional outcome, thus these two features must also be included in the classification system.

[Combined scaphoid and distal radius fractures in adults]

Although isolated distal radius and scaphoid fractures are common, the combination of both fractures is rare, with a reported frequency between 0.5% and 6%. This rarity is probably due to the fact that both fractures share the same injury mechanism. Published studies are limited, but most patients are males in their 40s and the injuries are typically due to high-energy trauma. In most studies, the distal radius fracture is displaced while the scaphoid fracture is not. Since the functional outcome depends of the severity of the radius fracture, we believe, as do others, that it is logical to fix both fractures with stable devices (i.e., screw fixation for the scaphoid, locking plate for the radius) to allow for early rehabilitation.

Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing?

Classification systems should be tools for concise communication, which ideally can predict prognosis and guide treatment. They should be relevant, reproducible, reliable, properly validated and most importantly simple to use and understand. There are 15 described distal radius classification systems present in the literature in the past 70 years, of which 8 are discussed in this paper. For each classification, we give an insight into its history, strengths and weaknesses, and provide evidence from the literature on reliability and reproducibility. Sadly, on completion of this paper we have not found a distal radius fracture classification that proved to be useful. Failings range from poor reproducibility and reliability, and over-complexity mainly emanating from the inability to classify this spectrum of injury in all of its manifestations. Consequently, we would suggest that classification systems for acute adult distal radius fractures are not useful clinical knowledge but mainly historical and/or research tools. Moreover, we would discourage trainees from spending time learning these classifications, as they serve not as essential clinical knowledge but more as forms of abstract memory testing.

Peripheral Nerve Compression Neuropathy after Fractures of the Distal Radius

Sixty patients with unilateral distal radius fractures were managed conservatively. Clinical assessment included objective and subjective evaluations of the outcome of treatment. Radiographic evaluation included fracture classification using the AO/ASIF system and measurement of volar tilt, radial inclination and radial height shortening at the end of treatment. Clinical signs of carpal tunnel syndrome were confirmed electrodiagnostically in 12 patients (20%) during the recovery period. Each patient had electrodiagnostic studies of both upper limbs performed to confirm the diagnosis. The mean time between injury and the onset of symptoms was 10 months (range 6.5 weeks–27 months). A statistically significant correlation between the final clinical results of treatment and post-traumatic median nerve compression neuropathy was found, but the occurrence of the neuropathy correlated with neither fracture type nor with the final radiographic findings. No clinical signs of ulnar or radial nerve compression occurred in this study.

Interobserver Agreement and Intraobserver Reproducibility of Barzullah Working Classification of Distal End Radius Fractures among Orthopaedic Residents

BACKGROUND

The purpose of this study is to test the hypothesis of the new classification system of distal end radius fractures (Barzullah working classification) proposed by one of the author in a prospective cohort study, among the orthopaedic residents.

METHODS

The initial post-injury radiographs of 300 patients with distal radius fractures in a tertiary centre were classified by two junior residents (JR1 and JR2) and two senior residents (SR1 and SR2) in the emergency department over a period of two years. The collected data was analysed statistically by using Cohan's kappa for measuring Intraobserver reproducibility and Fleiss kappa for measuring Interobserver agreement.

RESULTS

The mean kappa value for Interobserver agreement was 0.53 (moderate agreement) at the end of one year and the mean kappa value at the end of study period was 0.64 (substantial agreement). The mean kappa value for Intraobserver reproducibility of JR1 was 0.45 (moderate agreement), JR2 was 0.39 (fair agreement), SR1 was 0.62 (substantial agreement) and SR2 was 0.67 (substantial agreement).

CONCLUSIONS

Barzullah working classification of distal radius fractures presented in this study has good characteristics compared to those of already studied classification systems among orthopaedic residents.

Osteosynthesis in Distal Radius Fractures with Conventional Bridging External Fixator; Tips and Tricks for Getting Them Right

BACKGROUND

Distal radius fractures are the commonest fractures occurring in the upper extremity, accounting for 15-20% of patients treated in emergency department. Although distal radial fractures were described 200 years ago, they still remain as unsolved fractures with no clear guidelines. It is often reported that anatomical reduction has a bearing on the functional outcome.

AIM

To study the management of distal end radius fracture by utilizing the principle of ligamentotaxis where in the reduction obtained by closed means is maintained by external fixator till solid bony union occurs.

MATERIALS AND METHODS

A total of 26 cases were selected for study by scrutiny of the inclusion and exclusion criteria. Most of our cases were treated with external fixator within 8 hrs of injury. Small A.O external fixator (bridging ex-fix) with 2 pins each in radius and 2(nd) metacarpal percutaneously was used for all the cases. Selective k wire fixation was done in cases of instability. Fixator was removed after 6 weeks. Guided physiotherapy was ensured in all the cases. Patients were followed up for an average of 9 months.

RESULTS

Modified Gartland and Werley scoring system was used to evaluate the overall functional results. Excellent to good results were achieved in 88.45% of our cases while fair result was in 11.54 %. One case had pin loosening and two other cases had malunion.

CONCLUSION

External fixator used for ligamentotaxis is an effective method of treating unstable extraarticular and complex intraarticular fractures of distal radius. Improved anatomical restoration with early rehabilitation has produced favourable functional outcome in our series. The complications like pin tract infection is rare due to the availability of superior antibiotics and sterile surgical technique. complications like wrist and finger stiffness has improved with physiotherapy.

