Determinants of distal radius fracture management in polytrauma patients

Background

Over 640,000 distal radius fractures occur annually in the United States. No studies have been performed looking specifically at polytrauma patients who sustain distal radius fractures. We sought to determine variables affecting management of distal radius fractures in polytrauma patients.

Methods

An IRB-approved review of trauma patients from 2008–2011 was performed. Records for patients with distal radius fractures were examined, assessing age, gender, Glascow Coma Score, Injury Severity Score, mechanism, type, and characteristics of injury, as well as operative repair. A logistic regression was performed using SPSS 15.0.

Results

The database identified 12,054 patients, 434 sustaining a distal radius fracture. No statistically significant difference in operative repair based on mechanism of injury (p = 0.465) was identified. A total of 285 patients (65.7 %) underwent surgery for distal radius fractures. In univariate analysis, younger age was the only statistically significant demographic predictor of surgical intervention (p = 0.003). In both univariate analysis and logistic regression, open, intra-articular, displaced, and comminuted fractures, as well as those with concomitant ulna fractures were statistically significantly associated with operative repair. Fracture displacement was the most likely variable to be associated with surgical intervention (OR = 12.761, 95 % CI[7.219, 22.556]) (p < 0.001).

Conclusions

In polytrauma patients, surgery for distal radius fractures is associated with younger age, open, intra-articular, displaced, and comminuted fractures, as well as concomitant ulna fractures. Displaced fractures were almost 13 times more likely to undergo surgical intervention than non-displaced fractures. Gender and mechanism of injury are not predictive of surgical intervention.     

Conservative treatment of the distal radius fracture using thermoplastic splint: pilot study results

Introduction

Fractures of the distal radius are common accounting for approximately one-sixth of all fractures treated in the emergency room. This study reviews a series of patients with stable distal radius fractures who have been treated with thermoplastic splint.

Methods

This study was undertaken between November 2009 and May 2010 in a single orthopaedic fracture outpatient clinic. All patients had undisplaced or minimally displaced distal radius fractures. Children and open fractures were excluded. Patients had been reviewed in the outpatients with radiographs on 1, 2, 6 and 12 weeks after injury. Skin condition and satisfaction were assessed on splint removal. Radiological parameters of radial inclination, radial length and palmer tilt were measured.

Results

In total, 26 patients were treated with the splint. The average age of the patients was 45.1 (range, 21–73), and male/female ratio was 12:14. On average, the splint was removed at 5.1 weeks (mode = 6 weeks). The right- to left-side ratio was 11:15. Eleven of those fractures were on the dominant side. There was no significant difference in the radiological outcomes pre- and post-splinting. Nearly all patients had been satisfied with the splint. Two patients had minor cast complications whilst 23 patients were able to shower whilst in splint.

Conclusion

Patients treated with thermoplastic splint showed no deterioration in their radiological outcomes. Nearly all the patients had been satisfied with the splint.     

Radiographic assessment of ligamentous injuries in distal radius fractures after open reduction and internal fixation

Objectives

Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity.

Methods

Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods.

Results

Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture characteristics, surgical difficulty, and technique were not associated with scaphoid position.

Conclusions

Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF.     

Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures

Objective

The purpose of this study was to investigate the effect of untreated triangular fibrocartilage complex (TFCC) tear on the clinical outcome of conservatively treated distal radius fractures.

Materials and methods

This prospective study comprised 47 consecutive patients who presented at our clinic between January 2009 and January 2010 with displaced radius distal fracture and were treated with closed reduction and casting. During the first 15 days of treatment, all patients underwent wrist MR imaging to detect traumatic TFCC tears. At the final follow-up, all patients were evaluated with Mayo wrist function score and wrist radiographs. Patients were divided into two groups according to presence of TFCC tear, and two groups were analyzed statistically.

Results

The mean follow-up period was 38.9 ± 3.5 months (range 36–48). TFCC tear was detected in 24 cases, and remaining 23 cases had no TFCC tear. Both groups were statistically similar regarding age (p = 0.574), gender (p = 0.108), dominant side involvement (p = 0.339), fracture type (p = 0.709) and immobilization period (p = 0.514). According to Mayo wrist score, excellent results were obtained in 21 (44.7 %) cases, good in 16 (34.0 %) and satisfactory in 10 (21.3 %). No significant difference was observed between groups in wrist function scores (p = 0.451). Radiographic measurements were similar between groups (radial length p = 0.835, volar til p = 0.464, radial inclination p = 0.795).

