Where is the distal fracture line location of dorsally displaced distal radius fractures?

No consensus currently exists on the facture location of dorsally displaced distal radius fractures (DRFs). We present a systematic evaluation of the distal fracture line (DFL) location of DRFs and possible influencing factors. Determining the average location of DRFs provides a basis for developing more sensitive tests to determine bone strength using a variety of imaging techniques and for developing improved biomechanical models to test fracture characteristics and surgical implants. Initial radiographs of 157 DRFs dorsally displaced DRFs in patients aged 40–74 years were identified, patient and trauma specific data were collected, and standard radiographic measurements and (AO) fracture classification were performed. The dorsal and palmar DFL locations relative to the corresponding apex of the lunate facet were measured. The DFL was located dorsally 7.9 ± 2.7 mm and palmarly 11.7 ± 3.9 mm proximal to the corresponding lunate fossa apex. The dorsal DFL was significantly distal to the palmar one (p < 0.001), but the two did not correlate (r² = 0.018, p = 0.095). DFL location was independent of age, energy of the fall, and fracture complexity. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:489–494, 2011     

Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment?

The purpose of this study is to determine whether the addition of computed tomography (CT) results in changes in the evaluation and treatment of intra-articular distal radius fractures. Fifteen intra-articular distal radius fractures were evaluated independently by 4 hand surgeons. Plain x-rays were reviewed initially followed by the corresponding CT scans for comparison of articular step-off and gapping, comminution, and treatment. Kappa coefficients (kappa) of intraobserver and interobserver reliability for treatment plans were generated. Computed tomography scans improved the sensitivity of measurement of articular surface gapping, improved the accuracy of detection of comminution and distal radioulnar joint involvement, and altered proposed treatment plans within observers (intraobserver agreement: kappa =.54, moderate) and improved agreement of proposed treatment plans between observers (kappa =.34 to kappa =.44, fair to moderate). Computed tomography scanning influenced observers to change treatment plans and resulted in increased interobserver reliability in the proposed management of these injuries.     

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.     

External fixation and bone grafting for collapsed and comminuted distal radius fracture

Unstableandcomminutedfractureofthedistalpartoftheradiusremainsachallengingproblem.Thisfracturethatcausedbyhighenergyinjuryisveryunstable,andthereductionandfixationareverydifficult.Inrecentyears,manydifferentexternal fixationdeviceshavebeendevelopedandused.1 4They cankeepthepositionafterreductionwithgood functionalresults.Butforseverecollapsedcases,the bonedefectmayleadtoreductionandfixationfailure orprolongthefracturehealingtime.Thesefinally resultinwristswelling,progressivejointstiffnessand …     

Redisplacement of paediatric distal radius fractures: what is the problem?

PurposeDistal radius fractures represent one of the most common fractures in children. Our purpose is to analyze risk factors for redisplacement in children with distal radius fractures treated by means of closed reduction and plaster cast immobilization.MethodsRetrospective study, including children under the age of 17 years, who underwent closed manipulation and cast immobilization for a distal third radius fracture, between 2012 and 2015. Preoperative radiographs were reviewed for initial translation, angulation and shortening, distance of the fracture from the physis, degree of fracture obliquity and the presence of an ulna fracture. Postoperative radiographs were analyzed for translation, angulation and shortening, as well as the quality of closed reduction. Cast index, gap index and three-point index, were measured on the postoperative radiographs. Redisplacement and re-intervention during follow-up were registered.ResultsA total of 26 patients were included in this study. Comparison between post-reduction and immediate post-cast removal radiographs did not show any statistically significant difference between translation or shortening. Coronal (p = 0.002) and sagittal (p = 0.002) angulation showed a statistically significant difference, but both median values remained below cut-off values for redisplacement. Redisplacement was observed in four patients. Only one patient underwent remanipulation. All four had full remodelling and proper radiological alignment at final follow-up. Quality of reduction was found to be a statistically significant risk factor for redisplacement (p = 0.013).ConclusionClosed reduction and cast immobilization under general anaesthesia yields good results in the treatment of distal forearm fractures in paediatric patients. Quality of reduction was the only risk factor that we found to be predictive of redisplacement.Level of Evidence:Level III – Retrospective comparative study     

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.     

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.     

Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary?

Background

The aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization.

Materials and methods

Three hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler’s angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle–Hindfoot Scale and compared in both groups.

Results

The mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8–9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8–12.2 months). The immediate-postoperative Bohler’s angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler’s angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8°–6.2°) than in group B (mean 6.2°; 95 % CI 1.0°–11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8–82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3–88.8 points), but this difference was not significant (p > 0.05).

