- Email: [email protected]
Radiological results of surgical management of fracture of the distal radius treated with volar locking plates
ARTICLE IN PRESS
JID: JINJ
[m5G;February 26, 2020;13:19]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Radiological results of surgical management of fracture of the distal radius treated with volar locking plates ✩ I. García-Cepeda, I. Aguado-Maestro∗, I. De Blas-Sanz, A. Quintanilla-García, M. García-Alonso Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
a r t i c l e
i n f o
Article history: Accepted 19 February 2020 Available online xxx Keywords: Distal radius fracture Volar locking plate ORIF Radiological outcomes
a b s t r a c t Objectives: Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high. The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate. Methods: We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010–2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions. Results: A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1–83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0 0 01). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001). ROM was: flexion 63° [0–90°; 19.73], extension 57.67° [5–90°; 21.61], pronation 78.94° [40–90°] and supination 81.76° [38–90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = −0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007). Conclusion: Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population. Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes. © 2020 Elsevier Ltd. All rights reserved.
Introduction ✩
Disclosure: This paper is part of a Supplement supported by The Orthopaedic Surgery and Traumatology Spanish Society (SECOT). ∗ Corresponding author. E-mail address: [email protected] (I. Aguado-Maestro).
Distal radius fracture (DRF) is the most common upper extremity fracture, involving 10–25% of all fractures [1]. Due to the increase in life expectancy and the relationship between DRF and osteoporosis [2]. the incidence of these fractures is increasing
https://doi.org/10.1016/j.injury.2020.02.106 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ 2
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
constantly. DRF are the result of different causes depending on the age of the patient: they are usually a consequence of high energy injuries in the young, while they are secondary to low energy trauma in the elderly. [3]. Casting, percutaneous pinning, external fixation, or internal fixation can be the treatment of DRF. Closed reduction and cast application have been used for a long time as the main treatment, but the results are often poor with malunion or fracture collapse [4]. Pinning and external fixation allow the preservation of fracture reduction but are often related to pin site infections [5]. Internal fixation with a volar locking plate has become popular because it improves stability and grants early mobilization [6,7]. Volar approach of distal radius allows to ensure the anatomic reduction of distal radius while applying an angular stable implant with subchondral locking screws. This approach avoids dorsal dissection and its associated devascularization of dorsal fragments and decreases the complications regarding extensor tendons due to dorsal plates [6,8,9]. Many studies report that a better anatomical reduction of a DRF is related with a better functional outcome [10–14]. According to the guidelines, radiographic measurements of radial shortening, ulnar variance, dorsal/volar tilt, radial inclination and articular step off of the distal radius, are used by orthopaedic surgeons to choose the treatment for each DRF [15]. Radiographic criteria have been established to define an acceptable alignment and include: less than 3 mm of radial shortening, intraarticular step-off lower than 2 mm, a radial inclination above 10 degrees and a volar tilt between 10 degrees dorsal to 20 degrees volar [16,17]. A step-off of more than 2 mm or a dorsal tilt above 20° increase the probability of post-traumatic osteoarthritis [18–20]. However, while in young patients there is a strong association between functional outcomes and fracture reduction, in elderly patients this association remains controversial [21,22]. It is important to customize the recommendations for surgery, because malunion in many elderly patients does not necessarily correlate to poor functional results. Many reports show up to 39% complication rates in volar stabilized DRF [23,24]. These complications are mainly: hardware malfunction, infection, changes in