Conclusions

Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary. However, it should be borne in mind as a reason for continuing wrist pain and instability after distal radius fractures despite proper radiologic recovery.     

Volare winkelstabile vs. dorsale Plattenosteosynthese bei der distalen Radiusextensionsfraktur

Introduction

This study investigated the radiographic and functional outcomes of two different methods for treating fractures of the distal part of the radius.

Patients and methods

In a prospective controlled study patients with forearm fractures were randomized by age, handedness, and fracture type.

Results

The study included 120 patients, with a mean age of 66 years. Forty-nine percent of the fractures were extraarticular, and 51% were intraarticular. In the group treated with volar locking compression plates, six patients needed operative decompression of the median nerve and one needed reconstruction of the extensor pollicis longus (EPL) tendon. The group with dorsal plating had three complications requiring operative treatment: one deep infection, one dislocation of the plate, and one reconstruction of the EPL tendon. The radiological results for the Stewart 1 score showed 68% excellent results in volar locking compression plating compared with 57% in dorsal plating. Regarding functional outcome, 48% with volar plating showed excellent results compared with 22% with dorsal plating, as measured by the Stewart 2 score.

Conclusion

Despite significant advantages of the volar locked compression plating, subjective satisfaction did not differ between the two groups.     

Erste Ergebnisse der multidirektional-winkelstabilen palmaren Osteosynthese der distalen Radiusfraktur

Background

The management of fractures of the distal radius continues to evolve. New operative strategies have recently been developed including the use of fixed-angle plates. This study reviews the results of 20 patients with fractures of the distal radius treated with a new multidirectional fixed angle plate.

Method and materials

A total of 20 patients with closed Colles type fractures of the distal radius were treated with Medartis (Aptus 2.5) palmar fixed-angle plates. Surgery was performed under plexus anesthesia using the standard or extended flexor carpi radialis (FCR) approach. Patients were evaluated prospectively with a mean follow-up of 26 weeks (range 23–28 weeks). Pain, range of motion, grip strength, DASH score, modified Mayo wrist score and radiographs were obtained. The level of significance was set at 95% and the χ² and ANOVA tests in combination with a post hoc Tukey test were used for statistical analysis.

Results

The average range of motion (ROM) in extension-flexion was 87° (76% of the contralateral side) and in ulnar-radial deviation 42° (88% of the contralateral side). Pain values (visual analogue scale 0–100) at follow-up were 3 (without stress) and 24 (with stress). Grip strength improved to 84% of the contralateral side, the mean DASH score was 13 points and the modified Mayo wrist score confirmed the excellent results with a mean value of 83±27 points. Radiological examination showed a satisfactory result with an ulna variance of 0.9±0.4 mm, radio-ulnar inclination of 21±5° and palmar inclination of 4±6°.

Conclusions

Our data show that treating unstable distal radius fractures with multidirectional palmar fixed-angle plates is reliable and effective and produces good early functional and radiological results. However, long-term results with a larger number of patients and randomized prospective studies comparing this technique with other established procedures are required.     

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Introduction

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

Materials and methods

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

Results

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

Conclusions

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.     

Outcomes and complications of fractures of distal radius (AO type B and C): volar plating versus nonoperative treatment

Objectives

Management of AO type B and C fractures of the distal radius is controversial. This study compares outcomes and complications of AO type B and C fractures of the distal radius treated with volar locked plating and nonoperative methods.

Materials and methods

Sixty-four patients with fractures of the distal radius (AO type B and C) were included in this study, according to inclusion criteria, and were allocated to the volar plating group or nonoperative group by alternate randomization: 32 patients with odd numbers went into the nonoperative group and the other 32 with even numbers went into the volar plating group. Patients in the nonoperative group were managed with closed reduction of the fracture and plaster cast application under an image intensifier. Those in the volar plating group were managed by open reduction and fixation with a volar locked plate. Preoperative and postoperative serial clinico-radiological follow-up was done. The range of movement, grip strength, functional outcome scores and radiological parameters were compared. Student’s t-test was used for statistical analysis with significance at p < 0.05.

Results

Range of movement and functional scores were significantly (p < 0.001) better in the volar plating group, but the difference in ulnar variance and radial and ulnar deviation was insignificant as compared to the nonoperative group. At 24 months follow-up, the nonoperative group had significantly more cases with malunion, articular incongruity and osteoarthritis.

