Surgical treatment of unstable distal radius fractures with volar locking plates

BACKGROUND: Surgical treatment of unstable distal radius fractures does not always yield a satisfactory outcome. The several surgical strategies available have problems associated with them. This study was undertaken to determine if volar locking plate fixation could be useful for treating unstable distal radius fractures. METHODS: This retrospective follow-up study assessed 24 fractures in 24 patients with unstable distal radius fractures surgically treated with one of three volar locking plate systems. According to the AO classification system, 7 patients had type A3 fractures, 5 patients had type C2 fractures, and the remaining 12 patients had type C3 fractures. Radiographic measurements included volar tilt, radial inclination, and ulnar variance. Clinical outcomes were evaluated by active range of motion of the wrist and forearm, grip strength, Saito's wrist score, and the Japanese Society for Surgery of the Hand version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (JSSH version of the DASH). RESULTS: At the time of final follow-up (5 months minimum) the mean volar tilt was 8.1 degrees , radial inclination was 20 degrees, and ulnar variance was 0.4 mm. Mean wrist extension measured 61 degrees, wrist flexion 55 degrees, radial deviation 23 degrees, ulnar deviation 35 degrees, pronation 87 degrees, and supination 87 degrees. Grip strength recovered to a mean of 84% of the grip strength in the contralateral limb for patients who had injured their dominant hand and to a mean of 73% for patients who had injured their nondominant hand. Saito's wrist score calculations revealed 20 excellent and 4 good results. The mean DASH disability/symptom score was 9.9 points, and the mean DASH work module score was 8.2 points. CONCLUSIONS: The present study demonstrated that unstable distal radius fractures could be successfully treated with volar locking plate systems.     

Volar versus dorsal plating in the management of intra-articular distal radius fractures

PURPOSE: To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures. METHODS: This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score. RESULTS: Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score.Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one. CONCLUSIONS: Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

闭口式尺桡骨双侧截骨术治疗桡骨远端畸形愈合的病例对照研究

目的:比较传统桡骨开口截骨植骨术与闭口式截骨术治疗桡骨远端畸形愈合的临床和影像学结果.方法:对2004年1月至2012年12月采取矫形截骨治疗的47例桡骨远端关节外骨折畸形愈合患者的临床资料进行回顾性研究,4例失访,1例死亡,共42例纳入研究,分为桡骨开口式截骨植骨术组(A组)和闭口式尺桡骨截骨术组(B组).A组22例,其中男5例,女17例,年龄25～75岁;B组20例,其中男4例,女16例,年龄19～79岁.根据放射学结果和功能评估结果评估临床效果,包括腕关节活动度、握力、疼痛分级评估,Mayo腕关节评分及DASH评分.结果:A组患者平均随访36个月(12～101个月),B组患者平均随访28个月(12～87个月).A组掌倾角由术前(27±8)°(20°～38°)改善至术后(14±6)°(9°～22°),B组掌倾角由术前(26±5)°(20°～32°)改善至术后(10±5)°(3°～15°).A组尺骨变异术前(7±2) mm(0～10 mm),术后减小至(3±2) mm(-1～7 mm);B组由术前(6±2)mm(1～8 mm)减小至术后(0.2±0.7)mm(-1～2 mm);B组尺骨变异恢复优于A组.腕关节屈伸活动度A组由术前(74±30)°(30°～142°)提高至术后(108±23)°(65°～159°),B组由术前(95±35)°(30°～175°)提高至术后(154±16)°(115°～180°),B组腕关节屈伸活动度改善优于A组.术后Mayo腕关节评分A组78±10(55～100分),B组86±7(70～95分),B组优于A组;术后DASH评分A组14±12(0～44分),B组13±14(1～60分),两组差异无统计学意义.结论:闭口式尺桡骨双侧截骨术能有效治疗桡骨远端关节外骨折畸形愈合,并在恢复尺骨变异、腕关节屈伸活动度和Mayo评分方面优于开口式截骨术.     