Conclusions

Bohler’s angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar.     

Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result?

Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.     

Can external fixation maintain reduction after distal radius fractures?

BACKGROUND: The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction. METHODS: Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance. RESULTS: Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction. CONCLUSION: Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients.     

Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful?

OBJECTIVE: To determine whether autologous bone graft supplementation with open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures (DIACFs) is beneficial in achieving and maintaining restoration of calcaneal height and anatomic reduction of the posterior facet. DESIGN: Prospective historical cohort. SETTING: Level I trauma center, university hospital. PATIENTS AND INTERVENTION: Twenty DIACFs in twenty patients who received ORIF with bone graft supplementation were individually prospectively matched to twenty DIACFs in twenty patients who received only ORIF. Matching criteria for these pairs of patients included age, sex, occupational workload, Essex-Lopresti and Sanders classification, preoperative B?hler's angle, and fixation in the joint. MAIN OUTCOME MEASUREMENTS: Postoperative computed tomography assessed quality of anatomic reduction. Postoperative and three-month follow-up radiographs assessed B?hler's angle. A validated visual analog scale and Short Form-36 assessed functional outcome at a minimum of two years after surgery. RESULTS: Twenty-one fractures were (Orthopaedic Trauma Association) 73-C2 (Sanders Type III); fifteen fractures were 73-C1 (Sanders Type II); and four fractures were 73-C3 (Sanders Type IV). In the individually matched pairs of patients, the mean preoperative B?hler's angle was 2 degrees (standard deviation [SD] 14 degrees) for the bone graft group and 1 degree (SD 12 degrees) for the non-bone graft group. Preoperative B?hler's angle differed between individually matched pairs an average of 4 degrees (range 0 to 10 degrees). B?hler's angle increased with surgery a mean of 26 degrees (SD14 degrees) in the bone graft group and 27 degrees (SD 10 degrees) in the non-bone graft group. In the first three months after surgery, a mean decrease in B?hler's angle of 7 degrees (SD 4 degrees) in the bone graft group and 6 degrees (SD 7 degrees) in the non-bone graft group occurred. Statistical analysis of the individually matched pairs found no significant difference between the bone graft and non-bone graft patients regarding the change in B?hler's angle obtained with surgery (p = 0.98) and the change in B?hler's angle in the three months after surgery (p = 0.94). Quality of reduction was similar between groups, with eight matched pairs obtaining an equal reduction, six achieving a better reduction with bone graft, and six achieving a poorer reduction with bone graft. No differences in functional outcome were detected. CONCLUSIONS: We found no objective radiographic or functional benefit to the use of bone graft supplementation in the operative treatment of DIACFs.     

Initial shortening and internal fixation in combination with a Sauvé-Kapandji procedure for severely comminuted fractures of the distal radius in elderly patients

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure. At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O'Brien rating system, eight patients had an excellent, two a good and one a fair result. The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.     

External dynamic fixation in fractures of the humerus: can it still be considered treatment of second choice?

The authors report 40 patients affected with diaphyseal fracture of the humerus treated by dynamic axial fixator (FAD Orthofix). Minimum follow-up was 2 years. A clinical and radiographic retrospective study was conducted with the purpose of verifying the validity of external fixation as treatment of choice in diaphyseal fractures of the humerus. The results were evaluated considering healing time, extent and type of complications, long-term clinical, radiographic and functional findings. Results were: excellent: 35; good: 2; fair: 2; poor: 1. Complications were: nonunione: 1; reimplantation of FAD screws: 1; 4 infections of the screw holes, 3 realignments due to secondary displacement, 1 re-fracture after removal of the implant. There were no iatrogenic lesions of the radial nerve, or infections of the fracture site. The authors conclude that this semi-invasive, versatile and well-tolerated method, may be considered a valid alternative to conservative treatment, or to internal fixation even in cases of single trauma, despite limits related to the degree of collaboration of the patient, particularly with regard to debridement of the screw holes and periodical clinical and radiographic monitoring.     

What advantages does volar plate fixation have over K-wire fixation for distal radius extension fractures in the elderly?