sensitivity, tendon irritation and rupture, complex regional pain syndrome (CRPS), nonunion and osteoarthritis. Objectives To assess functional and radiological results of all distal radius fractures treated with open reduction and internal fixation with a volar locking plate. The aim of the study includes the comparison of the functional results (based on range of motion), surgery timing, fracture/patient characteristics and postoperative radiological parameters. Materials and methods Following institutional board approval, we conducted a retrospective longitudinal study in which we collected data from the clinical records of all the patients admitted in our institution during a period of eight years (January 2010–June 2018) with a diagnosis of fracture of the distal radius. Inclusion criteria included patients above 18 years old with a diagnosis of a fracture of the distal third of the radius treated with open reduction and internal fixation through a volar approach and a minimum follow up of 12 weeks. Criteria for surgery in our institution included the following fracture characteristics after a closed reduction and cast immobilization: >10° dorsal tilt, >3 mm radial shortening, >2 mm intra-articular displacement, <7° radial inclination. Exclusion criteria included loss to follow up, open fractures,
additional injuries in the ipsilateral upper extremity and stabilization with additional fixation methods such as K-wires or external fixators. Patients undergoing arthroscopy or anything but a single volar approach were also excluded. Surgery was performed in decubitus supine position with the arm abducted in extension on a surgical table under a C-arm fluoroscopic assistance and a pneumatic arm tourniquet. Regional anesthesia was used in all cases through an axillary or interscalenic block. Open reduction was done through a volar Henry approach. Reduction was assessed under fluoroscopic imaging and maintained with provisional K-wires. Definitive osteosynthesis was made with one of the following volar plates according to surgeon preferences: Variable Angle LCP Two-Column Volar Distal Radius Plate® (DePuy-Synthes, Synthes GmbH, Oberdorf, Switzerland), Variable Angle LCP Volar Rim Distal Radius Plate® (DePuy-Synthes, Synthes GmbH, Oberdorf, Switzerland), Acu-Loc 2 VDR® (Acumed LLC, Hillsboro, Oregon, USA), DVR® Crosslock plate (Biomet Orthopedics, Warsaw, Indiana, USA). A splint was used until staples/suture removal (approximately 2 weeks). Follow up protocol included visits and X-Rays 1 week postop, 4 weeks, and then every month until fracture union. Rehabilitation consultations were requested according to the surgeon criteria based on the patient needs. Data was collected from the digital clinical records and included variables such as: patient demographics, fracture characteristics (mechanism/cause of production, AO Classification [25]), time from the fracture event until surgery, surgery time, type of plate used, radiological parameters (such as radial inclination, palmar tilt, ulnar variance, depth of intra-articular step-off), range of motion (ROM), complications and need for reinterventions. For analysis purposes, radiological parameters were classified according to Sarmiento’s modification of Lidström criteria [26,27]. and calculating a punctuation based on the classification giving 3 points when “excellent”, 2 points when “good”, 1 point when “fair” and 0 points if “bad”, creating a new variable called quality score of reduction according to Sarmiento, being “excellent” when 9 points were obtained, “good” when 6–8 points, “fair” if 4–5 and “bad” if 3 or less. Variables were included in a Microsoft Excel spreadsheet (Microsoft® Excel for Mac, version 16, Microsoft Corporation, Redmond, Washington, USA). Statistical analysis was performed with IBM SPSS Statistics version 21 (SPSS inc., Chicago, Illinois, USA) for Mac®. Parametric and non-parametric tests were used as appropriate. Results were considered significant for p < 0.05. Results A total of 170 patients (63.5% female) met the inclusion criteria and were selected for the analysis. The mean age was 55.9 years [Range: 24.1–83.7; Standard Deviation (SD): 13.76]. 44.7% of the patients were 60 years old or above. 