Assessment of instability factors in adult distal radius fractures

BACKGROUND: The purpose of this study was to evaluate the radiographic outcome of unstable distal radius fractures treated by closed reduction and sugar tong splinting and to quantitatively evaluate Lafontaines' criteria of instability. METHODS: Fifty patients with 3 or more instability factors as described by Lafontaine were treated by finger trap traction, closed reduction, and sugar-tong splinting. They were evaluated radiographically for initial angulation, radial inclination, radial length, and palmar tilt at the time of injury, after reduction, and 1 week, 2 weeks, and 4 weeks after reduction. The fracture either maintained an adequate reduction or failed to maintain an adequate reduction and showed secondary displacement based on specific criteria. RESULTS: At 4 weeks after reduction 46% of these unstable distal radius fractures maintained an adequate reduction. Of the 54% of fractures that failed to maintain an adequate reduction, age was the only statistically significant predictor of secondary displacement. After obtaining an acceptable initial closed reduction, patients 58 years of age were found to be at 50% risk for secondary displacement. The risk for displacement with an unacceptable radiographic result was found to increase with increasing age and decrease with decreasing age. CONCLUSION: In the closed management of these potentially unstable distal radius fractures, age was the only statistically significant risk factor in predicting secondary displacement and instability. These data help guide treatment by closed reduction and immobilization with serial x-rays or by surgical stabilization.     

Low-profile dorsal plating for dorsally angulated distal radius fractures

Dorsal plating emerged as an effective treatment for dorsally displaced distal radius fractures in the late 1980s. In addition to some mechanical advantages, this method provided a clear view of the articular surface and the ability to restore the anatomy. However, because of the frequent occurrence of extensor tendon complications in the early designs of dorsal plates, the volar approach gained favor for repairing these types of fractures. Recent improvements in dorsal plating designs have yielded increasingly thinner, precontoured plates with rounded edges and low-profile flush screw heads. These new plates have shown decreased rates of extensor tendon complications while retaining the advantages of the original dorsal approach. The authors have used this technique in more than 70 cases during a 4-year period. This article will review the history, indications, contraindications, technique, and rehabilitation for dorsal plating of dorsally angulated distal radius fractures.     

An evaluation of two scoring systems to predict instability in fractures of the distal radius

BACKGROUND: Various scoring scales have been introduced in the management of patients with multiple injuries and lower extremity injuries. Two scoring systems have been introduced to predict instability in distal radius fractures. The purpose of this investigation was to evaluate the accuracy of these two models in predicting instability. METHODS: A prospective study of 105 consecutive patients sustaining unilateral closed distal radius fractures was performed. Two scoring systems--the MacKenney formula and the Adolphson formula--were used to calculate the probability of fracture instability on the basis of initial presentation and injury films. The predicted probability of instability calculated from both models was then compared with actual results of instability on the basis of specific radiographic criteria at follow-up. RESULTS: Final follow-up information was available on 80 patients. There were 44 unstable fractures and 36 stable fractures at final follow-up. Using the MacKenney formula, of the 38 fractures predicted to have a low probability of instability (Pinstability < 30%), 18 (47.4%) were found to be unstable. Using the Adolphson formula, of the 28 fractures predicted to have a low probability of instability (Pstability > 70%), 14 (50%) were actually unstable. CONCLUSION: Both scoring systems were found to underestimate the degree of fracture instability and to have a negative predictive value between 47 and 50% in a prospective series of patients. In fractures predicted to have a low probability of instability in both models, we found a poor correlation between predicted instability and actual instability. Our results demonstrate the limitations of two scoring systems in predicting fracture stability and in making clinical decisions on the basis of their results.     