Volar fixation of distal radial fracture using compression plate: clinical and radiographic evaluation of 20 patients

Distal radius fractures can be treated with different methods, depending on the type of fracture and, on our experience, according to the Fernandez algorithm. The report presents our experience treating distal radius fractures using a volar plate. We reviewed retrospectively 20 patients treated, during a period of 3 years (May 2008–May 2011) at our center, for unstable distal radius fractures using a volar plate. All patients were reviewed by thorough clinical examination and standard radiographs of the operated wrist. For the clinical evaluation, we used Mayo Wrist Score and DASH Score. At review, the injured wrist had recovered an average range of motion in flexion–extension of 120°, and the grip strength was an average of 50 % compared to contralateral side. Overall, results at Mayo Wrist Score were good to excellent in 30 %, satisfactory in 55 %, and poor in 15 %; results at DASH Score were good to excellent in 90 %, satisfactory in 10 % with no poor case. The majority of patients were fully satisfied with the results (65 %), 20 % of patients were partially satisfied, 5 % were poorly satisfied, and 10 % were not satisfied. At review, 4 patients reported the presence of transient paresthesia localized to the first three rays of the hand. At radiographic evaluation, the majority of patients had a radial tilt between 20 and 23, ulnar variance between 0 and 3, and dorsal tilt between 9 and 14. The treatment of unstable distal radius fractures with a volar plate provided stable internal fixation and allowed early function and was associated with a low complication rate.     

The functional outcome of acute scapholunate ligament repair in patients with intraarticular distal radius fractures treated by internal fixation

Background

Intra-articular fractures of the distal radius (DRF) are associated with a twofold increase in the risk of scapholunate ligament injury (SLI). The aim of this study was to compare functional outcome, pain, and disability between patients with operatively treated DRF and either an acute, repaired scapholunate ligament injury or no ligament injury.

Methods

We retrospectively analyzed 18 patients with an intraarticular DRF and SLI that was diagnosed and treated (Group I) and compared them with 20 patients with DRF without associated ligament injury (Group II) (20 women, 18 men; average age 55 years, range 19–72). The two cohorts were analyzed for differences in motion, grip strength, pain, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score an average of 43 months (range 12–73) after surgery. Radiographic assessment included fracture union, palmar tilt, radial inclination, ulnar variance, intercarpal angles, and arthrosis (according to Knirk and Jupiter). We used T-tests to compare range of motion, grip strength, pain (visual analog scale), DASH scores, and radiographic alignment between cohorts. A Chi-squared analysis was used to determine radiographic differences of arthritis.

Results

There were no significant differences in mean range of motion, grip strength, Quick DASH score, Mayo wrist score, pain level, or radiographic arthrosis between cohorts. There was no correlation between radiographic signs of osteoarthritis and the QuickDASH score, and pain level.

Conclusion

The outcomes of intraarticular fractures of the distal radius with operatively treated associated SLI are comparable with the outcomes of intraarticular fractures of the distal radius without associated SLI.     

Volar plate versus k-wire fixation of distal radius fractures

The optimal management of distal radius fractures remains controversial. The aim of this study was to compare the radiographic and functional outcomes of 318 patients who underwent k-wire fixation or volar plating for fractures of the distal radius. Patients were aged between 20 and 65 years and followed for a mean of 32 months. The mean values for volar tilt, radial inclination, radial length and ulnar variance were all significantly better in the volar plate group. Malunion occurred in 13.2% of patients undergoing k-wiring and 4% of patients treated with a volar plate (p < 0.007). Higher values for radial inclination, radial length and volar tilt correlated with better functional outcome as measured by disabilities of the arm shoulder and hand (DASH) and patient rated wrist evaluation (PRWE) scores. Lower values for ulnar variance correlated with better functional outcome. Although volar plate treatment resulted in a superior radiological outcome, there was no evidence that this translated into a superior functional outcome (DASH 13.12 vs. 11.25, p = 0.28) (PRWE 17.56 vs. 16.31, p = 0.69). The k-wiring procedure remains a suitable inexpensive option for simple fractures. Volar plating should be reserved for complex fractures that cannot be reduced by closed means.     

两种内固定治疗桡骨远端骨折伴尺骨茎突基底部骨折的疗效比较

目的比较采用桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定和单纯桡骨远端掌侧锁定钢板治疗桡骨远端骨折伴尺骨茎突基底部骨折的疗效。方法将73例桡骨远端骨折伴尺骨茎突基底部骨折患者按治疗方法的不同分为观察组(采用桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定治疗,38例)和对照组(采用单纯桡骨远端掌侧锁定钢板治疗,35例)。测量桡骨远端掌倾角、尺偏角、桡骨高度。术后4个月采用Dienst功能评分标准评价临床疗效。末次随访时采用腕关节活动度评价腕关节功能恢复情况。结果患者均获得随访,时间9~16个月。术后掌倾角、尺偏角、桡骨高度两组比较差异均无统计学意义(P>0.05)。术后4个月采用Dienst功能评分标准评价临床疗效的优良率,观察组明显高于对照组(P<0.05)。末次随访时两组腕关节功能均已恢复。结论与采用单纯桡骨远端掌侧锁定钢板治疗相比,桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定治疗桡骨远端骨折伴尺骨茎突基底部骨折更利于改善患者临床症状,更利于恢复腕关节的稳定性。     