143 (84.1%) fractures were produced by low energy trauma, whereas 27 (15.9%) were caused by high energy trauma such as traffic accidents or sport injuries. High energy injuries were more frequent in younger patients (25.56% vs 3.95% p < 0.0 0 01). Fractures were classified according to AO classification and included 40 (23.5%) extraarticular fractures (2R3A), 41 (24.1%) partial articular fractures (2R3B) and 89 (52.4%) complete articular fractures (2R3C). A full categorization in the AO classification is shown in Table 1. The average time from the fracture event until surgery was 8.5 days [0–28 days; 9.74]. This time was longer in extraarticular fractures (AO-2R3A: 12.22 days) than in intraarticular fractures (AO2R3B: 7.97 days and 2R3C: 7.04 days) p = 0.018. Open reduction and internal fixation was performed on a mean time of 86.72 min [45–134 min; 18.85] and the plates used for the fixation were: LCP Volar Rim Plate (5 cases, 2.9%), LCP Two-Column Plate (107 cases, 62.9%), Acu-Loc 2 (50 cases, 29.4%) and DVR Crossloc (8 cases,
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
ARTICLE IN PRESS
JID: JINJ
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
3
Table 1 AO Classification of the fractures. Type
Group
2R3A 2R3A1 2R3A2 2R3A3 2R3B 2R3B1 2R3B2 2R3B3 2R3C 2R3C1 2R3C2 2R3C3
N 40 (23.5%) 1 (0.6%) 7 (4.1%) 32 (18.8%) 41 (24.1%) 1 (0.6%) 4 (2.4%) 36 (21.2%) 89 (52.4%) 21 (12.4%) 34 (20%) 34 (20%)
4.7%). Longer surgery times were needed for high energy fractures (85.27 vs 94.33 min, p = 0.02) and AO type 2R3C fractures (AO2R3A: 82.75 min; AO-2R3C: 89.99 min; p = 0.047). 3 surgeons performed 53% of the surgeries (more than 25 each), being the rest performed by other surgeons in the unit of trauma surgery (less than 10 fractures per surgeon). We could not find any statistical differences in the outcomes of either of the groups, although we noticed a non-significant (p = 0.08) difference in the radiological step-off (0.70 mm in the less experienced group and 0.43 mm in the more experienced). Fracture union was achieved in all cases. Radiological parameters and their classification according to Sarmiento’s modification of Lidström criteria are shown in Table 2. For statistical purposes, we calculated a punctuation based on this classification as described in materials and methods, being the mean quality score of 7.11 points out of 9 [2–9 points; 0.89]. We compared the relationship between the quality of reduction score and the AO fracture type and found poorer results in fractures AO-2R3C (AO-2R3A: 7.4 points; AO-2R3B: 7.41 points; AO-2R3C: 6.84 points; p = 0.025). We analyzed the radiological outcomes observed in patients above and below 60 years old and found that younger patients had better results regarding radial inclination (excellent results in 85.1% vs 59.21%, good results in 12.76% vs 26%, fair results in 0.1% vs 10.52%, poor results in 0.1% vs 3.9%; p = 0.001) and radial shortening (ulnar variance) (excellent results in 100% vs 88.15%; p = 0.001). Regarding range of motion (ROM), 153 patients (90%) made rehabilitation within the hospital facilities, whereas 17 (10%) didn’t need consultation with this department. At the end of the follow up (mean: 6.82 months; range: 2.8–34.1; SD: 5.19) there was a mean flexion of 63° [0–90°; 19.73], extension 57.67° [5–90°; 21.61], pronation 78.94° [40–90°] and supination 81.76° [38–90°; 8.87]. We found a weak correlation between radial shortening and the range of motion in flexion-extension (r = 0.218; p = 0.001) and again with the articular step-off (r = −0.269; p = 0.002). These results are shown in Fig. 1. No differences were found between time until surgery and ROM. We found a total of 39 complications in 36 patients (21.18%): complex regional pain syndrome (CRPS: 11 cases, 6.5%); intraarticular screw penetration (10 cases, 5.9%); tendinous rupture (5 cases; 2.9%; being in 3 patients a rupture of the extensor pollicis longus and in 2 patients a rupture of the extensor digitorum of the 2nd finger); painful or hypertrophic scar (5 cases, 2.9%); carpal tunnel syndrome (3 cases, 1.8%); painful ulnar impingement (2 cases, 1.2%); pain related to osteosynthesis hardware (1 case, 0.6%); stiffness (1 case, 0.6%) and ulnar nerve compression (1 case, 0.6%). These complications weren’t related to the experience of the surgeon, type of fracture, energy of the traumatism, time until surgery, type of implant, surgical time or radiological reduction. However, although not statistically significant we observed a
Fig. 1. Relationship between Range of Motion (ROM) in flexo-extension measured in degrees and radial shortening (according to Sarmiento’s modification of Lidström criteria: excellent: <3 mm; good: 3–6 mm; fair: 7–11 mm; poor: >12 mm) and articular step-off (excellent: 0 mm; good: 0.1–1 mm; fair 1.1–2 mm or less; poor: 2.1–3 mm).
