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"Sandwich" plating for intra-articular distal radius fractures with volar and dorsal metaphyseal comminution.

ABSTRACT: INTRODUCTION: Intra-articular distal radius fractures with volar and dorsal comminution present a special challenge to the hand surgeon. METHODS: Ten patients formed the study cohort. All plates were low profile and stainless steel. Radiographic parameters, range of motion, and strength compared to the uninjured side were recorded. Functional outcome was evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Gartland and Werley scoring system. RESULTS: Median age at surgery was 58 years (range, 24 to 86). Mean follow-up was 17 months (range, 12 to 28). According to the AO classification system, there were three type C2 and seven type C3 fractures. Median preoperative dorsal angulation was 24 deg; median postoperative dorsal angulation was 3 deg. Eighty percent (8) of the fractures also had an intra-articular step-off or gap, all of which were corrected to neutral by the procedure. Compared with the contralateral side, mean extension and flexion were 73 and 75%, respectively, pronation and supination were 95 and 88%, respectively, and grip strength and thumb pinch were 72 and 87%, respectively. Mean postoperative DASH score was 16 points, and 70% (7) of the patients had Gartland and Werley scores of good or excellent. None of the patients needed to have their plates removed, and no extensor tendon rupture was reported. CONCLUSIONS: The "sandwich" plating technique is an effective method of regaining near-anatomic reconstruction of intra-articular, volarly and dorsally comminuted distal radius fractures. Results from this study demonstrate that patients can expect to regain about 80% of their range of motion and strength. Moreover, 70% of the patients will have good to excellent functional outcomes. This is the first study to examine range of motion and functional outcome of low-profile "sandwich" plating without plate removal.

SUBMITTER: Day CS

PROVIDER: S-EPMC2528974 | biostudies-other | 2008 Mar

REPOSITORIES: biostudies-other

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Project description:BackgroundThe most commonly used approach for distal radius fractures is the traditional Henry approach. However, it requires an intraoperative incision of the pronator quadratus (PQ) muscle, which results in a series of complications if the repair of the PQ fails.AimThe objective of this study was to investigate the efficacy of sparing the pronator quadratus for volar plating of the distal radius fractures.MethodsSeventy-six patients who suffered from distal radius fractures of types 23-B, 23-C1, and 23-C2 as per the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification were treated with volar locking plate fixation using either the PQ muscle incision and repair (group A, n = 39) or the PQ muscle preservation approach (group B, n = 37). Intraoperative index, postoperative efficacy and complications of patients were recorded and evaluated.ResultsAll patients were followed up for more than one year after surgery. All fractures achieved union. There were significant differences in mean operative time, mean intraoperative blood loss, and mean fracture healing time between the two groups. Still, there were no significant differences in limb function scores between the two groups at the 12-month postoperative follow-up. Outcomes assessed at 1 week, 1 month, and 3 months after surgery demonstrated significant differences in the mean range of motion and pain-related visual analog scale (VAS) between the two groups. As the range of motion and grip strength increased, the VAS scores decreased, and there was no significant difference between the two groups at 12 months postoperatively. Although tendon irritation and delayed carpal tunnel syndrome were more common in group A than in group B (7.6% vs. 0% and 5.1% vs. 0%, respectively), the differences were not statistically significant.ConclusionThe modified Henry approach with sparing pronator quadratus muscle has no significant advantage in the range of wrist motion and upper limb function in the late stage. Nevertheless, the intraoperative placement of the plate under the pronator quadratus muscle can shorten the operation time, reduce intraoperative bleeding, reduce early postoperative pain, promote early activity, and improve the patient's quality of life. It is recommended that the pronator be preserved at the time of surgery.

Project description:BACKGROUND:Distal radius fracture (DRF) is the most common upper extremity fracture that requires surgery. Operative treatment with a volar locking plate has proved to be the treatment of choice for unstable fractures. However, no consensus has been reached about the benefits of pronator quadratus (PQ) repair after volar plate fixation of DRF in terms of patient-reported outcome measures, pronation strength, and wrist mobility. METHODS:We searched the PubMed, Embase, Cochrane Central, and China National Knowledge Infrastructure (CNKI) databases up to March 13, 2020, and included randomized-controlled, non-randomized controlled, or case-control cohort studies that compared cases with and without PQ repair after volar plate fixation of DRF. We used a random-effects model to pool effect sizes, which were expressed as standardized mean differences (SMDs) and 95% confidence intervals. The primary outcomes included Disabilities of the Arm, Shoulder, and Hand scores and pronation strength. The secondary outcomes included the SMDs in pain scale score, wrist mobility, and grip strength. The outcomes measured were assessed for publication bias by using a funnel plot and the Egger regression test. RESULTS:Five randomized controlled studies and six retrospective case-control studies were included in the meta-analysis. We found no significant difference in primary and secondary outcomes at a minimum of 6-month follow-up. In a subgroup analysis, the pronation strength in the PQ repair group for AO type B DRFs (SMD = - 0.94; 95% CI, - 1.54 to - 0.34; p < 0.01) favored PQ repair, whereas that in the PQ repair group for non-AO type B DRFs (SMD = 0.39; 95% CI, 0.07-0.70; p = 0.02) favored no PQ repair. DISCUSSION:We found no functional benefit of PQ repair after volar plate fixation of DRF on the basis of the present evidence. However, PQ muscle repair showed different effects on pronation strength in different groups of DRFs. Future studies are needed to confirm the relationship between PQ repair and pronation strength among different patterns of DRF. REGISTRATION:This study was registered in the PROSPERO registry under registration ID No. CRD42020188343 . LEVEL OF EVIDENCE:Therapeutic III.