Essential radiographic evaluation for distal radius fractures

Fractures of the distal radius can be complex injuries, often generating multiple fragments with distortion of the normal anatomy in all three dimensions. Superficial assessment of the injury on the standard PA and lateral radiographs often can result in incomplete recognition of the injury pattern and a misdirected approach to treatment. In addition, failure to recognize subtle radiographic findings may result in the acceptance of a reduction that has significant residual incongruency and articular surface disruption.Standard radiographs of the distal radius can provide a wealth of information about the topography of the bone if the surgeon knows what to look for. The ability to recognize detailed landmarks and parameters on the radiographic images and convert this information into a three-dimensional visual image is a skill that requires education and training. As more aggressive treatments have emerged for anatomic restoration of the bony and articular anatomy, accurate identification of the pattern of injury has become essential. Parameters such as the tear drop angle, AP distance, and articular separation have been recognized only recently. Because these parameters reflect the congruency of the articular surface,it would be natural to assume that postreduction films in which these parameters are abnormal would compromise clinical outcome. Because nearly all historical studies do not include routine evaluation of these parameters, knowledge of radiographic correlation with clinical outcome is still incomplete. At the same time, previous studies to assess outcome of distal radius fractures may be compromised by the failure to recognize residual deformity and articular incongruency that would have been evident with measurement of these parameters.With careful understanding of the radiographic landmarks, radiographic parameters, and patterns of injury, the surgeon can visualize a more accurate picture of the fracture itself and the reduction. As a result, treatment decisions for distal radius fractures can be based on a more thorough understanding of the anatomy of the injury, and future grading of radiographic results may reflect more accurately the precision of the articular restoration.     

Volar collapse after dorsal plating of comminuted distal radius fractures

Between 1997 and 2001, 58 patients received dorsal plating for comminuted distal radius fractures. In 8 of these patients, subsequent collapse led to palmar flexion deformity, loss of rotation, and hardware prominence. In retrospectively reviewing this subgroup's range of motion, radiographic volar tilt, and complications, including tenosynovitis and extensor tendon rupture, we found that (1) with both palmar and dorsal comminution of distal radius fractures, dorsal plating may not prevent palmar cortex collapse; (2) deformity of the distal radius fragment causes palmar displacement of the radius relative to the intact ulna; (3) resultant incongruity at the distal radioulnar joint causes a significant loss of supination; and (4) palmar distal radius displacement leads to dorsal hardware prominence and may contribute to tenosynovitis and attritional extensor tendon ruptures.     

Intra-articular distal radius fractures involving the distal radioulnar joint (DRUJ): three dimensional computed tomography-based classification

Purpose

The purpose of this study was to analyze fracture patterns and the magnitude of displacement in the distal radioulnar joint (DRUJ), by three-dimensional (3D) computed tomography (CT), for distal radius fractures with intra-articular displacement of the radiocarpal joint.

Methods

We reconstructed 3D images for 72 consecutive patients with displaced intra-articular distal radius fracture on the basis of fine-cut axial CT data. The fracture patterns involving the DRUJ were classified on the basis of the location and direction of fracture lines, and the extent of fracture comminution. We measured the maximum spatial distance of the gap and the step between the fragments in each 3D image, and the magnitudes of displacement between the groups were compared by analysis of variance followed by post-hoc analysis by use of Tukey’s test.

Results

Sixty wrists had a fracture involving the DRUJ. We classified the 60 wrists into 3 types of fracture pattern. Type 1 was a transverse fracture with minimum displacement. Type 2, in which fracture lines extended into the distal margin of the sigmoid notch, was the most common longitudinal fracture. Type 3 was a fracture with multiple fragments. The step and gap in Type 3 was significantly larger than that in the other types.

Conclusions

Eighty-three percent of intra-articular distal radius fractures had DRUJ involvement, and 28 % of the wrists had multiple fragments. For Type 3 fractures with dorsal or proximal comminution displacement was significantly larger than for simple Type 1 and 2 fractures. Surgical intervention for the DRUJ fragment may be beneficial when there is remarkable intra-articular displacement.     