Intraoperative computed tomography with an integrated navigation system versus freehand technique under fluoroscopy in the treatment of intra-articular distal radius fractures

Abstract

Volar locking plate (VLP) fixation for distal radius fractures (DRF) is a technically demanding procedure, where accurate placement of the distal screws for subchondral articular support is essential. The purpose of this retrospective, case-control study was to compare a computed tomography (CT) navigation system for VLP fixation of intra-articular DRF with conventional freehand fluoroscopy guided surgery. Twelve consecutive patients with DRF, AO type C3.1, underwent VLP fixation using intraoperative CT navigation (navigated group) and 16 consecutive patients had conventional freehand fluoroscopy guided surgery (non-navigated group). Follow-up was done mean 12 (range, 4–18) months after surgery. Radiological outcomes included evaluation of placement for the distal fixation screws and radiological parameters such as; radial inclination, palmar tilt, ulnar variance, fracture-gap, and step-off. Clinical outcomes included grip strength, wrist range of motion, Mayo wrist score, and the Disabilities of the arm, shoulder and hand (DASH) questionnaire. Dorsal cortical and articular screw penetrations were significantly more common in the non-navigated group compared with the navigated group. At the final follow-up, a significantly larger intra-articular fracture gap was observed in the non-navigated group compared to the navigated group. There were no significant differences in clinical outcomes between the two treatment groups. Our results suggest that CT navigation guided surgery for VLP fixation of type C3 DRF, compared with conventional freehand fluoroscopy guided surgery, provides a more accurate placement of the distal screws which minimize the risk for intra-articular and dorsal cortical screw penetration.     

Outcome following distally locked volar plating for distal radius fractures with metadiaphyseal involvement

BackgroundThe surgical treatment of metadiaphyseal distal radius fractures may be difficult due to the associated articular or periarticular extension that limits standard fixation techniques. Longer distal radius volar locking plates allow stable fixation of the distal fragments while providing standard plate fixation in the proximal radius. We hypothesize that this plating technique allows adequate fixation to both the distal radius and metadiaphyseal fragments. The purpose of the study is to describe the outcomes, radiographic parameters, secondary surgeries, and complication rate with this device.MethodsA retrospective chart review was conducted on adult patients with a distal radius fracture and metadiaphyseal involvement treated with a volar, distally locked plate. All patients were followed up for radiographic union, with a mean time of 219 days (range 38–575). Fracture patterns, outcomes of range of motion, grip strength, and complications, as well as injury, post open reduction and internal fixation (ORIF), and finally, healed radiographic parameters were recorded.ResultsTwenty patients with 21 fractures were included. At union, mean radiographic parameters were the following: volar tilt of 8°, radial inclination of 27°, radial height of 14 mm, and ulnar variance of −1 mm. The mean final range of motion was 52° flexion, 50° extension, 68° pronation, and 66° supination. Complications included one infection and one plate removal. Four patients developed a nonunion requiring secondary procedures. There were no incidents of hardware failure or adhesions requiring tenolysis.ConclusionDistally locked long volar plating for metadiaphyseal distal radius fractures is a safe and effective treatment option for these complex fracture patterns allowing anatomic restoration of the radial shaft and distal radius.     

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

PurposeAn 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.MethodsA 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.ResultsTen 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.ConclusionsBased 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 osteotomy in the elderly patient using angular stable implants and Norian bone cement