Project description:BackgroundThe surgical technique of radius distraction for stabilization of distal radioulnar joint (DRUJ) if intraoperative DRUJ instability was found after the fixation of distal radius fracture has been previously described, but this surgical technique lacks clinical and radiographic effect in minimal 3 years follow-up. We therefore evaluated the clinical outcome and radiographic results of radius distraction in minimal 3 years follow-up as long-term evaluation.MethodsWe reviewed the case series of distal radius fracture with concomitant DRUJ instability receiving radius distraction from the senior author over a 5-year period (January 1st, 2013, to June 30th, 2017) retrospectively. Radius distraction during volar plating was performed by moving the volar plate distally via compression screw loosening/fastening to achieve firm endpoint on the dorsopalmar stress test. The evaluations of radiographic, including bone union time and ulnar variance, and clinical outcomes, including grading of DRUJ instability, NRS of wrist pain, DASH score, MMWS score, and range of motion of operated wrist at final follow-up, were performed at clinic as minimum 3-year follow-up; a total 34 patients had been evaluated.ResultsAt minimal post-operative 36 months follow-up, all cases demonstrated acceptable wrist range of motion with stable DRUJs, low NRS of wrist pain (0.6, SD 0.7), and satisfactory DASH score (mean 9.1, SD 6.2) and MMWS score (mean 87, SD 10). There were no cases suffering from nonunion of distal radius. The mean ulnar variance of injured wrist and uninjured wrist were -1.2 mm and 0.2 mm, respectively (SD 1.0 and 0.6) with significant statistical difference.ConclusionsRadius distraction during volar fixation of distal radius fracture should be considered if DRUJ instability was found by the dorsopalmar stress test intraoperatively, and the long-term DRUJ stability could be achieved by maintenance of normal-to-negative ulnar variance, with decreased wrist pain and satisfactory function outcome.Level of evidenceTherapeutic Level IV.

Project description:INTRODUCTION: Extensor tendon irritation and attritional tendon ruptures are potentially serious complications after open reduction and internal fixation of distal radius fractures. These complications are well recognized after dorsal plating of distal radii; and these are now being reported after errant screw placement during volar fixed-angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken before completion of the operative procedure. The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and to compare pronation and supination fluoroscopic images with standard lateral images in demonstrating dorsal screw prominence during volar locked plating. METHODS: Eight fresh-frozen human cadaveric upper extremities underwent fixation with a volar, fixed-angle distal radius locked plate (Wright Medical Technology, Arlington, TN). Three fluoroscopic views (lateral, supinated, and pronated) followed by dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Subsequently, screws measuring 2, 4, 6, 8, and 10(mm longer than the measured depths were sequentially inserted into each distal locking screw, with each image deemed either "in" (completely inside the bone) or "out" (prominent screw tip dorsally-would typically be exchanged for a shorter screw intraoperatively). RESULTS: The radial most distal locking screw (position 1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was: 6.5(mm for lateral views and 2(mm for supinated views. Pronated views did not identify prominent screws. Screws occupying plate position 2 consistently entered Lister's tubercle, with 5/8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were: 2.75(mm-lateral views and 3.0(mm-supinated views. Although the screws entered the second dorsal compartment, they did not encroach upon either of the tendons. Screws occupying plate position 3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the Ulan base of Lister's tubercle. The average screw prominences for radiographic detection were: 3.5(mm-lateral views and 2.5(mm-pronated views. Supinated views did not identify prominent hardware. Screws occupying plate position 4 all violated the IV dorsal extensor compartment-2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were: 4.0(mm-lateral views and 2.5(mm-pronated views. The supinated views did not identify prominent screws. CONCLUSIONS: Volar fixed-angle plating has shown great promise in the advancement of distal radius fracture management. We have seen in our referral practices and in the literature an increase in the number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard PA and lateral radiographs cannot adequately visualize screw position and length secondary to the complex geometry of the dorsal cortex. We believe this study supports the routine application of intraoperative, oblique pronosupination fluoroscopic imaging for enhanced confirmation of distal locking screw position and length.

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"Sandwich" plating for intra-articular distal radius fractures with volar and dorsal metaphyseal comminution.

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