Midcarpal instability caused by malunited fractures of the distal radius

Thirteen patients with malunited fractures of the distal radius developed symptoms of pain and instability of the midcarpal joint. In six cases, a recurrent voluntary midcarpal subluxation was also present during ulnar deviation. These symptoms were first noticed several weeks, and at times several months, after all immobilization for the treatment of the original fracture had been discontinued. We believe that the loss of the normal palmar tilt of the distal articular surface of the radius prepositions the carpus in a dorsal collapse alignment, which enables this instability to develop. Although the instability is localized to the midcarpus , it is treated best, in our opinion, by a corrective osteotomy of the distal radius. In nine patients, osteotomies resulted in relief of preoperative symptoms and correction of midcarpal instability. In one patient, osteotomy of the radius was deemed unnecessary because the loss of palmar tilt of the radius was minimal. Instead the midcarpal ( triquetrohamate ) joint was stabilized by ligament reconstruction. Only transient correction was obtained, with later recurrence of the voluntary midcarpal subluxation.     

Intraoperative evaluation of dorsal screw prominence after polyaxial volar plate fixation of distal radius fractures utilizing the Hoya view: a cadaveric study

Background

The irregular nature of the dorsal surface of the distal radius makes it difficult to detect prominent screws with volar plate fixation for distal radius fractures using standard fluoroscopic images. This study evaluates the accuracy of a new radiographic method, the Hoya view, for the assessment of dorsal cortical screw penetration with volar plate fixation.

Methods

Eight cadaveric upper extremities underwent application of a volar distal radius plate with polyaxial locking screws placed distally. Utilizing a mini C-arm, lateral and Hoya views were obtained with notation of any dorsal cortical screw prominence. Dissection of the cadavers was then performed for direct visualization of screw prominence. The screws were then exchanged sequentially for screws 2-mm longer than their initial measurements with repeated imaging and direct visualization.

Results

The Hoya view revealed that 9.4 % of the screws penetrated the dorsal cortex with an average screw prominence of 1.08 mm (range 0.5–2 mm). None of the six prominent screws were detected with lateral views. With the Hoya view, six of six prominent screws were identified. With locking screws exchanged for screws 2-mm longer, 76.6 % of the screws had violated the dorsal cortex; of these, 24.5 % were detected with lateral imaging versus 100 % with the Hoya view.

Conclusions

This study supports the intraoperative use of the Hoya view to evaluate screw length and dorsal cortical screw penetration in volar plate fixation of distal radius fractures. However, this view may be difficult to obtain in patients with limitations in elbow or shoulder range of motion.     

DVR解剖型锁定钢板治疗陈旧性桡骨远端骨折的评价

[目的]评估解剖型桡骨远端掌侧锁定接骨板系统(DVR system)在陈旧性桡骨远端骨折中的应用及其治疗效果。[方法]自2012年6月至2015年2月收治陈旧性桡骨远端骨折38例,其中男27例,女11例,年龄29~68岁,平均51.21岁。所有病例术前均行三维CT重建评估骨折情况。原始骨折根据AO分型标准,A2型3例;A3型6例;B1型6例;B2型8例;B3型5例;C1型4例;C2型4例;C3型2例。所有桡骨远端骨折均寻原骨折线复位或截骨矫正畸形,其中单纯掌侧入路DVR固定31例;掌、背联合入路掌侧DVR固定7例;尺骨远端骨折钢板固定2例,克氏针固定3例;桡尺远侧关节克氏针固定3例。18例骨缺损采用自体骨移植。[结果]术后伤口均一期愈合,无伤口感染发生。术后随访18~36个月,平均27.83个月,所有骨折均在6个月内愈合,其中解剖复位30例。本组患者术后第6个月和第18个月时的PRWE平均分数分别为22.9和18.6。手术合并症主要包括:螺钉过长穿入伸肌间隔2例;骨折复位丢失2例;创伤性关节炎4例;尺骨撞击综合征1例。[结论]采用DVR系统手术治疗是矫正移位明显、畸形严重的陈旧性桡骨远端骨折的有效方法。     

Contemporary evaluation and treatment of distal radius fractures

Distal radius fractures are among the most common fractures encountered by orthopedic surgeons. Because of many fracture patterns and types, it has been difficult to develop a comprehensive classification. Treatment options vary depending on injury severity and stability of the fracture reduction. Closed reduction and immobilization can be used for stable fractures. Common surgeries include pinning with and without external fixation and open reduction and internal fixation. Technological advances such as locking and fixed angle plates have made the volar approach feasible. Dorsal plating with low profile plates and fragment-specific techniques can be successful in treating distal radius fractures. Following fracture reduction and stabilization, assessment of distal radioulnar joint stability is essential and must be stabilized when necessary.     

