Surgical Correction of Dorsally Angulated Distal Radius Malunions With Fixed Angle Volar Plating: A Case Series

Background Length of immobilization after operative fixation of unstable distal radius fractures and management in elderly patients is an area of debate. Purpose The purpose of this study is to delineate common practices of fellowship-trained hand surgeons and how they compare with current evidence-based protocols. Methods Surveys were distributed to American Society for Surgery of the Hand members on preferred methods of fixation, postoperative immobilization, and variations in treatment of elderly patients with unstable distal radius fractures. Responses were analyzed in comparison to a literature review. Subgroups were compared with regard to training, practice type, and years in practice. Results Four-hundred eighty-five surveys were analyzed. Volar fixed-angle plating was the most common choice of fixation (84.7%). Patients are most often immobilized for 1 to 2 weeks (40.0%) with range of motion (ROM) therapy begun most commonly between 1 and 4 weeks (47.2%). The majority of surgeons do not treat fractures differently in patients more than 65 years old. Physicians with more than 20 years of experience were significantly more likely to begin wrist ROM sooner with volar plating versus other fixation techniques compared with physicians with less than 20 years of experience (40.7% vs. 34.2%, respectively). Also, physicians in academic-only practices were more likely to immobilize patients for a shorter time after volar plating compared with those in privademics. Conclusion Volar fixed-angle plating is the dominant fixation method for unstable distal radius fractures among fellowship-trained hand surgeons. Elderly patients are not treated more conservatively and rigid immobilization after operative fixation remains the treatment of choice despite current evidence-based protocols.

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Reduced-dose computed tomography to detect dorsal screw protrusion after distal radius volar plating

F1000Research ◽

10.12688/f1000research.15056.1 ◽

2018 ◽

Vol 7 ◽

pp. 1428

Author(s):

Kevin J. Leffers ◽

John W. Kosty ◽

Glenn M. Garcia ◽

Daniel C Jupiter ◽

Ronald W. Lindsey ◽

...

Keyword(s):

Radiation Exposure ◽

Correlation Coefficient ◽

Distal Radius ◽

Standard Dose ◽

Dorsal Cortex ◽

Volar Plating ◽

Fixed Angle ◽

Reduced Dose ◽

Ct Protocol ◽

Screw Penetration

Background: Tenosynovitis and tendon rupture caused by screw penetration of the dorsal cortex are common complications after fixed-angle volar plating of a distal radius fracture. Detecting screw prominence with plain radiography is difficult due to the topography of the distal radius dorsal cortex. Computed tomography (CT) offers more detailed imaging of the bone topography, but is associated with radiation exposure. The present cadaveric study compared reduced-dose and standard-dose CT protocols in the detection of dorsal screw protrusion after fixed-angle volar plating of distal radius fracture. If found equivalent, a reduced-dose protocol could decrease the total radiation exposure to patients. Methods: Standard size distal radius volar locking plates were placed using a standard Henry approach in 3 matched pairs of cadaver wrists. A total of 3 distal locking screws were placed at 3 different lengths for a total of 3 rounds of CT scans per wrist pair. Each wrist pair was imaged by CT using standard-dose and reduced-dose protocols. Dorsal screw penetration was measured in each imaging protocol by 3 radiologists at two time periods to calculate inter- and intra-observer variability. Variability was calculated using the concordance correlation coefficient (CCC), intra-class correlation coefficient (ICC), and Pearson correlation coefficient (PCC). Bland-Altman plots were used and assessed 95% limits of agreement. Results: Intra- and inter-observer variabilities, either with the reduced-dose or standard-dose protocol, were >0.85. Pairwise CCC, ICC, and PCC were >0.91. In the comparison of reduced dose versus standard dose between radiologists, correlations were always >0.95. Conclusions: Comparison of a reduced-dose CT protocol and a standard-dose CT protocol for the detection of dorsal penetrating screws after fixed-angle volar plating showed >0.95 correlation in this cadaveric model. A reduced-dose CT protocol is equivalent to a standard dose CT protocol for orthopedic imaging and should reduce radiation exposure.

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Minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study

Annals of The Royal College of Surgeons of England ◽

10.1308/003588411x12851639107151 ◽

2011 ◽

Vol 93 (1) ◽

pp. 57-60 ◽

Cited By ~ 14

Author(s):

DC Perry ◽

DMG Machin ◽

JA Casaletto ◽

DJ Brown

Keyword(s):

High Risk ◽

Distal Radius ◽

Plate Fixation ◽

Tendon Injury ◽

Distal Radius Fractures ◽

Volar Plate ◽

Radius Fractures ◽

Extensor Pollicis Longus ◽

Fixed Angle ◽

Volar Plate Fixation

INTRODUCTION Rupture of extensor pollicis longus (EPL) tendon is a recognised complication following volar plate fixation of distal radius fractures, usually from attrition caused by prominent screws. We sought to identify the screw holes in some of the most commonly used plates which may precipitate tendon injury. SUBJECTS AND METHODS Three fixed-angle volar locking plates were sequentially positioned into 18 cadaveric arms. A wire was passed through each of the holes in the plates using a locking guide and the dorsal relationships noted. RESULTS Each plate had specific ‘high-risk’ holes which directed the wire towards the EPL groove. The central screw holes appeared mostly implicated in EPL injury. CONCLUSIONS Awareness of ‘high-risk’ holes and appropriate minor alterations in surgical technique may consequently decrease the incidence of EPL irritation and rupture.