Catastrophic Thinking Is Associated With Finger Stiffness After Distal Radius Fracture Surgery

OBJECTIVES

To identify demographic, injury-related, or psychologic factors associated with finger stiffness at suture removal and 6 weeks after distal radius fracture surgery. We hypothesize that there are no factors associated with distance to palmar crease at suture removal.

DESIGN

Prospective cohort study.

SETTING

Level I Academic Urban Trauma Center.

PATIENTS

One hundred sixteen adult patients underwent open reduction and internal fixation of their distal radius fractures; 96 of whom were also available 6 weeks after surgery.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

At suture removal, we recorded patients' demographics, AO fracture type, carpal tunnel release at the time of surgery, pain catastrophizing scale, Whiteley Index, Patient Health Questionnaire-9, and disabilities of the arm, shoulder, and hand questionnaire, 11-point ordinal measure of pain intensity, distance to palmar crease, and active flexion of the thumb through the small finger. At 6 weeks after surgery, we measured motion, disabilities of the arm, shoulder, and hand, and pain intensity. Prereduction and postsurgery radiographic fracture characteristics were assessed.

RESULTS

Female sex, being married, specific surgeons, carpal tunnel release, AO type C fractures, and greater catastrophic thinking were associated with increased distance to palmar crease at suture removal. At 6 weeks, greater catastrophic thinking was the only factor associated with increased distance to palmar crease.

CONCLUSIONS

Catastrophic thinking was a consistent and major determinant of finger stiffness at suture removal and 6 weeks after injury. Future research should assess if treatments that ameliorate catastrophic thinking can facilitate recovery of finger motion after operative treatment of a distal radius fracture.

LEVEL OF EVIDENCE

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

Proposed Guidelines for Treatment of Concomitant Distal Radius and Distal Ulna Fractures

BACKGROUND

Concomitant distal radius and distal ulna metaphysis or head fractures (DRUF) are uncommon and acceptable results have been reported from cast immobilisation and internal fixation.

METHODS

We reviewed the charts of 1094 patients treated for distal radius fracture at our institution in a two year period from 2009 to 2010. 24 patients with concomitant DRUF with were treated by cast immobilisation (group 1, n = 11), internal fixation of both bones (group 2, n = 7), internal fixation of radius alone (group 3, n = 2), and internal fixation of radius with distal ulna resection (group 4, n = 4). Patients treated by surgery underwent intraoperative assessment of distal ulna stability to determine the indication for ulna fixation. Post surgical range of motion, clinical parameters, and functional outcome scores (Gartland-Werley and modified Mayo) were measured.

RESULTS

Wrist motion was comparable in each group. Radiographic parameters were better in surgical groups. 23 of 24 patients achieved excellent/good outcomes based on Gartland-Werley scores, while 12 of 24 achieved good modified Mayo wrist score. There was a case of distal ulna non-union in group 1, and another case of delayed distal radius union in group 2.

CONCLUSIONS

By evaluating patients' functional requirement, and dynamic fluoroscopy examination, satisfactory outcomes can be achieved for various presentations of DRUF.

Is it time to revisit the AO classification of fractures of the distal radius? Inter- and intra-observer reliability of the AO classification

We conducted an observational radiographic study to determine the inter- and intra-observer reliability of the AO classification of fractures of the distal radius. Plain posteroanterior and lateral radiographs of 456 patients with an acute fracture of the distal radius were classified by a consultant orthopaedic hand specialist and two specialist trainees, and the k coefficient for the inter- and intra-observer reliability of the type, group and subgroup classification was calculated. Only the type of fracture (A, B or C) was found to provide substantial intra-observer reliability (k type 0.65). The inclusion of 'group' and 'subgroup' into the classification reduced the inter-observer reliability to fair (kgroup 0.29, ksubgroup = 0.28) and the intra-observer reliability to moderate (kgroup 0.53, ksubgroup 0.49). Disagreement was found to arise between specific subgroups, which may be amenable to clarification.

[Fractures of the distal radius]

The most prevalent fractures managed by trauma surgeons are those involving the distal radius. The injury occurs in two peaks of prevalence: the first peak around the age of 10 years and the second peak around the age of 60 years. Distal radius fracture management requires sensitive diagnostics and classification. The objectives of treatment are the reconstruction of a pain-free unlimited durable functioning of the wrist and avoidance of typical fracture complications. Non-operative conservative management is generally employed for stable non-displaced fractures of the distal radius with the expectation of a good functional outcome. Unstable comminuted fractures with intra-articular and extra-articular fragment zones are initially set in a closed operation and finally by osteosynthesis. An armament of surgical implants is available for instable fractures requiring fixation. Palmar locked plate osteosynthesis has been established in recent years as the gold standard for operative management of distal radius fractures. Complex Working Group on Osteosynthesis (AO) classification type 3 fractures require extensive preoperative diagnostics to identify and treat typical associated injuries around the wrist.

Fractures of distal radius: an overview

Fractures of distal radius account for up to 20% of all fractures treated in emergency department. Initial assessment includes a history of mechanism of injury, associated injury and appropriate radiological evaluation. Treatment options include conservative management, internal fixation with pins, bridging and non-bridging external fixation, dorsal or volar plating with/without arthroscopy assistance. However, many questions regarding these fractures remain unanswered and good prospective randomized trials are needed.