Dorsal bridging plates for the treatment of high and low energy distal radius fractures

Distal radius fractures are common and treatment of complex fracture pattens can be challenging. We assessed functional outcomes, radiographic analysis, and complications of 26 distal radius fractures treated with dorsal bridging plate (DBP) at a mean of 14 months post plate removal (6–34 months). Radiographic parameters were measured pre- and post-operatively and patient reported wrist evaluation scores, patient reported wrist range of movement and satisfaction scores. Mean post-operative total PRWE was 26 (range 0–76) and mean wrist mobility 52° flexion (range 10°–85°) and 50° extension (range 10°–85°). Mean post-operative patient satisfaction score was 89% (range 50–100%). Four patients developed complications (one EPL rupture and three developed CRPS). DBP can reliably restore distal radius anatomy and is associated with good functional outcome scores, return of functional range of wrist movement and high levels of patient satisfaction.Level of EvidenceIII     

Ultrasound changes in the extensor pollicis longus tendon following fractures of the distal radius--a preliminary report

Extensor pollicis longus tendon rupture occurs in 0.2% to 3% of fractures of the distal radius. The underlying mechanism, or mechanisms, of rupture are unknown. This study evaluated this tendon and its surrounding structures using high-resolution ultrasound in 62 patients with distal radius fracture at 6 weeks after injury. The uninjured wrist was examined as a control. The ultrasound measurements at 6 weeks were then correlated with the patients' presenting X-rays. Significant findings included a reduced peak velocity of tendon movement and an increased thickness of both the extensor retinaculum and the tendon sheath on the fractured side. In respect of tendon sheath thickness, these changes were particularly associated with intraarticular fractures. We postulate that the increased thickness of the EPL tendon sheath may further impair an already tenuous blood supply and/or affect the diffusion of nutrients to the tendon within the third extensor compartment, leading to tendon attrition and rupture.     

拇长伸肌腱自发性断裂桡侧腕短伸肌腱替代术的临床应用

目的 探讨腕部拇长伸肌腱自发性断裂,采用桡侧腕短伸肌腱替代术的临床疗效.方法 1996年2月-2005年7月,对12例拇长伸肌腱自发性断裂的患者采用桡侧腕短伸肌腱移位替代术.其中桡骨远端骨折愈合后肌腱断裂6例,类风湿骨关节炎4例,不明原因2例.术后均不用石膏固定,术后2d开始练习伸手、伸腕、伸拇动作,2～3次/d;术后7d停止练习;术后4～5周可缓慢伸手持物.结果 12例术后随访均在1年以上,12个月后平均伸拇肌力已达4～5级,腕背肌腱滑动时无障碍.术后无肌腱再断裂者,伸腕、伸指时拇指末节过伸2°～5°,平均3°,拇对掌、对指功能正常.根据中华医学会手外科学会手部肌腱修复后功能评定标准评价,优良率达100%.全部患者对术后功能满意.结论 拇长伸肌腱自发性断裂,应用桡侧腕短伸肌腱移位替代术,对供区损伤小,操作方便,肌腱缝合牢固,有利早期功能恢复.     

Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series

Rupture of the extensor pollicis longus (EPL) tendon after a distal radius fracture is an uncommon event; the incidence is 3%,according to a review of treatment of 200 consecutive patients with Colles fractures. Diagnosis is based on persistent dorsal wrist pain and a positive retroflexion sign. Recommended treatments in the prerupture setting include a third dorsal compartment release with or without an extensor retinacular patch graft. Also recommended are a palmaris longus graft in the acute rupture setting and a transfer from the extensor indicis proprius to the EPL tendon in the subacute or chronic setting. Results of all treatments seem to be clinically satisfactory.     

Measurement of gliding resistance of the extensor pollicis longus and extensor digitorum communis II tendons within the extensor retinaculum

PURPOSE: The etiology of spontaneous extensor pollicis longus (EPL) tendon rupture is still largely unknown. It is possible that friction within the sheath may play a role. The purposes of this study were to compare gliding resistance of the EPL tendon with that of the extensor digitorum communis tendon of the index finger (EDC II) and to find the wrist position that gives the EPL tendon the lowest gliding resistance. METHODS: Fifteen fresh-frozen cadavers were used. Gliding resistance was measured directly in 7 different wrist positions. RESULTS: The mean gliding resistance of the EPL tendon was 0.16 +/- 0.08 N and that of the EDC II tendon was 0.11 +/- 0.06 N. This difference was significant. There was also a significant effect on gliding resistance due to wrist position. For the EPL tendon, the gliding resistance was significantly greater in 60 degrees wrist flexion compared with all other wrist positions tested. Additionally the gliding resistance of the EPL in 30 degrees flexion, 60 degrees extension, and 15 degrees radial deviation was significantly higher than wrist positions of 30 degrees extension, neutral, and 30 degrees ulnar deviation. CONCLUSIONS: Positioning the wrist close to neutral flexion/extension and in some ulnar deviation minimizes the friction within the EPL sheath. Such positions may be advantageous for splinting patients at risk for EPL rupture.     

