Locking versus nonlocking palmar plate fixation of distal radius fractures

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Detection of dorsal screw penetration during volar plating of the distal radius fractures: A comparison of different fluoroscopic views and screw sizes

OBJECTIVE

The objective of this study was to compare different screw lengths combined with different fluoroscopic views to detect intraoperative dorsal screw penetration in distal radius fractures treated with volar locked plating.

MATERIAL AND METHODS

From April 2014 to October 2018, one hundred and eighty patients were included. We divided the patients into four groups. Intraoperative AP and lateral views were taken and sizes of the screws were chosen based on actual measurement (Group A, 45 patients). AP, lateral and tangential views were taken and sizes of the screws were also chosen based on actual measurement (Group B, 45 patients). Intraoperative AP and lateral views were taken and the selected screws were 2mm shorter than actual measurement (Group C, 45 patients). AP, lateral and tangential views were taken and the selected screws were 2mm shorter than actual measurement (Group D, 45 patients). Prominent screws were changed intraoperatively according to each view. A computed tomography (CT) was taken postoperatively to identify residual prominent screws.

RESULTS

The number of dorsally prominent screws exceeding 1mm was 6 of 301 in Group A (2.0%), 15 of 290 (5.2%) in Group B, 2 of 289 in Group C (0.7%), and 2 of 282 (0.7%) in Group D. All these prominent screws (25 screws) were exchanged for shorter screws during surgery. Group A and Group B had significant difference in detecting intraoperative dorsal screw penetration (p<0.05). Group C and Group D had no significant difference in detecting intraoperative dorsal screw penetration (p>0.05). Postoperative CT identified 12 additional prominent screws with≥1mm dorsal penetration in Group A, 2 screws in Group B, 1 screw in Group C and 0 screw in Group B respectively. Significant difference was found between Group A and Group B of CT results (p<0.05) while no statistical difference was found between Group C and Group D of CT results (p>0.05).

DISCUSSIONS

Tangential view helped identify screw penetration. If tangential view was not available intraoperatively, screw penetration could also be avoided by downsizing the distal locking screw by 2mm shorter than actual measurement.

Management of Unstable Distal Radius Fractures: A Survey of Hand Surgeons

Background  Length of immobilization after operative fixation of unstable distal radius fractures and management in elderly patients is an area of debate. Purpose  The purpose of this study is to delineate common practices of fellowship-trained hand surgeons and how they compare with current evidence-based protocols. Methods  Surveys were distributed to American Society for Surgery of the Hand members on preferred methods of fixation, postoperative immobilization, and variations in treatment of elderly patients with unstable distal radius fractures. Responses were analyzed in comparison to a literature review. Subgroups were compared with regard to training, practice type, and years in practice. Results  Four-hundred eighty-five surveys were analyzed. Volar fixed-angle plating was the most common choice of fixation (84.7%). Patients are most often immobilized for 1 to 2 weeks (40.0%) with range of motion (ROM) therapy begun most commonly between 1 and 4 weeks (47.2%). The majority of surgeons do not treat fractures differently in patients more than 65 years old. Physicians with more than 20 years of experience were significantly more likely to begin wrist ROM sooner with volar plating versus other fixation techniques compared with physicians with less than 20 years of experience (40.7% vs. 34.2%, respectively). Also, physicians in academic-only practices were more likely to immobilize patients for a shorter time after volar plating compared with those in privademics. Conclusion  Volar fixed-angle plating is the dominant fixation method for unstable distal radius fractures among fellowship-trained hand surgeons. Elderly patients are not treated more conservatively and rigid immobilization after operative fixation remains the treatment of choice despite current evidence-based protocols.

Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial

OBJECTIVES

The purpose of this study was to compare the pain scores and the rates and doses of opioid use in patients undergoing volar locked plate fixation of intra-articular distal radius fractures using or not postoperative immobilization.

METHODS

This was a prospective randomized controlled trial. Thirty-nine patients with distal radius fractures scheduled to receive volar plate fixation were randomly assigned to receive a short forearm splint for two weeks postoperatively or conventional bandage with early wrist mobilization. Thirty-six patients completed the follow-up. The outcome measurements included pain scores (0-10 points); rates and doses of tramadol use; DASH score; wrist range of motion; patient satisfaction; and complication rates. The last follow-up assessment was performed at 6 months.