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.     

Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.     

Displaced distal radius fractures

Summary A comparison of the radiographical and functional results after displaced distal radius fractures in 41 patients treated by external fixation (EF), 36 patients treated by functional bracing in supination (FUSU), and 49 patients treated by dorsal plaster immobilization (DPI) was performed. The rate of initial complications after EF was 53%, compared with 22% after FUSU and 14% after DPI. The radiographical result after EF was significantly better than after nonoperative treatment, but the functional result after 3 and 6 months demonstrated no significant difference between the three series. Consequently, EF and FUSU do not restore wrist function faster than conventional plaster treatment (DPI), but EF improves the radiographical result, though the rate of complications is higher.     

桡骨远端不稳定骨折掌侧或背侧内固定的选择

目的 探讨T型钢板在治疗桡骨远端不稳定骨折中的应用及对治疗效果的影响。方法 根据桡骨远端不稳定骨折的特点,就不同类型骨折分别采用T型钢板掌侧或背侧固定,对于骨皮质破坏较严重,支撑不满意的病例,通过植入人工骨或自体骨来恢复局部的稳定性。结果 本组64例病例,经手术复位,纠正畸形满意,术后2～3d开始指导下的功能训练。平均随访时间29．63个月,总体优良率达90．77％。其中,55侧行掌侧固定(其中30侧为桡骨远端骨折向背侧移位),优良率达92．72％;伤后6周以上陈旧骨折或损伤情况估计从掌侧入路有困难的患者,采用背侧入路钢板固定,优良率为77．77％。结论 桡骨远端骨折向掌侧移位的病例,掌侧入路是理想的方式,对于向背侧移位的病例(Colles骨折),同样也具有良好的手术效果。桡骨远端掌侧切口治疗桡骨远端不稳定骨折具有：骨床平坦,易操作,符合张力带原则,软组织破坏相对较少,维持背侧软组织合页的完整性,植骨不易外漏等优点。掌侧入路钢板固定对于桡骨远端不稳定骨折的治疗效果是满意的,特别是对新鲜骨折;陈旧骨折在6周以内有条件仍可从掌侧入路,并疗效满意。背侧入路钢板固定,治疗效果稍差,背侧截骨后植骨的患者,对功能恢复有一定影响。     

Palmar locking plate for treatment of unstable dorsal dislocated distal radius fractures

Introduction This study investigates the clinical and radiological results of open reduction and internal fixation of unstable distal radial fractures using a palmar placed interlocking plate system with no substitutes for treatment of the dorsal metaphyseal fracture void.Materials and methods Nineteen patients with a mean age of 61 years (range 49–78 years) and a dorsally displaced distal radial fracture were treated using a palmar placed 2.4 mm interlocking plate system. All 17 women and 2 men were followed up according to the study protocol. Standardised radiographs in anteroposterior and lateral projection were performed before reduction and at 2, 6, 12 and 24 weeks after surgery. Radiological measurements included palmar tilt, radial inclination and radial shortening as defined by ulnar variance and intra-articular steps. Clinical assessment included active range of motion (ARM) of the wrist, pain according to a visual analogue scale (VAS), grip power, working ability, Disability of Arm, Shoulder and Hand-Score (DASH Score) and Mayo Wrist Score.Results At final follow-up after a minimum of 11 months, the palmar tilt was +1°, radial inclination 19.8° and ulnar variance 1.0 mm. Mean loss of palmar tilt measured 1.9°, radial inclination 1.3° and ulnar variance 0.4 mm. Mean wrist extension measured 58°, wrist flexion 41°, pronation 83° and supination 84°. The Mayo Wrist Score showed 21% excellent, 58% good, 16% fair and 5% poor results.Conclusion The treatment of unstable, dorsally dislocated, distal radius fractures AO types A3, C1 and C2, with a palmar placed 2.4 mm interlocking plate system and without additional treatment of the metaphyseal defects showed good radiological and functional results with minimal loss of reduction.