The role of post-operative radiographs in predicting risk of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures – A case control study

Background and aimVolar plating of distal radius fractures is one of the common procedures performed in trauma surgery. Flexor pollicis longus (FPL) rupture has been described as complication following volar plating of distal radius fractures.The aim of our study was to investigate the possible relation between parameters measured on post-operative radiographs and the occurrence of FPL ruptures.Materials and methodsThis was a case control study. The post-operative radiographs of 11 FPL rupture, and 22 non-FPL rupture patients were reviewed with respect to fracture reduction and plate position and the various parameters were calculated by five independent people.Logistic regression was used to examine the importance of the variables.ResultsWe identified two significant factors to predict FPL rupture after volar plating of distal radial fractures. These were radial tilt and plate distance from the joint line. The odds ratio of ruptures was 0.74 (95% CI 0.57–0.95) for every degree of radial tilt <25° and 0.50 (95% CI 0.28–0.88) for every millimetre that the distal end of the plate was away from the volar lip of the distal radius at the wrist joint.ConclusionPost-operative radiographs could help us predict FPL rupture after distal radius volar plating. The findings also highlight the need for good fracture reduction and thoughtful placement of the volar plate intraoperatively to minimise the risk of FPL tendon rupture.     

Predictors of wrist function and health status after operative treatment of fractures of the distal radius

PURPOSE: To identify the most important determinants of physician-based and patient-based scoring systems for the wrist and upper extremity after operative treatment of a fracture of the distal radius, with the hypothesis that pain is the strongest determinant of both types of scores. METHODS: Eighty-four patients were evaluated a minimum of 6 months after operative fixation of an unstable distal radius fracture using 2 physician-based evaluation instruments (the Mayo Wrist Score and the Gartland and Werley Score) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder, and Hand; DASH). Multivariate analysis of variance and multiple linear regression modeling were used to identify the degree to which various factors affect variability in the scores derived with these measures. RESULTS: The physician-based scoring systems showed moderate correlation with each other and with DASH scores. The results of multiple linear regression modeling were as follows (percent variability accounted for by the best fit model/model with top factor alone): Mayo: 54% grip and flexion arc/47% grip alone; Gartland and Werley: 70% pain, flexion arc, radiocarpal arthritis, and duration of follow-up/53% pain alone; DASH: 71% pain, forearm arc, and type of fracture/65% pain alone. CONCLUSIONS: At early follow-up, pain dominates the patient's perception of function after recovery from an operatively treated distal radius fracture as measured by the DASH score and the physician-based rating according to the system of Gartland and Werley. The Mayo Wrist Score is determined primarily by grip strength rather than pain. Because perception of pain and strength of grip have been shown to be influenced by psychosocial factors in some individuals, both patient-based and physician-based measures of wrist function may be vulnerable to illness behavior. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.     

Transfer of either index finger extensor tendon to the extensor pollicis longus tendon

BACKGROUND:

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method.

OBJECTIVES:

To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand.

METHODS:

Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles’ fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery.

RESULTS:

All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side.

CONCLUSIONS:

These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.     

Palliative tendon transfer for reanimation of the wrist and finger extension lag. Report of 14 transfers for radial nerve palsies and ten transfers for brachial plexus lesions

