Carpal canal pressures after volar plating of distal radius fractures

Elevated pressures within the carpal canal are known to occur after distal radius fractures. Controversy exists regarding prophylactic carpal tunnel release after open reduction with internal fixation of distal radius fractures. The purpose of this study was to determine the tissue pressures within the carpal canal after volar plating of distal radius fractures. This study was a prospective, observational, IRB approved research study. Ten consecutive patients undergoing volar plating of distal radius fractures were enrolled. After the distal radius fractures were reduced and fixed with volar plates, slit catheters were inserted into the carpal canals for continuous postoperative pressure monitoring for 24 hours. The maximum recorded pressure was 65 mmHg, which occurred in the only patient with fracture blisters. Peak pressures remained at 40 mmHg or less (range 16-40, mean 29) in all patients without fracture blisters. At the conclusion of data collection, all pressures were at 31 mmHg or less. No patient complained of median nerve dysfunction during the study period. Routine prophylactic carpal tunnel release is not recommended after volar plating of distal radius fractures based on these pressure recordings.     

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up

BackgroundVolar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate.MethodsRetrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd–5th year resident or consultant), type of plate (VariAx^®, Acu-Loc^®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted.Results576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n = 451) of the patients were treated with VariAx^® and 22% (n = 125) with Acu-Loc^®.The overall complication rate was 14.6% (95% CI 11.8–17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed.ConclusionThe majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.     

Flexor tendon injuries following locked volar plating of distal radius fractures

We present 2 cases showing that flexor pollicis longus and flexor digitorum profundus index injury can occur after placement of 2 commonly used locked volar plates. In contrast with the literature, the radii healed in an anatomic position without plate lift-off. The patients presented 6 and 8 months after surgery with new onset of radial wrist pain and tenderness at the site of the plate and absence or weakness of the flexor pollicis longus. In both cases, the plate was positioned anterior to the distal radial rim on the lateral radiograph. We suggest close follow-up of all fractures in which the distal end of the plate is anterior to the radial rim and removal of hardware if symptoms suggest tendon irritation.     

Scapholunate instability after distal radius volar plating

Background

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability.

Methods

We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59 years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3 mm and scapholunate angle ≥60°.

Results

Six patients (3 %) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3 %) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2 %) underwent primary scapholunate ligament repair at the time of distal radius fixation.

Conclusions

In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.     

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.     

The 45 degrees pronated oblique view for volar fixed-angle plating of distal radius fractures

Distinctive to volar fixed-angle plating of the distal radius, the optimal position of the distal fixed-angle support is in the subchondral bone immediately proximal to the articular surface. Standard intraoperative radiographic imaging of the distal radius during placement of a volar fixed-angle plate does not provide adequate visualization of the subchondral bone-distal support interface. A 45 degrees pronated oblique view is described to address this specific issue of whether volar hardware placed at the immediate subchondral bone level has effectively avoided the radiocarpal joint. This is a quite important radiographic consideration when pursuing the strategy of volar fixed-angle plating of distal radius fractures.     

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically in to immediate, early (less than 6 weeks), and late (greater than 6 weeks).     

Locked volar plating for complex distal radius fractures: Patient reported outcomes and satisfaction

Background  

Distal radius fractures are common. The increasing prevalence of osteoporosis contributes to frequently complex articular injuries sustained even after low energy falls. The best method of treating complex type C distal radius fractures is debated. Locked volar plating and external fixation are both widely used with good reported results. Measures of success are traditionally based on technical measurements or the perception of the surgeon. Patient reported measures of outcome are increasingly recognised as important markers of surgical success. We report our experience using locked volar plating for complex type C distal radius fractures as well as patient reported measures of success and satisfaction.     

Dorsal plating for distal radius fractures

A dorsal approach to the distal radius for comminuted intra-articular fractures affords excellent exposure of the joint surface. Dorsal plating can reliably buttress the joint, leading to low rates of arthrosis, but at the expense of wrist stiffness and high rates of extensor tendon problems. New, smaller implants may prove capable of supporting the joint with lower rates of extensor irritation.     

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience

Background  

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications.     

Internal distraction plating of distal radius fractures

Internal distraction plating can be used for the treatment of highly comminuted distal radius fractures especially in elderly patients. The technique involves the use of 3.5, 2.7, or 2.5 dynamic compression plates. The instrumentation is applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, and fixed distally to the long metacarpal. The advantages of this technique are: a) it can be used as an alternative for managing difficult fractures in the elderly population; b) it is indicated in patients with osteoporotic bone; c) complications associated with external pins are avoided; and d) the stability of the plate allows patients to use the extremity for transfer and activities of daily living. On the other hand, possible disadvantages to be considered are: a) the need of a second operation to remove the plate; and b) the prolonged duration of immobilization. Elderly patients with osteoporotic bone who undergo treatment of comminuted distal radius fractures may result in poor outcomes with high rates of complications if external fixation or standard internal fixation is used. The current approach represents an alternative that provides union of the fracture with excellent alignment, functional range of motion, and minimal functional disability.     