Conclusion

In cases of AO type B or C fractures of the distal radius, volar locked plating provides anatomical stable fixation and early mobilization with better clinico-radiological outcome as compared to conservative treatment.     

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.     

Karpale Begleitläsionen bei dislozierter distaler Radiusfraktur

Background

The functional outcome of surgically treated dislocated fractures of the distal radius is limited and does not correlate with radiographic results. Additional carpal lesions are assumed to be the cause. This study has evaluated which carpal lesions are associated with dislocated fractures of the distal radius.

Material and methods

A total of 104 consecutive patients with dislocated fractures of the distal radius were included in the study. The injured wrist was examined by radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine additional carpal lesions.

Results

Radiographically 51 of the 104 fractures presented as type A according to the AO classification, 10 as type B and 39 as type C. The CT scan detected that only 5 of the 51 type A fractures were exclusively metaphyseal fractures. All type A fractures were associated with ligamental lesions in MRI.

Conclusions

The results of the study confirm the hypothesis that every dislocated fracture of the distal radius is a combined carpal trauma associated with additional osseous and/or ligamental lesions.     

Three-dimensional analysis of osteophyte formation on distal radius following scaphoid nonunion

Background

The purposes of this study were to quantitatively analyze osteophyte formation of the distal radius following scaphoid nonunion and to investigate how fracture locations relate to osteophyte formation patterns.

Does an ulnar styloid fracture interfere with the results of a distal radius fracture?

Background  

The ulnar styloid is a supportive structure for the capsular ligament complex of the distal radioulnar joint. The relation between fractures of the ulna and distal radius is not clear, especially in regard to whether ulnar fractures predict worse outcomes for distal radius fractures. The objective of this study was to analyze the influence of ulnar styloid fractures in patients with reducible and unstable distal radius fractures.     

Impact of ulnar styloid fractures in nonoperatively treated distal radius fractures

Purpose

The effect of an ulnar styloid fracture (USF) on the stability of nonoperatively treated distal radius fractures (DRF) is unknown. The aim of this study was to evaluate the influence of USFs on the dislocation of DRFs treated by closed reduction.

Methods

Standardized radiographs of 100 nonoperatively treated DRFs were evaluated. DRFs with a USF were compared to DRFs without a USF with respect to dorsal tilt, radial inclination, and ulnar variance.

Results

We evaluated the radiographs of 100 DRFs in 99 consecutive patients, of whom 84 were women. An accompanying USF was present in 58 wrists, of which 49 were displaced. On the trauma radiograph, the USF group showed significantly more overall dislocation. After closed reduction, fracture position improved, and no significant differences in dislocation were observed between groups. After a mean of 42 days, radial inclination significantly decreased if a USF was present. When USF displacement was taken into account, significantly more ulnar variance occurred in the displaced USF group on the trauma and follow-up radiograph compared to the nondisplaced USF group and no-USF group.

Conclusions

The results of this study show that presence of a dislocated USF in patients with a DRF is associated with a worse position directly after trauma, and with recurrence of radial shortening after adequate reduction. These results warrant early radiologic follow-up in patients with reduced combined DRFs and USFs in order to evaluate the redislocation of the distal radius. Early detection of redislocation in these combined fractures may induce early surgical intervention.     

Osteosynthesis of distal radius fractures with the Micronail®

Introduction

The Micronail^® is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures.

Patients and methods

In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail^®. Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome.

Results

According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail^®, we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10° in all directions.

Conclusion

This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail^® causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.     

Inter-observer variation in the diagnosis of coronal articular fracture lines in the lunate facet of the distal radius

Background

Several studies support the use of CT for diagnosing coronal fractures of the distal radius but the inter-observer reliability of these observations is less well studied. We tested the null hypothesis that radiographs alone and the combination of radiographs and two-dimensional computed tomography scans (2DCT) have the same inter-observer variation for the diagnosis of coronal articular fracture lines in the distal radius.

Methods

Using a web-based survey, 63 surgeons were randomized to evaluate 16 fractures of the distal radius on radiographs alone or radiographs and 2DCT for the presence or absence of a coronal fracture line of the lunate facet and, if present, the stability of the fracture. The kappa multirater measure was calculated to estimate agreement between observers.

Results

The inter-observer variation in diagnosis of a coronal fracture line was fair with both radiographs and 2DCT, as was the diagnosis of instability of the volar lunate facet fracture when present.