higher complication rate in more complex articular fractures. (AO2R3A: 15%; AO-2R3B: 17.1%; 2R3C: 25.8%; p = 0.288). Up to 10.6% (18 cases) of the patients needed a new surgery, being the procedures performed: hardware removal (11 cases, 6.5%), tendinous disruptions repairs or transfers (4 cases, 2.4%), neurolysis (2 cases, 1.2%) and new osteosynthesis (1 case, 0.6%). We noticed that the need of reintervention was associated to the type of fracture (need for re-operation: AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and the energy of the injury (low energy mechanism: 8.4%; high energy mechanism: 22.2%; p = 0.044). We couldn’t observe any relationship with any radiological measurement. Younger patients had a higher incidence of reintervention (14.9% vs 5.3%; p = 0.042). When we adjusted the results by age, and type of fracture, AO type 2R3C fractures had an odds ratio for reintervention of 3.866 (IC95% 1.18–12.63). Patients undergoing reintervention had worse functional outcomes with a decreased range of motion in flexion-extension (94.44° vs 123.83°, p = 0.007). Discussion Longer life expectancy has led to an increase in the incidence of distal radius fractures. Their treatment includes a wide variety of options from closed reduction and cast application to open reduction and internal fixation. According to Lafontaine there are five circumstances that increase the rate of secondary displacement after closed reduction [28]. These predictors of instability are: a dorsal angulation greater than 20°, intraarticular fractures, associated ulna fractures, dorsal metaphyseal comminution and age above 60 years old. However, other authors consider that the only significant risk factor for failure of closed treatment is age [29]. Despite these findings, multiple studies have suggested that clinical outcomes are not correlated with radiographic results in elderly patients [30–32]. Closed reduction and cast application has historically been the main treatment for DRF, but high incidence of malunion [4] has limited its indications to stable fractures [33]. Percutaneous fixation with kirschner wires is a good treatment for extraarticular fractures [34] but provide limited stability requiring further immobilization which may result in high rates of complications [5]. Open reduction and internal fixation restore the anatomy of the wrist and favors a faster rehabilitation with good clinical results [35]. Volar approach allows an anatomic reduction in cases with severe comminution or osteoporotic bone maintaining a correct radius length [36]. This approach avoids dorsal dissection and the
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
ARTICLE IN PRESS
JID: JINJ 4
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx Table 2 Radiological measurements and classification according to Sarmiento’s modification of Lidström criteria.
Mean Range Standard Deviation Excellent Good Fair Poor ∗
Radial shortening (ulnar variance)
Palmar tilt
Radial inclination
Articular step-off∗
−0.483 mm −6.5–5 mm 2.32 161 (94.7%) 9 (5.3%) 0 0
8.36° −10°–30° 6.80 9 (5.3%) 128 (75.3%) 2 (1.2%) 31 (18.2%)
20.12° 5–34° 5.21 125 (73.5%) 32 (18.8%) 9 (5.3%) 4 (2.4%)
0.55 mm 0–3.90 mm 0.89
AO 2R3A fractures were excluded from the analysis.
Table 3 Comparison of radiological results according to Sarmiento’s modification of Lidström criteria.
Radial shortening Radial inclination Palmar tilt
García-Cepeda et al. n = 170
Orbay et al. n = 29
Jose et al. n = 53
Lattmann et al. n = 91
−0.48 mm 20.12° 8.36°
0 mm 20° 5°
−0.15 mm 21.03° 9.51°
0.5 mm Not reported 4.6°
Table 4 Comparison of range of motion (ROM) with the results published by Duramaz et al. and Orbay et al.
Flexion Extension Pronation Supination
García-Cepeda et al. n = 170
Duramaz et al. n = 114
Orbay et al. n = 29
63° 57.67° 78.94° 81.76°
68° 64° 72° 71°
59° 57° 90° 78°
devascularization of its fragments at the same time that prevents harm to the extensor tendons by dorsal plates [6,8,9]. Most of the patients (63.5%) were females in the present series, mean age reached 55.9 years, and 84.1% of the fractures were the result of a low energy trauma (fall from standing height). These results are similar to those described by other studies which confirm that DRF rise with age, are more common in female and are usually caused by low energy impacts [3]. This is due to the increased fragility caused by osteoporosis. Our observed radiological results (ulnar variance, palmar tilt and radial inclination) did not differ with those reported in other publications [6,37,38]. and are described in Table 3. As expected, quality of reduction was significantly better in extraarticular and partial articular fractures than in complete articular fractures. Range of motion achieved after follow up has been summarized and compared to the results obtained by other authors such as Duramaz [39]. and Orbay [8]. in Table 4, in which we can’t account major differences. Overall satisfaction on discharge from the clinics was high with most of the patients not referring disabilities for their routine activities despite the lack of final degrees in the range of motion. We could not find differences in range of motion when comparing the fractures in our sample according to the AO classification. Our study suggests that a better anatomical reduction of a DRF (radial shortening and articular step-off) is associated with a better range of motion (flexion-extension) [13,14]. Batra et al. also found a relationship between ulnar variance and functional outcomes, considering radial shortening as the most important factor affecting functional outcome [40]. while Trumble et al. described the close correlation between postoperative step-off and functional outcomes in 1994 [21]. The average time from the fracture event until surgery was 8.5 days. This time was longer in extraarticular fractures (AO-2R3A: 12.22 days) than in intraarticular fractures (AO-2R3B: 7.97 days and 2R3C: 7.04 days). The reason for this relies on our indication for surgery, where we always attempt an initial treatment with closed reduction and cast application. Decision for surgery is taken when