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Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis

Hand ◽

10.1177/1558944721999733 ◽

2021 ◽

pp. 155894472199973

Author(s):

Nicholas Munaretto ◽

Adam Tagliero ◽

Raahil Patel ◽

Peter C. Rhee

Keyword(s):

Distal Radius Fracture ◽

Distal Radius ◽

Case Series ◽

Distal Radius Fractures ◽

Radius Fracture ◽

Functional Classification ◽

Radius Fractures ◽

Radiographic Outcomes ◽

Ipsilateral Hemiparesis

Background Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. Methods Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. Results There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. Conclusions Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

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145 Outcomes of Unstable Distal Radius Fractures – A Meta-Analysis of Bridging External Fixation Versus Volar Plating

British Journal of Surgery ◽

10.1093/bjs/znab135.012 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

J Mulrain ◽

K Joshi ◽

F Doyle ◽

A Abdulkarim

Keyword(s):

External Fixation ◽

Distal Radius ◽

Plate Fixation ◽

Meta Analysis ◽

Distal Radius Fractures ◽

Complication Rates ◽

Volar Plating ◽

Radius Fractures ◽

Increased Risk

Abstract Introduction Distal radius fractures are common and trends for fixation have changed with increased use of volar locking plates in recent time. A meta-analysis will summarise the best evidence for treatment. Method A systematic review was conducted using PRISMA methodology to identify studies that reported clinical and/or radiological outcomes in patients with AO type C distal radius fractures when treated with external fixation versus ORIF. Results 10 randomised trials were included in this review, reporting on 967 patients. Clinical outcomes are in favour of volar plating at 3 months post-operation, but no difference between the two groups is seen at 6 or 12 months. Analysis of complication rates shows a minute increase in risk-ratio for volar plating versus external fixation. Subgroup analysis showed significantly higher re-operations after plate fixation and significantly higher infection after external fixation. Conclusions Internal fixation of complex distal radius fractures confers an improved clinical outcome at early follow up only and a minimally increased risk of complications. The improved grip strength with volar plating is only superior at early follow up and no long-term superiority is seen with either intervention. The type of surgery in this injury type therefore remains at the surgeon’s consideration on a case-by-case basis.

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Assessment of penetration of dorsal screws after fixation of the distal radius using ultrasound: cadaveric study

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0045 ◽

2016 ◽

Vol 98 (2) ◽

pp. 138-142 ◽

Cited By ~ 4

Author(s):

D Williams ◽

J Singh ◽

N Heidari ◽

M Ahmad ◽

A Noorani ◽

...

Keyword(s):

Distal Radius ◽

Intraoperative Imaging ◽

Accurate Method ◽

Cadaveric Study ◽

Dorsal Cortex ◽

Volar Plating ◽

Specificity And Sensitivity ◽

Soft Tissue Impingement ◽

Screw Penetration ◽

Aids Diagnosis

Introduction Volar locking plates are used to treat unstable and displaced fractures of the distal radius. Potential advantages of stable anatomical reduction (eg early mobilisation) can be limited by penetration of dorsal screws, leading to synovitis and potential rupture of extensor tendons. Despite intraoperative imaging, penetration of dorsal screws continues to be a problem in volar plating of the distal radius. Ultrasound is a well recognised, readily available, diagnostic tool used to assess soft-tissue impingement by orthopaedic hardware. In this cadaveric study, we wished to ascertain the sensitivity and specificity of ultrasound for identification of protrusion of dorsal screws after volar plating of the distal radius. Methods Four adult, unpaired phenol-embalmed cadaveric distal radii were used. A VariAx™ Distal Radius Volar Locking Plate system (Stryker, Kalamazoo, MI, USA) was employed for instrumented fixation. A portable SIUI CTS 900 ultrasound machine (Providian Medical, Eastlake, OH, USA) was used to image the dorsal cortex to ascertain screw penetration. Results Specificity and sensitivity of ultrasound for detection of screw protrusion through the dorsal cortex was 100%. Conclusions Ultrasound was found to be a safe and accurate method for assessment of dorsal-screw penetration through the dorsal cortex of the radius after volar plating of the distal radius. It also aids diagnosis of associated tendon disorders (eg tenosynovitis) that might cause pain and limit wrist function.

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Classification and Management of Failed Fixation of the Volar Marginal Fragment in Distal Radius Fractures

Journal of Wrist Surgery ◽

10.1055/s-0041-1735885 ◽

2021 ◽

Author(s):

M. Carolina Orbay ◽

Jorge L. Orbay

Keyword(s):

Distal Radius ◽

Patient Characteristics ◽

Distal Radioulnar Joint ◽

Distal Radius Fractures ◽

Volar Plating ◽

Radius Fractures ◽

Fracture Patterns ◽

Loss Of Reduction ◽

Operative Fixation ◽

Specific Fracture

AbstractGreater understanding of specific fracture patterns following distal radius fractures has arisen with the advent of volar plating. The volar marginal fragment (VMF) is a small peripheral piece of bone which is critical to carpal stability. Failure to achieve good fixation of the VMF can result in volar subluxation of the carpus and distal radioulnar joint instability. Due to its small, distal nature, this fragment can be easily missed and difficult to fix. Loss of reduction of the VMF following operative fixation presents specific challenges and surgical considerations dictated by patient characteristics and timing. Our goal of this review is to present a classification system for these failed VMFs which can help guide surgical treatment as well as expected outcomes.

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