Conclusion

Two-dimensional computed tomography does not improve observer agreement on the diagnosis of coronal plane articular fracture lines in the lunate facet of the distal radius.     

The use of bone cement in difficult distal radius fractures

Background

The lack of structural support remains a challenge in the treatment of comminuted distal radius fractures. Calcium phosphate and calcium sulfate bone cement has been used in other fracture locations in addition to fixation and has been shown to allow for retention of reduction in difficult cases.

Methods

A case-control retrospective review of 34 consecutive distal radius fractures treated with surgery was performed with the patients classified by Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Complications and postoperative radiographs were evaluated.

Results

Cement was used in the most difficult cases. Radial height was retained in both groups. Volar tilt was significantly better in the cement group. There were no significant differences between the case and control groups for any complication. No complications related to the use of the cement were found.

Conclusions

The use of bone cement as an adjunct to fixation of distal radius fractures seems to include minimal risks and may afford a technical advantage in maintaining reduction during surgery for difficult fractures. Since there is an aspect of fracture difficulty that we cannot control for by using radiographic assessment alone, cement may provide an advantage over fixation without cement, despite similar outcomes. Bone cement can be part of the "tool box" for difficult distal radius fractures. Further study is necessary to define the technical advantages and limitations of each particular cement product.     

Treatments for acute and old distal radius fracture with lunate dislocation

Purpose

Our study was undertaken to determine the correct treatment protocol for distal radius fracture with lunate anterior dislocation.

Methods

From 2000 to 2007, 58 patients (36 with acute injury and 22 with old injury) with distal radius fracture with lunate anterior dislocation were enrolled in the study. Among acute injury patients, 15 were treated through manipulative reduction and plaster fixation and 21 were treated through minimal invasive poking reduction followed by Kirschner wire and plaster fixation. Among old injury patients, 8 underwent operative reduction of lunate dislocation through the palmar approach and Kirschner wire and plaster fixation, whereas 14 patients underwent operative reduction and fixation through the dorsal approach combined with reparation of the dorsal radiolunate ligament. Lidstrom wrist function scores and the morbidity of lunate necrosis and osteoarthritis were documented and evaluated.

Results

Lidstrom wrist function scores revealed that the rate of excellent and good scores was higher in acute injury patients than in old injury patients (91.7 versus 54.5%, respectively; P = 0.018). The lunate necrosis rate was lower in acute injury patients than in old injury patients (0 versus 27.2%, respectively; P = 0.027). For old injury patients, the lunate necrosis rate was higher in those treated with the palmar approach than in those treated with the dorsal approach (50 versus 14.3%, respectively; P = 0.033).

Conclusions

The key points for resolving distal radius fracture with lunate dislocation are prompt and precise diagnosis and treatment of lunate dislocation to prevent old lunate dislocation. We recommend that the surgical procedure is performed through the dorsal approach with reparation of the dorsal radiolunate ligament.     

AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases

Background

LCP extra-articular plate designed by AO has been used in extra-articular fractures of the distal humerus, mal-unions, and nonunions of the distal humerus. They provide anatomically shaped and angular stable fixation system for extra-articular fractures of the distal humerus. We extended the usage spectrum of this plate to the extra-articular with intra-articular distal humerus fractures and compared it with the standard orthogonal locking plate fixation.

Methods

We included 22 consecutive distal humerus intra-articular fractures with metaphyseal and diaphyseal extension into the study. Each case underwent osteosynthesis with LCP extra-articular plate fixation and augmented the intra-articular fragments with 4.0 mm partially threaded cancellous screws. The cost, surgical time, VAS, Modified Mayo Clinic Performance Index for elbow, and postoperative complications were recorded. The radiological union and postoperative elbow range of motion were assessed at 6 weeks, 6, and 12 months of follow-up. Twenty cases completed the scheduled follow-up. The results were compared with retrospective data of 20 cases from our institute where similar fractures were treated with standard orthogonal LCP distal humerus plate (LCPDHP).

Results

The radiological union rates and the range of motion at 6 weeks, 6, and 12 months in both the groups were comparable and did not vary significantly (p > 0.05). The cost and operative time with the LCP extra-articular plates were significantly less (p < 0.05) when compared to the group LCPDHP.

Conclusion

The usage spectrum of extra-articular distal humerus locking plate can be extended to intra-articular fractures. It provides good results and significantly reduces the cost and operative time.