This retrospective study is based on 23 males and one female, of an average age of 36.2 years that presented to us between 1982 and 2000 with an average follow up of 61 months, with fully established paralysis of wrist and fingers extension. Fourteen patients had isolated radial nerve palsy, while ten patients had brachial plexus lesions. 1) The tendon transfer for radial nerve palsy was: PT to ECRB, FCU to ED + EPL and PL to APL + EPB; 2) for brachial plexus injury, the tendon transfer was: PT (n = 4) or FDS III or IV (n = 5) to ECRB, FCU (n = 8) or FDS IV (n = 1) to ED + EPL, PL to APL + EPB and wrist arthrodesis with transfer of FDS IV to ED + EPL and PL to APL + EPB. The results were evaluated according to the degree of wrist movement, MP extension of long fingers, opening of first commissure, thumb opposition, grip power and the subjective evaluation of results. Concerning the radial nerve palsy: results are excellent in nine cases and good in one case. An active extension of the wrist of 38 degrees was obtained as well as MP extension of 0 degree with the wrist straightened. Thumb oppositioned was conserved (Kapandji = 8.2), opening of the first commissure 40 degrees and grip power was 20 kg. Concerning the brachial plexus lesions: results are excellent in five cases and good in the other five. An active wrist extension of 32 degrees was obtained, as well as MP extension deficit of 16 degrees with wrist straightened. Opposition was concerned (Kapandji = 7.2), opening of first commissure of 38 degrees and grip power of 13 kg. The functional results are satisfactory, but the analytic study shows some effect of tenodesis of MP extension.     

Gliding Distance of the Extensor Pollicis Longus Tendon with Respect to Wrist Positioning: Observation in the Hands of Healthy Volunteers Using High-Resolution Ultrasonography

Study DesignCross-sectional experimental bench.IntroductionOptimal tendon gliding is necessary for normal thumb function.Purpose of the StudyMeasure the gliding distance of the extensor pollicis longus (EPL) tendons during passive thumb flexion from high-resolution echo images at four wrist positions.MethodsGliding distance of the EPL tendon in zone 4 of the thumb was measured during passive flexion in four different wrist positions in 25 healthy female volunteers. Tendon gliding was evaluated from high-resolution ultrasonography in a frame-by-frame cross-correlation analysis.ResultsMean gliding distance of the EPL tendon was 1.79, 2.45, 1.09, and 1.36 mm with the wrist positioned in neutral, 30 degrees of extension, 30 degrees of flexion, and 20 degrees of ulnar deviation, respectively. There were statistically significant differences in the gliding distance of the EPL tendon among all of four wrist positions except for that between the wrist flexion and wrist ulnar deviation conditions.ConclusionsWrist extension induces the greatest magnitude EPL tendon gliding.     

Acute true trigger wrist following partial extensor carpi radialis brevis tendon rupture

Triggering in association with movements of the wrist or “true trigger wrist” due to the extensor tendon is rare. There are only few case reports in literature, but none were associated with the acute partial tendon rupture. We present a case of true trigger wrist originating from partial rupture of extensor carpi radialis brevis tendon (ECRB). In contrast to the other reports, the interval between an initial injury and development of triggering was short because the partial tendon rupture was bunching and forming a nodule. The triggering was attributed to the snapping of the nodule under the extensor pollicis longus tendon (EPL).     

Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures

BackgroundIn the setting of intra-articular distal radius fractures, the volar lunate facet (VLF) is the only articular segment that resists volar carpal subluxation. So, it is important to achieve a stable fixation of this key fragment. The VLF, when small (also called as volar marginal fragment, VMF) is located distal to the watershed line making fixation with the conventional volar locking plates difficult or impossible.Methods18 patients with either an AO: 2R3B3 or a C3 fracture consisting of a VMF underwent surgical repair through a volar approach. The VMF was stabilised using a anatomical volar hook plate. Remaining fracture components were stabilised using 2.4/ 2.0 mm locked plates. Fracture healing, ability of the hook plate to maintain reduction of the VMF and complications were assessed during follow up. Functional outcome was evaluated using Mayo score and patient rated wrist evaluation questionnaires.ResultsAll fractures united at follow up. Reduction of the VMF was maintained through healing with a stable radiocarpal and distal radioulnar joint. The mean flexion - extension wrist arc was 105° ± 10.2° The mean grip strength reached 74.6 ± 6% of the opposite side. The mean Mayo wrist score was 75 ± 5.3 and the mean patient rated wrist evaluation (PRWE) score was 15.2 ± 4.3 indicating recovery of wrist function.ConclusionIt is important to identify VMFs in intra-articular distal radius fractures. Anatomically designed volar hook plate achieves excellent low-profile stable fixation of this key fragment to allow early mobilisation without fearing loss of reduction and volar carpal subluxation.     