The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating

Background

Open reduction internal fixation (ORIF) of distal radius fractures via a volar approach involves surgical release of the overlying pronator quadratus (PQ) muscle. Complete repair of the PQ, defined as full and stable replacement of the periphery of the PQ back to its original anatomic location, is not always possible upon conclusion of the operation. Postoperative consequences of incomplete PQ repair with regards to range of motion (ROM), grip strength, and complications are not well documented. It was hypothesized that the completeness of PQ repair would yield no significant difference in the postoperative ROM, grip strength, and incidence of complications.

Methods

A retrospective review was performed of 110 repairs of distal radius fractures with ORIF via placement of a volar locking plate. The following clinical data were extracted: complete or incomplete PQ repair, patient age, gender, follow-up ROM/grip strength, and incidence of postoperative complications.

Results and conclusions

No significant difference in ROM, grip strength, and postoperative complications was detected between the complete and incomplete PQ repair groups. Complications consisted of two incidences of malunion requiring revision surgery and one occurrence of complex regional pain syndrome. There were no tendon ruptures. No statistical difference in ROM/grip strength or incidence of postoperative complications was detected between the complete and incomplete PQ repair groups. Regardless of the level of injury sustained by the PQ, surgeons should make an effort to cover the distal aspect of the volar plate during closure following distal radius fracture ORIF. Coverage of the distal aspect of the plate with the PQ (at a minimum) provides adequate results in ROM and grip strength, as well as protection against flexor tendon injury.

Level of evidence

Therapeutic Level III: Retrospective Comparative Study.     

Minifragment plating for fractures of the distal radius

Twelve patients with fracture of the distal radius were treated by open reduction and internal fixation with titanium minifragment plates. There were 8 women and 3 men, with a mean age of 42 years. The mean follow-up was 18 months. According to the score of Gartland and Werley, 11 patients had an excellent result and one patient had a good result. All patients reported no pain in their activities of daily living and were satisfied with the result. All workers returned to work. One patient developed reflex sympathetic dystrophy which resolved with treatment. No patients needed plate removal because of irritation of the tendons. The results obtained with this technique appear promising, although more cases are needed to achieve a definitive conclusion.     

Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius

PURPOSE: Despite the recent popularity of volar plating for dorsally displaced distal radius fractures there is a paucity of data documenting the results of this treatment method. The purpose of this study was to determine the functional outcome of patients treated with volar fixed-angle plating for dorsally displaced, unstable distal radius fractures. METHODS: We reviewed the records of all patients treated at our institution with internal fixation using volar plates for dorsally displaced, comminuted distal radius fractures. Patients with follow-up periods shorter than 12 months were excluded from the study. Outcomes were evaluated at the latest follow-up examination with the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scoring systems. RESULTS: We studied 41 patients with a mean age of 53 years. The average follow-up period was 17 months. All fractures were stabilized with volar locking plates. Radiographs in the immediate postoperative period showed a mean radial height of 11 mm, mean radial inclination of 21 degrees , and mean volar tilt of 4 degrees. At fracture healing the mean radial height was 11 mm, mean radial inclination was 21 degrees, and mean volar tilt was 5 degrees. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 14 and all patients achieved excellent and good results on the Gartland and Werley scoring system, indicating minimal impairment in activities of daily living. Nine patients experienced postoperative complications. There were 4 instances of loss of reduction with fracture collapse, 3 patients required hardware removal for tendon irritation, 1 patient developed a wound dehiscence, and 1 patient had metacarpophalangeal joint stiffness. CONCLUSIONS: Patients with unstable, dorsally displaced fractures of the distal radius treated with volar fixed-angle devices have good or excellent functional outcomes despite a high complication rate. When compared with previous reports on dorsal plating volar plates appear to have a higher incidence of fracture collapse but a lower rate of hardware-related complications. Complex fracture patterns thus mandate a careful and individualized approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

掌侧锁定钢板内固定治疗C型桡骨远端骨折的临床疗效观察

目的探讨采用掌侧锁定钢板内固定治疗不稳定桡骨远端骨折的疗效。方法自2010-03—2012-03诊治不稳定桡骨远端骨折35例,采用切开复位,掌侧锁定钢板内固定。结果除1例失访外,其余患者获得平均30.2个月(24~48个月)的随访。X线片显示骨折全部一期愈合,平均愈合时间为8周。1例骨缺损严重及5例骨质疏松患者,术中植入人工骨。患者均无感染、骨不连、钢板松动、腕管综合征等并发症发生。疗效按Cooney腕关节评分标准评定:优19例,良11例,可3例,差1例,优良率88.2%。结论采用掌侧锁定钢板内固定治疗不稳定桡骨远端骨折,疗效确切,可以提供坚强内固定,早期功能锻炼,恢复正常的掌倾角、尺偏角、桡骨远端长度,腕关节Cooney评分满意。