a correct reduction is not achieved or when secondary displacement of the fracture happens. According to our data, there were no clinical or statistically significant differences when comparing early vs delayed osteosynthesis regarding radiological or functional outcomes. These results don’t differ to the published by Yamashita et al. [41]. who described no differences in radiological outcomes of a group of patients treated within the first day when comparing them to those undergoing surgery after one week. In their study, they identified differences in ROM during the first 12 weeks of follow up, however, these differences were not significant when follow up was extended to 48 weeks. We couldn’t find any publication regarding the optimal timing for internal fixation in DRF. We found that longer surgery times were needed for high energy fractures and AO type 2R3C fractures, which we think is due to the higher severity of these fractures. We didn’t notice any differences in the results when comparing the experience of the surgeon. However, we need to take into account that this is a retrospective study. Randomization could have avoided bias: perhaps more experience surgeons tend to perform more complex surgeries. The rate of complications in our sample is as high as 21.18%, ranging the reported complications by other authors from 8% to 39% [7,23,42–44]. The most common observed complication was CRPS (6.5%), which is close to the results outlined by Roh et al. [45]. involving 8.8% of patients. The pathophysiology for this is still unclear, but DRF are closely related to the diagnosis of CRPS. Vitamin C may prevent the development of this terrific syndrome [46] while bisphosphonates may reduce the pain associated to the disease [47]. Regarding extensor tendon ruptures, we found an incidence of 2.9%, slightly higher than the 1.7% detailed in the systematic review by Bentohami et al. [48]. 1.7% of our complications were ruptures of the extensor pollicis longus, similar to 1.4% described by Arora [23]. Tendon injuries may be produced by too distally positioned plates, poor dorsal reduction or long screws that protrude in the dorsal cortex [49,50]. Radioscopic skyline view obtained intraoperatively may prevent this protrusion [51]. Intraarticular screws are the result of hardware mispositioning and loss
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
of reduction that usually appears in comminuted fractures. Our reported incidence of intra-articular screws was of 5,9%, higher than those described by other authors (0,5–1,3%) [23,44,52] which we can’t relate to the experience of the surgeons performing the surgeries as mentioned before. In 2001 Kumar et all published how to perform intraoperative tangential radioscopic views to avoid intraarticular penetration [53]. We found a non-significant higher complication rate in complex intraarticular fractures (AO-2R3C). Thorninger et al. revealed significant results, which could be explained as more severe fractures could have more complications [54]. The need for reintervention was 10.6%. Our results are slightly higher than those published in other series, which are close to 7.5% [55,56]. Need for hardware removal could be related to intraarticular screws, tendon rupture or tendon irritation. Younger patients had a higher incidence of reintervention compared to those above 60 years old (14.9% vs 5.3%), although no differences were assessed in radiological results or complications. This difference could be based on different lifestyles, as younger patients tend to develop more demanding activities for work or sports. We observed that the need for reintervention was associated to the type of fracture and the energy of the injury, as complete articular fractures and high energy traumatism resulted in a higher revision rate. When we adjusted the results by age and mechanism of injury, which could act as confusion factors, we still found that the odds ratio for reintervention in complete articular fractures (AO-2R3C) was of 3.866. To our knowledge this is the first study which shows a correlation between the articular step-off and the range of motion in the treatment of DRF with volar locking plates, and one of the publications with a wider sample describing radiological outcomes. The limitations of our study correspond to its retrospective design, lack or randomization and follow up time. We could not obtain a contralateral radiography for measuring radiological parameters in the uninjured limb, however, none of the studies mentioned in our publication take these measurements into account.
Conclusions Radial shortening and articular step-off were the most important predictors for postoperative range of motion in our cases. Worse radiological outcomes were observed in complete articular fractures and those affecting elder population. The results of our study suggest that although radiological and functional results are good or excellent in most cases, the incidence of complications and need for reintervention still remains noticeable. The need for a new surgery was higher in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes. Attempt to close reduction, cast and follow up of distal radius fractures instead of early intervention hasn’t shown to be related to the outcomes.