PURPOSE: To report our results after testing the combination of two technologies--angular-stable locking screw implants and Norian SRS cement--in corrective osteotomies of the distal radius in the elderly. This technique eliminates donor site bone-graft morbidity and expands the indications of corrective osteotomies to older patients with osteoporotic bone. METHODS: Our retrospective series include 6 patients (5 women and 1 man) with an average age of 60 years. Three patients had corrections through a dorsal approach, 1 through a volar approach, and 2 through a combined approach. Two corrections included an intraarticular osteotomy. We used 2.4-mm volar T plates in patients approached volarly and 2.4-mm L and T plates for those approached dorsally; the osseous defect was filled with bone cement (Norian SRS). Range of motion and grip strength were measured at 16 months average follow-up. Standard wrist radiographs were taken to evaluate alignment and determine improvement. At final follow-up, patients completed the Modified Mayo Wrist score, the Modified Gartland and Werley score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: There were no perioperative complications. All corrective osteotomies healed. One patient required a Darrach procedure at 6 months. The average wrist and forearm motion was 77% of the opposite side and grip strength 88% of the opposite side. The average total correction in the sagittal plane was 22 degrees with all patients returning to neutral or better alignment. The average ulnar variance improvement was 2 mm. Average postoperative DASH was 28 points; average Modified Mayo Wrist score was 68; and the Modified Gartland and Werley score averaged 9 points. CONCLUSIONS: We believe that corrective osteotomy of the distal radius in the elderly using angular stable implants and Norian calcium phosphate cement is a safe and predictable surgical technique, even in patients with underlying osteoporosis. It eliminates donor site morbidity, and patient-rated outcome measures demonstrated acceptable daily living function return.     

Should ulnar styloid be fixed following fixation of a distal radius fracture?,

IntroductionFracture of the base of the ulnar styloid has shown to have higher incidence of TFCC tears and DRUJ instability leading to nonunion and impaired function. Poorer functional outcomes of the distal radius fracture have been attributed to the untreated associated ulnar styloid fractures while some studies have shown no difference. Thus, the treatment remains controversial. However, it has been shown that fractures at the base of the ulnar styloid have a higher incidence of tears in the triangular fibrocartilage complex (TFCC) and instability in the distal radioulnar joint (DRUJ), which can lead to nonunion and impaired function. Despite this, there are currently no studies comparing the outcomes of surgically and conservatively treated patients.MethodsA retrospective study was conducted to analyze the outcomes of intra-articular distal radius fractures associated with base of ulnar fracture treated with distal radius LCP fixation. The study included 14 patients who were treated surgically and 49 patients who were treated conservatively, with a minimum follow-up of 2 years. Radiological parameters such as union and amount of displacement, VAS score for ulnar-sided wrist pain, functional assessment using the modified Mayo score and the quick DASH questionnaire and complications were analyzed.ResultsAt the final follow-up, the mean scores for pain (VAS), functional outcomes (modified Mayo score), disability (QuickDASH score), range of motion, and non-union rate were found to be statistically insignificant (p > 0.05) between the surgically treated and conservatively treated groups. However, patients with non-union had statistically significant higher scores for pain (VAS), greater post-operative displacement of the styloid, poorer functional outcomes, and higher disability (p < 0.05).ConclusionWhile there was no significant difference in ulnar-sided wrist pain and functional outcomes between the surgically treated and conservatively treated groups, the conservatively treated cases had a higher risk of non-union, which can negatively impact functional outcomes. The amount of pre-operative displacement was found to be a key factor in predicting non-union and can be used as a guide for determining the management of this type of fracture.     

Corrective osteotomy for malunion of the distal radius in young and middle-aged patients: an outcome study

INTRODUCTION: We report the outcome of osteotomy for malunion of the distal radius. MATERIAL AND METHODS: Twenty-one wrists in 21 patients (mean age 38 years) with a malunion of the distal radius were treated with an osteotomy. An opening wedge osteotomy was performed when the distal radioulnar joint (DRUJ) could be saved; a closing wedge osteotomy was done when the DRUJ was treated with resection (Darrach) or arthrodesis (Sauvé-Kapandji). The clinical and radiographic outcomes were evaluated together with the DASH score (disability of shoulder and hand). RESULTS: Extension improved to an average of 48 degrees in the Smith-type group and flexion improved to an average of 51.8 degrees in the Colles-type group. The postoperative DASH-score averaged, respectively, 17.3 and 33. There were four poor, four fair, seven good and six excellent scores on the scale of Fernandez and there were four poor, seven fair, three good and seven very good results on the Fernandez point score. Grip strength postoperatively averaged 70% of the contralateral side. Radiographically, there was a correction of increased volar tilt of the articular surface from 30.6 to 4.0 degrees in the Smith-type group and a correction of increased dorsal tilt of the articular surface of 24.6 degrees (from -21.3 to 3.3 degrees) in the Colles-type group. Nine patients had surgery on the distal ulna at the time of the radial correction. Their average DASH score was 16.8 compared to the 33.97 average DASH score of those with radial correction without ulnar surgery. CONCLUSION: Osteotomy of the distal radius in cases of malunion gives favorable outcomes. Treatment of the DRUJ is mandatory.     

Les fractures du radius distal après 70 ans : ostéosynthèse par plaque palmaire ou broches ?