Bilateral rupture of the extensor pollicis longus tendon. A case report

Bilateral rupture of the extensor pollicis longus (EPL) is a rare entity and the few cases that have been reported were associated with an underlying systemic condition such as rheumatoid arthritis or following an injury. We present the case of a patient who was referred to us with a spontaneous rupture of the EPL tendon of the right wrist and that of the left side observed 2 months after tenosynovectomy. The patient had not any pathologic condition or evidence of trauma in both wrists. In the left side, he was operated on and a tenolysis and subcutaneous tendon transposition was performed. Despite this preventive surgery, the patient suffered from a tendon rupture. The possible causes of surgery failure are discussed.     

Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients

BackgroundThere is a conflict in the treatment of distal radius fractures in elderly patients, because fracture reduction does not appear to be as strongly associated with functional outcomes as in younger patients. The purpose of this study was to evaluate radiographic findings of acceptable reduction without leading to wrist dysfunction and poor outcomes.MethodsFifty-two active and healthy elderly patients with conservatively managed distal radius fractures were included in the study. They consisted of 7 men and 45 women, all 60 years or older. Radiographic assessment included volar tilt, radial inclination and ulnar variance, and outcome evaluation included the Mayo wrist score and DASH score. As a control group, the preoperative radiographic and clinical outcomes were examined as well for 19 patients older than 60 with malunion, for whom corrective osteotomy was performed because of wrist dysfunction. The radiographic parameters and clinical outcomes were compared between the two groups in a statistical manner. Correlation coefficients of the radiographic parameters with Mayo wrist score and DASH score were analyzed by multiple regression.ResultsVolar tilt (mean —1.2°) and ulnar variance (mean 2.5 mm), as well as Mayo wrist score (mean 80.0 points) and DASH score (mean 8.6 points) in the objective group were significantly superior to those in the control group when comparing radiographic parameters and clinical outcomes. There was no significant difference between the two groups in regard to RI (mean 14.9°). Multiple regression analysis revealed that volar tilt and ulnar variance were significantly correlated with the clinical outcomes in the objective.ConclusionThe parameters of volar tilt and ulnar variance had a significant correlation with clinical outcomes. Clinical outcomes significantly worsened when those parameters exceeded a tolerable range. In elderly patients, it is important to determine an appropriate therapeutic modality for a distal radius fracture when considering the acceptable parameters for alignment.     

Rupture of the extensor pollicis longus tendon: a study of aetiological factors

Although rupture of the extensor pollicis longus (EPL) tendon is a wellknown complication of distal radial fractures, a number of patients rupture the EPL because of other conditions. We have retrospectively studied the aetiology of 27 ruptures of the EPL in 26 consecutive patients. Of 19 patients with injured wrists 12 had distal radial fractures, five had blunt trauma, and two had stab wounds that resulted in rupture. In the radial fractures operated on, the EPL rupture was caused by chafing against a dorsal plate (n?=?2) or wear against the pins of an external fixator (n?=?2). Six patients were taking steroids for systemic diseases and in two cases a local steroid injection was given just before the rupture. We conclude that previous injury is the most common cause of rupture of the EPL, but that rheumatoid arthritis or local or systemic steroids, or both, are also important aetiological factors. Seven patients had an iatrogenic cause for their rupture.     

Minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study

INTRODUCTION

Rupture of extensor pollicis longus (EPL) tendon is a recognised complication following volar plate fixation of distal radius fractures, usually from attrition caused by prominent screws. We sought to identify the screw holes in some of the most commonly used plates which may precipitate tendon injury.

SUBJECTS AND METHODS

Three fixed-angle volar locking plates were sequentially positioned into 18 cadaveric arms. A wire was passed through each of the holes in the plates using a locking guide and the dorsal relationships noted.

RESULTS

Each plate had specific ‘high-risk’ holes which directed the wire towards the EPL groove. The central screw holes appeared mostly implicated in EPL injury.

CONCLUSIONS

Awareness of ‘high-risk’ holes and appropriate minor alterations in surgical technique may consequently decrease the incidence of EPL irritation and rupture.     

Rupture of the extensor pollicis longus tendon: a study of aetiological factors.

Although rupture of the extensor pollicis longus (EPL) tendon is a well-known complication of distal radial fractures, a number of patients rupture the EPL because of other conditions. We have retrospectively studied the aetiology of 27 ruptures of the EPL in 26 consecutive patients. Of 19 patients with injured wrists 12 had distal radial fractures, five had blunt trauma, and two had stab wounds that resulted in rupture. In the radial fractures operated on, the EPL rupture was caused by chafing against a dorsal plate (n = 2) or wear against the pins of an external fixator (n = 2). Six patients were taking steroids for systemic diseases and in two cases a local steroid injection was given just before the rupture. We conclude that previous injury is the most common cause of rupture of the EPL. but that rheumatoid arthritis or local or systemic steroids, or both, are also important aetiological factors. Seven patients had an iatrogenic cause for their rupture.     