PURPOSE: The purpose of this retrospective study was to compare the outcome of open reduction and internal fixation (ORIF) followed immediately by physiotherapy and of percutaneous K-wire-fixation and casting for unstable distal radius fractures in elderly patients, considering the results both in general, for all such fractures, and selectively for A3 and C2 fractures. METHODS: Follow-up examinations were performed 26 (18-48) months after surgery in 43 patients (median age 67 (60-83) years) treated with K-wire fixation and 9 (5-17) months after surgery in 46 patients (median age 76 (60-90) years) treated with ORIF, and the outcome of each was recorded as Disabilities of the Arm, Shoulder and Hand (DASH), Gartland-Werley and Castaing scores; the radiological loss of correction was also assessed. Statistical analysis was performed first without reference to the specific type of fracture for the K-wire- and the total ORIF -groups, and then selectively for A3 and C2 -fractures only; in the second analysis the patients were divided into three groups: KD, ORIF with and ORIF without angular stability. RESULTS: The Garland-Werley and Castaing scores do not indicate any significant difference between the procedures specified. According to the Garland-Werley score 37 patients (86%) treated by K-wire fixation and 39 (85%) treated by ORIF achieved "excellent" and "good" results; according to the Castaing score there were 33 (77%) "good" results after K-wire fixation and 34 (74%) good results after ORIF. The radiological loss of correction (K-wire fixation/ORIF) as measured by the radial inclination (median 2/2.5 degrees), the palmar tilt (median 3/5 degrees) and the radial shortening (median 1/1 degrees mm) do not differ significantly. Suboptimal radiological results do not always correlate with results that are only "fair" or "poor". The non-fracture-specific DASH score suggests a higher degree of patient satisfaction after K-wire fixation (7 [0-87] points) than after ORIF (17 [0-82] points), which is not confirmed by fracture-specific evaluation. There is a significantly earlier return to the "activities of daily living" (4 as against 8 weeks) after ORIF. CONCLUSION: All the treatments compared are suitable for the treatment of A3 and C2 fractures. The important advantages of ORIF are the early functional physiotherapy without casting and without obligatory second surgery and the earlier return to "activities of daily living", which are all of decisive importance for older patients, who are the ones most frequently affected.     

Palmar multidirectional fixed-angle plate fixation in distal radius fractures: do intraarticular fractures have a worse outcome than extraarticular fractures?

Introduction

The results and complications using a palmar plate system with the possibility of multidirectional fixed-angle screw fixation (Aptus^® Radius 2.5 mm by Medartis^®) for the treatment of unstable distal radius fractures were evaluated in a single cohort study including 62 patients.

Patients

Patients with extra- and intraarticular fractures were evaluated separately. The mean follow-up was 14.7 months. Active wrist motion averaged 60.1° extension, 52.0° flexion, 86.3° pronation, and 84.6° supination. Grip strength averaged 89% of the contralateral wrist.

Results

There was no loss of the initial reduction with bony union in all cases. The mean DASH-score was 12.6 points. Postoperative complications included two extensor pollicis longus tendon ruptures, two median nerve compression syndromes, one complex regional pain syndrome, and one postoperative haematoma. In our series the results of the intraarticular fracture group were similar to the extraarticular fracture group. The complication rate, however, was substantially higher in the intraarticular fracture group.

Conclusion

We conclude that palmar plating with multidirectional fixed-angle screw insertion is an effective and useful treatment option, especially for complex intraarticular distal radius fractures.     

Check radiography after fixation of hip fractures: is it necessary?

Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also be reversed into 'positives' at a later date. However, requesting routine post-operative check radiographs for these fractures are still a common practice. A retrospective study was carried out to compare the quality of image intensifier films with conventional post-operative radiographs. 79 sets of films were reviewed with particular reference to adequacy of fixation and possible joint penetration by the screws. No significant difference was noted between the two sets of films. We suggest that routine post-operative radiographs after femoral neck fracture fixation are unnecessary unless there is some clinical indication. This has significant implications in relation to patient discomfort, radiation exposure and cost-effectiveness.     

The pronator quadratus muscle after plating of distal radius fractures: is the muscle still working?

The purpose of this study is to define the function of the pronator quadratus muscle after plating of a distal radius fracture using anterior (volar) approach. Fourteen cases with volar plating after for a distal radius fracture were included in the study. Sixteen healthy volunteers were selected to determine the effect of dominant arm on pronation torque of the forearm for the control group. Biodex System 4 PRO (Biodex Medical Systems Inc., New York) torque meter was used for pronation torque measurement. In healthy volunteer group, there was no statistically significant difference in mean pronation torque values between the dominant arm and nondominant arms. The mean loss of pronator strength was 18.5 % and the mean loss of pronator durability was 12.9 % indicating a pronator insufficiency in the cases operated by a volar approach compared to uninjured forearm. Two patients among the operated group, who had further strengthening exercises beyond their own rehabilitation regimes, had improved pronator torque compared to uninjured forearm. In conclusion, the results of this study indicate that following volar plating of distal radius fractures, there is a significant loss in pronator strength of the forearm. As the two of the patients had improved pronator strength of their operated forearm, further rehabilitation regimes should be considered to prevent pronator weakness following volar plating for distal radius fractures.