Compliance with ethical standards All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
Declaration of Competing Interest
5
References [1] Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin 2012;28:113–25. doi:10.1016/j.hcl.2012.02.001. [2] Figl M, Weninger P, Jurkowitsch J, Hofbauer M, Schauer J, Leixnering M. Unstable distal radius fractures in the elderly patient–volar fixed-angle plate osteosynthesis prevents secondary loss of reduction. J Trauma 2010;68:992–8. doi:10.1097/TA.0b013e3181b99f71. [3] Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,0 0 0 adults: the influence of age and gender. J Bone Joint Surg Br 1998;80:243–8. [4] Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006;88:1944–51. doi:10.2106/JBJS.D.02520. [5] Handoll HHG, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev 20 07:CD0 06080. doi:10. 10 02/14651858.CD0 06080.pub2. [6] Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg 2004;29:96–102. [7] Quadlbauer S, Pezzei C, Jurkowitsch J, Kolmayr B, Keuchel T, Simon D, et al. Early rehabilitation of distal radius fractures stabilized by volar locking plate: a prospective randomized pilot study. J Wrist Surg 2017;6:102–12. doi:10.1055/ s- 0036- 1587317. [8] Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27:205–15. [9] Jupiter JB, Ring D, Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg 2002;27:714–23. [10] Khatri K, Sharma V, Farooque K, Tiwari V. Surgical treatment of unstable distal radius fractures with a volar variable-angle locking plate: clinical and radiological outcomes. Arch Trauma Res 2016;5:e25174. doi:10.5812/atr.25174. [11] Abramo A, Kopylov P, Geijer M, Tägil M. Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Acta Orthop 2009;80:478–85. doi:10.3109/ 17453670903171875. [12] Catalano LW, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am 1997;79:1290–302. [13] Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am 2013;95:1737–44. doi:10.2106/JBJS.L.00232. [14] Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am 2009;91:1837–46. doi:10.2106/JBJS.H. 01478. [15] Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, et al. American academy of orthopaedic surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011;93:775–8. doi:10.2106/JBJS.938ebo. [16] Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159–71. [17] null Graham. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997;5:270–81. [18] Murray J, Gross L. Treatment of distal radius fractures: aaos appropriate use criteria summary. J Am Acad Orthop Surg 2013;21:502–5 n.d. [19] Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68:647–59. [20] Pogue DJ, Viegas SF, Patterson RM, Peterson PD, Jenkins DK, Sweo TD, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg 1990;15:721–7. [21] Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19:325–40. doi:10.1016/0363- 5023(94)90028- 0. [22] Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop 2009;467:1612– 20. doi:10.10 07/s11999-0 08-0660-2. [23] Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma 2007;21:316–22. doi:10.1097/BOT. 0b013e318059b993. [24] Haug LCP, Deml C, Blauth M, Arora R. Dorsal screw penetration following implant removal after volar locked plating of distal radius fracture. Arch Orthop Trauma Surg 2011;131:1279–82. doi:10.10 07/s0 0402- 011- 1300- y. [25] Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018;32(Suppl 1):S1– 170. doi:10.1097/BOT.0 0 0 0 0 0 0 0 0 0 0 01063. [26] Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures. Functional bracing in supination. J Bone Joint Surg Am 1975;57:311–17. [27] Gauresh V. Distal end radius fractures: evaluation of results of various treatments and assessment of treatment choice. Chin J Traumatol 2014;17:214–19. doi:10.3760/cma.j.issn.10 08-1275.2014.04.0 06. [28] Lafontaine M, Delince P, Hardy D, Simons M. [Instability of fractures of the lower end of the radius: apropos of a series of 167 cases]. Acta Orthop Belg 1989;55:203–16.
None. Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ 6
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
[29] Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg 2004;29:1128–38. doi:10.1016/j.jhsa.20 04.06.0 08. [30] Jaremko JL, Lambert RGW, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol 2007;62:65–72. doi:10.1016/j.crad. 2006.08.013. [31] Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg 20 0 0;25:19–28. doi:10.1053/jhsu.20 0 0.jhsu025a0 019. [32] Anzarut A, Johnson JA, Rowe BH, Lambert RGW, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg 2004;29:1121–7. doi:10.1016/j.jhsa.20 04.07.0 02. [33] Fernandez DL. Closed manipulation and casting of distal radius fractures. Hand Clin 2005;21:307–16. doi:10.1016/j.hcl.2005.02.004. [34] Mah ET, Atkinson RN. Percutaneous kirschner wire stabilisation following closed reduction of Colles’ fractures. J Hand Surg Edinb Scotl 1992;17:55–62. [35] Park JH, Hagopian J, Ilyas AM. Variable-angle locking screw volar plating of distal radius fractures. Hand Clin 2010;26:373–80 vi. doi:10.1016/j.hcl.2010.04. 003. [36] Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg 2005;30:1185–99. doi:10.1016/j.jhsa.2005.08.009. [37] Jose A, Suranigi SM, Deniese PN, Babu AT, Rengasamy K, Najimudeen S. Unstable distal radius fractures treated by volar locking anatomical plates. J Clin Diagn Res JCDR 2017;11:RC04–8. doi:10.7860/JCDR/2017/24114.9261. [38] Lattmann T, Dietrich M, Meier C, Kilgus M, Platz A. Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius. J Hand Surg 2008;33:1135–43. doi:10.1016/j.jhsa.2008.03.016. [39] Duramaz A, Bilgili MG, Karaali E, Bayram B, Zirog˘ lu N, Kural C. Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: a comparison of functional and radiological outcomes. Ulus Travma Ve Acil Cerrahi Derg Turk J Trauma Emerg Surg TJTES 2018;24:255–62. doi:10.5505/tjtes.2017.35837. [40] Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury 2002;33:499–502. [41] Yamashita K, Zenke Y, Sakai A, Oshige T, Moritani S, Maehara T. Comparison of functional outcome between early and delayed internal fixation using volar locking plate for distal radius fractures. J UOEH 2015;37:111–19. doi:10.7888/ juoeh.37.111. [42] Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146–53. doi:10.2106/JBJS.J.01597. [43] Erhart S, Toth S, Kaiser P, Kastenberger T, Deml C, Arora R. Comparison of volarly and dorsally displaced distal radius fracture treated by volar locking plate fixation. Arch Orthop Trauma Surg 2018;138:879–85. doi:10.1007/ s00402- 018- 2925- x.
[44] Soong M, van Leerdam R, Guitton TG, Got C, Katarincic J, Ring D. Fracture of the distal radius: risk factors for complications after locked volar plate fixation. J Hand Surg 2011;36:3–9. doi:10.1016/j.jhsa.2010.09.033. [45] Roh YH, Lee BK, Noh JH, Baek JR, Oh JH, Gong HS, et al. Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture. Arch Orthop Trauma Surg 2014;134:1775–81. doi:10.10 07/s0 0402- 014- 2094- 5. [46] Aïm F, Klouche S, Frison A, Bauer T, Hardy P. Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: a systematic review and meta-analysis. Orthop Traumatol Surg Res OTSR 2017;103:465–70. doi:10.1016/j.otsr.2016.12.021. [47] Chevreau M, Romand X, Gaudin P, Juvin R, Baillet A. Bisphosphonates for treatment of complex regional pain syndrome type 1: a systematic literature review and meta-analysis of randomized controlled trials versus placebo. Jt Bone Spine Rev Rhum 2017;84:393–9. doi:10.1016/j.jbspin.2017.03.009. [48] Bentohami A, de Burlet K, de Korte N, van den Bekerom MPJ, Goslings JC, Schep NWL. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol 2014;39:745–54. doi:10.1177/1753193413511936. [49] Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 2011;93:328–35. doi:10.2106/JBJS.J.00193. [50] Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop 2006;445:58–67. doi:10.1097/01.blo. 0 0 0 0205891.96575.0f. [51] Riddick AP, Hickey B, White SP. Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation. J Hand Surg Eur Vol 2012;37:407–11. doi:10.1177/1753193411426809. [52] Esenwein P, Sonderegger J, Gruenert J, Ellenrieder B, Tawfik J, Jakubietz M. Complications following palmar plate fixation of distal radius fractures: a review of 665 cases. Arch Orthop Trauma Surg 2013;133:1155–62. doi:10.1007/ s00402- 013- 1766- x. [53] Kumar D, Breakwell L, Deshmukh SC, Singh BK. Tangential views of the articular surface of the distal radius-aid to open reduction and internal fixation of fractures. Injury 2001;32:783–6. [54] Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury 2017;48:1104–9. doi:10.1016/j.injury.2017.03.008. [55] Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg 2006;31:359–65. doi:10.1016/j.jhsa.2005.10.010. [56] Johnson NA, Cutler L, Dias JJ, Ullah AS, Wildin CJ, Bhowal B. Complications after volar locking plate fixation of distal radius fractures. Injury 2014;45:528– 33. doi:10.1016/j.injury.2013.10.003.