Concomitant Rupture of Extensor Pollicis Longus and Index Extensor Tendons following Distal Radius Plating—Report of Two Cases and Their Clinical Implication for Tendon Transfer Surgery

Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the thumb extension following rupture of extensor pollicis longus (EPL). In its standard form often the EIP is transferred to the EPL without inspection of the extensor tendons in the fourth compartment and it is retained in its anatomical fourth compartment. However, in a setting of EPL rupture in relation to the distal radius fracture (with or without fixation), concomitant injury to the extensor tendons to the index finger may result in failure of the transfer and even a loss of index finger extension (index finger drop) further complicating the reconstruction and resulting in immense patient dissatisfaction. We herein present two such rare cases to highlight this clinical scenario and how an awareness of this possibility and inspection of the extensor tendons to the index finger before EIP transfer allowed us to prevent this complication. In essence, if we know it, we can prevent it.     

Long-term results of dorsally displaced distal radius fractures treated with the pi-plate: is hardware removal necessary?

The purpose of this study was to evaluate the outcome of patients treated with open reduction and internal fixation (ORIF) using dorsal plates and screws (AO/ASIF pi-plate) for dorsally displaced fractures of the distal radius. Although extensor tendon rupture is a recognized complication of all distal radial fractures, there appears to be an increased risk of this using dorsal plating. In addition, there is the added complication of extensor tendon irritation and dorsal wrist pain, which may necessitate plate removal. The low-profile pi-plates intended to overcome this problem have not done so, with quoted rates ranged from 19% to 55%.We treated 32 completely evaluated patients (13 men and 19 women) in our department between 2000 and 2004, with an average age of 46 years. They underwent ORIF of dorsally displaced fractures of the distal radius using the specially designed pi-plate. Bone graft was used in 18 patients who had significant metaphyseal defect. Clinical examination, plain radiographs, and functional assessments using the modified Mayo Wrist Score were performed at an average follow-up of 86 months (range, 56-115 months). Satisfactory reduction was achieved in all 32 fractures at the time of operative fixation with no instances of loss of fracture reduction during the study period. According to the Mayo Wrist Score, 23 patients (72%) had excellent or very good results, 7 (22%) had fair results, and 2 (6%) had poor results. Two cases (6.25%) of extensor tendon rupture were noted during the first postoperative month, and 2 other patients showed progressive weakness of index finger extension 6 months postoperatively. The remaining 28 patients had no soft tissue problems.     

Begleitverletzungen distaler Radiusfrakturen

Background

Following treatment of distal radius fractures poor functional results can still be found despite satisfactory radiological findings. This may be due to concomitant carpal lesions occurring together with these fractures. The aim of this prospective study was to analyze the clinical outcome depending on the type of fracture and concomitant carpal lesions.

Patients and methods

A total of 66 patients with distal radius fractures treated over a 1-year period could be assessed. The functional results were compared with the uninjured contralateral side. The follow-up examination included patient history, physical and radiographic examination as well as the DASH (Disability of the arm, shoulder and hand) questionnaire and the modified Mayo wrist score.

Results

The average follow-up time was 12.7 months and the mean age of the examined patients was 53 years. The fracture classification according to AO (AO Working party for osteosynthesis questions) showed 32% type A, 10% type B and 58% type C fractures. In 55% a concomitant carpal lesion was found and 44% of the patients required surgical treatment. All fractures united without complications. In all cases X-rays showed no loss of reduction postoperatively. Overall grip strength and wrist motion was reduced to 81% compared to the uninjured side. Patients regained good function represented in a mean DASH score of 24.8 points and a Mayo score of 70.6 points. The number of complete intraarticular fractures (type C) was significantly higher in patients who needed surgical treatment for carpal lesions compared to the groups where concomitant carpal lesions did not require invasive treatment or those where no carpal lesions were found. However, due to the operative treatment a comparable functional result could be obtained in all groups independent of the injury severity.

Conclusions

The results demonstrate, if a correct restoration and surgical stabilization technique is used, clinical outcome following fractures of the distal radius also depends on an optimized management of concomitant carpal lesions.