In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (?0.7 mm versus ?0.1 mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.     

Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation

PURPOSE: The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixed-angle implant and a standard external fixation (EF) method. METHODS: This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12-84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12-24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups. RESULTS: The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 degrees extension and 57 degrees flexion, compared with 63 degrees extension and 64 degrees flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 degrees volar tilt and 25 degrees radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 degrees volar tilt and 22 degrees radial inclination, with .5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and .4 mm in the ORIF group. CONCLUSIONS: The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction.     

掌侧钢板结合外固定架治疗老年桡骨远端C3型骨折

目的比较掌侧钢板结合外固定架和闭合复位石膏外固定治疗老年桡骨远端C3型骨折的临床疗效。方法分析本院2006年7月至2012年12月收治的老年桡骨远端C3型骨折62例,31例采用掌侧钢板结合外固定架手术治疗,31例采用闭合复位管型石膏外固定保守治疗。两组均在术后12个月行X线片检查,测量桡骨远端掌倾角、尺偏角及桡骨高度。腕关节功能评分采用Krimmer评分和患者主观功能评价臂肩手功能缺陷,用于了解术后腕关节功能受限程度以及患者主观感受,对手术和保守治疗效果进行评价。结果 62例患者均获得随访,随访时间12~18个月,平均14.8个月。术后12个月,手术组患者掌倾角、尺偏角和桡骨远端高度显著优于保守治疗组(P0.01);手术组患者腕关节伸屈、旋转、尺桡偏的角度、手的握力均大于保守治疗组(P0.01);Krimmer评分和DASH评分手术治疗组优于保守治疗组(P0.05);两组患者VAS痛觉评分没有明显区别(P0.05)。结论对于桡骨远端C3型骨折的老年患者,首选手术治疗,掌侧支撑钢板结合外固定架治疗可以取得良好的效果。     

Fixed-Angle Volar Plate Fixation for Distal Radius Fractures in Immunosuppressed Patients

The aim of this study was to define the outcome and complications following open reduction and internal fixed-angle plating of distal radius fractures for patients on chronic immunosuppression medications. A retrospective study identified 11 patients with distal radius fractures that had been on chronic immunosuppressive medication. The mean patient age was 59.9 years (40–82 years). According to the Orthopedic Trauma Association classification, there was one 23A3, one 23B3, and nine 23C type fractures. There were two open fractures. All patients received preoperative antibiotics and underwent reduction and fixation with a volar, fixed-angle plate. Postoperative measurements included postoperative and final radiographic indices, wrist flexion and extension, forearm rotation, and grip strength. Clinical follow-up averaged 13 months, and radiographic follow-up averaged 14.9 months. Statistical analysis was performed comparing means of various parameters with a two-sided t test with an alpha value ≤0.05. All fractures healed, and there were no infections. The final mean ulnar variance, volar tilt, and radial inclination were −0.1 mm (ulnar negative; −2.0 to +2.5 mm), 13° (5–23°), and 21° (15–27°), respectively. The mean articular gap or step was 0.4 mm. There was a small but significant decrease between the final and postoperative mean ulnar variance (p = 0.03). Mean wrist flexion was 47°, extension 47°, pronation 77°, and supination was 76°. Grip strength averaged 16.3 kg versus 25.1 kg for the opposite extremity. The one major complication included a postoperative carpal tunnel syndrome. Fixed-angle volar plate fixation for distal radius fractures in patients with chronic immunosuppression was associated with union (with acceptable radiographic alignment), no wound-healing problems or infections, and with functional wrist and forearm motion and grip strength.     

Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures

PURPOSE: There have been few prospective studies of elderly patients with conservatively treated distal radius fractures and little is known about the relationship between acceptable radiographic reduction and functional outcomes in this population. We hypothesized that acceptable fracture reduction (according to standard radiographic dorsal/volar tilt criteria) would be associated with better functional outcomes and greater satisfaction. METHODS: Seventy-four patients who were at least 50 years of age with conservatively managed distal radius fractures were recruited from 2 large urban emergency departments from January 2001 to December 2001. Patients with wrist fractures treated in the emergency department and discharged home were included; patients admitted to the hospital or who required surgical reduction were excluded. Standard lateral radiographs were taken after the final cast was removed. These were reviewed independently by a reference-standard musculoskeletal radiologist and the degree of dorsal/volar tilt was recorded. This value was dichotomized according to standard published dorsal/volar tilt criteria as acceptable (dorsal tilt <10 degrees or volar tilt <20 degrees ) or unacceptable (dorsal tilt >10 degrees or volar tilt >20 degrees ). The Medical Outcomes Study Short-Form 12 (SF-12); the Disabilities of the Arm, Shoulder, and Hand questionnaire; and a patient satisfaction survey were used to assess patient-reported outcomes 6 months after the injury. RESULTS: The average dorsal/volar tilt measured by the reference standard radiologist was 3.4 degrees (SD=13.6) dorsal; overall 47 patients (64%) were considered to have an acceptable radiographic reduction. Acceptable radiographic reduction was not associated with better generic physical or mental health status, lesser degrees of upper-extremity disability, or greater satisfaction with outcomes than was unacceptable reduction. Overall 44 of 74 patients (59%) reported being satisfied or very satisfied with their functional status at 6 months. CONCLUSIONS: Contrary to our hypotheses we found that acceptable radiographic reduction (according to dorsal/volar tilt criteria) was not associated with better self-reported functional outcomes or increased satisfaction at 6 months in elderly patients with conservatively treated distal radius fractures.     

Korean Type Distal Radius Anatomical Volar Plate System: A Preliminary Report

Background

Distal radius fracture is the most common fracture of the upper extremity, and approximately 60,000 distal radius fractures occur annually in Korea. Internal fixation with an anatomical volar locking plate is widely used in the treatment of unstable distal radius fractures. However, most of the currently used distal radius anatomical plate systems were designed based on the anatomical characteristics of Western populations. Recently, the Korean-type distal radius anatomical volar plate (K-DRAVP) system was designed and developed based on the anatomical characteristics of the distal radius of Koreans. The purpose of this study was to evaluate the preliminary results of the new K-DRAVP system, and to compare its radiologic and functional results with those of the other systems.

Methods

From March 2012 to October 2012, 46 patients with acute distal radius fractures who were treated with the K-DRAVP system at three hospitals were enrolled in this study. Standard posteroanterior and lateral radiographs were obtained to assess fracture healing, and three radiographic parameters (volar tilt, radial inclination, and radial length) were assessed to evaluate radiographic outcomes. The range of motion and grip strength, the Gartland and Werley scoring system, and the disabilities of the arm, shoulder and hand (DASH) questionnaire were used to assess clinical and functional outcomes.

Results

All radiologic parameters were restored to normal values, and maintained without any loosening or collapse until the time of final follow-up. Grip strength was restored to 84% of the value for the unaffected side. The mean range of motion of the wrist at final follow-up was restored to 77%-95% of the value for the unaffected side. According to the Gartland and Werley scoring system, there were 16 excellent, 26 good, and 4 fair results. The mean DASH score was 8.4 points. There were no complications after surgery.

Conclusions

The newly developed K-DRAVP system could be used to restore and maintain good anatomical parameters, and provide good clinical outcomes with low complication rates. This system is a promising surgical option for the treatment of distal radius fractures in the Korean population.     

Computer-assisted distal radius osteotomy

PURPOSE: To establish the accuracy, precision, and clinical feasibility of a novel technique of computer-assisted distal radius osteotomy for the correction of symptomatic distal radius malunion. METHODS: Six patients underwent a computer-assisted distal radius osteotomy and were followed-up for an average of 25 months. Objective radiographic measurements and functional outcomes, as measured by clinical examination including grip strength and range of motion, and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, were used. RESULTS: The mean radiographic parameters included an increase of radial inclination to 21 degrees from 12 degrees (normal, 23 degrees ). Dorsal and volar tilt (malunion) were corrected to 9 degrees from -30 degrees and 21 degrees, respectively (normal, 10 degrees ). Ulnar variance was corrected to 1.9 mm from 7.5 mm (normal, +1.5 mm). Normal is defined as the average of the contralateral limb radiographs. The mean clinical outcome measures at an average of 25 months included a DASH global score of 14, a DASH individual item average score of 1.6, and an average affected side grip strength of 79% when compared with the unaffected side. CONCLUSIONS: The results of the computer-assisted technique were comparable with published results of traditional non-computer-assisted opening wedge osteotomy techniques. This technique allows a surgeon to accurately and precisely recognize and correct 3-dimensional deformities of the distal radius including axial malalignment (supination). The technique has the added benefit of reducing radiation exposure to the patient and surgical team because fluoroscopy is not used during the procedure. Additional benefits of the computer-assisted technique include the ability to perform multiple surgical simulations to optimize the alignment plan, and it serves as an excellent teaching tool for less-experienced surgeons.