RESULTS

The pain scores were similar between the groups during hospital stay, as well as after hospital discharge within the first week and in subsequent assessments up to six months. The rates of tramadol use were greater in the No splint group during hospital stay, but this difference was not statistically significant (No splint = 65%; Splint = 47%; p = 0.296). Likewise, the doses of tramadol intake were higher in the No splint group during hospital stay (No splint = 218 mg; Splint = 167 mg; p = 0.273) and after discharge (2^nd day: No splint = 112 mg; Splint = 75 mg; p = 0.286), with no statistically significant differences. The functional results and complication rates were similar between the groups.

CONCLUSIONS

In this study, there was a trend to a greater use of tramadol in patients who did not use immobilization and started early wrist mobilization after volar locked plating of distal radius fracture, compared with patients who were immobilized for two weeks. The pain scores were similar but may have been influenced by the unbalanced use of opioids between the groups. The functional results and complication rates were not influenced by the use of immobilization.

LEVEL OF EVIDENCE

Therapeutic Level I.

[Surgical techniques and effectiveness of volar locking plates for senile delayed distal radius fractures]

Objective

To investigate the surgical technique and effectiveness of volar locking plates for senile delayed distal radius fractures.

Methods

Between October 2014 and September 2015, 25 cases of delayed distal radius fractures were treated by volar locking plates. There were 3 males and 22 females with an average age of 73 years (range, 65-87 years). Injury was caused by tumble in 19 cases and by traffic accident in 6 cases. All the cases had closed fracture. According to the AO classification, 10 cases were rated as type A2, 7 cases as type A3, 3 cases as type B3, and 5 cases as type C1. The manual reduction and plaster immobilization were performed in 18 cases first, but reduction failed; no treatment was given in 7 cases before surgery. The time from injury to surgery was from 33 to 126 days (mean, 61 days). Preoperatively, the volar tilting angle was (-16.0±3.1)°; the ulnar inclining angle was (10.8±7.0)°; the radial shortening was (11.2±3.6) mm; the wrist range of motion was (41.0±7.5)° in flexion and was (42.0±6.3)° in extension; and the grip strength was 33.0%±3.1% of normal side.

Results

All incisions healed primarily, and no postoperative complication occurred. The patients were followed up 1-1.5 years (mean, 1.3 years). The X-ray films showed that fracture union was achieved in all the patients, with the mean healing time of 9.2 weeks (range, 8-12 weeks); the displacement of the articular surface was less than 1 mm. At last follow-up, the volar tilting angle was (13.1±3.2)°; the ulnar inclining angle was (21.9±4.6)°; the radial shortening was (2.0±1.1) mm; the wrist range of motion was (52.0±11.7)° in flexion and was (65.0±4.8)° in extension; and the grip strength was 84.0%±4.2% of normal side; all showed significant difference when compared with preoperative ones ( P<0.05). According to the Gartland and Werley score, the results were excellent in 15 cases, good in 6 cases, fair in 2 cases, and poor in 2 cases at last follow-up; the excellent and good rate was 84%.

Conclusion

By the good design of the volar locking plate and the command of surgical techniques, good effectiveness can be achieved in the treatment of senile delayed distal radius fracture.

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

Introduction

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

Results and Discussion

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

Trial Registration

German Clinical Trials Register (DRKS) DRKS00006097

Salter-Harris II forearm fracture reduction and fixation using a buttress plate

Distal radius fractures are common injuries in children. Those that affect the growth plate (physis) need to be managed carefully as inadequate management may lead to long-term deformity and a reduction in function. However, different management strategies all have drawbacks and controversy exists over how best to manage these cases. This is the case of a 13-year-old girl who presented with a Salter Harris II fracture, which was managed using a novel approach of utilising a T plate in a buttress mode to stabilise the fracture after anatomical reduction. This provided effective fracture fixation and should allow good bone healing without causing any iatrogenic growth plate damage and without fixing a plate across the physis, which may need removal in the future.