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ
[m5G;February 26, 2020;13:19]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Radiological results of surgical management of fracture of the distal radius treated with volar locking plates ✩ I. García-Cepeda, I. Aguado-Maestro∗, I. De Blas-Sanz, A. Quintanilla-García, M. García-Alonso Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
a r t i c l e
i n f o
Article history: Accepted 19 February 2020 Available online xxx Keywords: Distal radius fracture Volar locking plate ORIF Radiological outcomes
a b s t r a c t Objectives: Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high. The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate. Methods: We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010–2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions. Results: A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1–83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0 0 01). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001). ROM was: flexion 63° [0–90°; 19.73], extension 57.67° [5–90°; 21.61], pronation 78.94° [40–90°] and supination 81.76° [38–90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = −0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007). Conclusion: Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population. Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes. © 2020 Elsevier Ltd. All rights reserved.
Introduction ✩
Disclosure: This paper is part of a Supplement supported by The Orthopaedic Surgery and Traumatology Spanish Society (SECOT). ∗ Corresponding author. E-mail address: [email protected] (I. Aguado-Maestro).
Distal radius fracture (DRF) is the most common upper extremity fracture, involving 10–25% of all fractures [1]. Due to the increase in life expectancy and the relationship between DRF and osteoporosis [2]. the incidence of these fractures is increasing
https://doi.org/10.1016/j.injury.2020.02.106 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ 2
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
constantly. DRF are the result of different causes depending on the age of the patient: they are usually a consequence of high energy injuries in the young, while they are secondary to low energy trauma in the elderly. [3]. Casting, percutaneous pinning, external fixation, or internal fixation can be the treatment of DRF. Closed reduction and cast application have been used for a long time as the main treatment, but the results are often poor with malunion or fracture collapse [4]. Pinning and external fixation allow the preservation of fracture reduction but are often related to pin site infections [5]. Internal fixation with a volar locking plate has become popular because it improves stability and grants early mobilization [6,7]. Volar approach of distal radius allows to ensure the anatomic reduction of distal radius while applying an angular stable implant with subchondral locking screws. This approach avoids dorsal dissection and its associated devascularization of dorsal fragments and decreases the complications regarding extensor tendons due to dorsal plates [6,8,9]. Many studies report that a better anatomical reduction of a DRF is related with a better functional outcome [10–14]. According to the guidelines, radiographic measurements of radial shortening, ulnar variance, dorsal/volar tilt, radial inclination and articular step off of the distal radius, are used by orthopaedic surgeons to choose the treatment for each DRF [15]. Radiographic criteria have been established to define an acceptable alignment and include: less than 3 mm of radial shortening, intraarticular step-off lower than 2 mm, a radial inclination above 10 degrees and a volar tilt between 10 degrees dorsal to 20 degrees volar [16,17]. A step-off of more than 2 mm or a dorsal tilt above 20° increase the probability of post-traumatic osteoarthritis [18–20]. However, while in young patients there is a strong association between functional outcomes and fracture reduction, in elderly patients this association remains controversial [21,22]. It is important to customize the recommendations for surgery, because malunion in many elderly patients does not necessarily correlate to poor functional results. Many reports show up to 39% complication rates in volar stabilized DRF [23,24]. These complications are mainly: hardware malfunction, infection, changes in sensitivity, tendon irritation and rupture, complex regional pain syndrome (CRPS), nonunion and osteoarthritis. Objectives To assess functional and radiological results of all distal radius fractures treated with open reduction and internal fixation with a volar locking plate. The aim of the study includes the comparison of the functional results (based on range of motion), surgery timing, fracture/patient characteristics and postoperative radiological parameters. Materials and methods Following institutional board approval, we conducted a retrospective longitudinal study in which we collected data from the clinical records of all the patients admitted in our institution during a period of eight years (January 2010–June 2018) with a diagnosis of fracture of the distal radius. Inclusion criteria included patients above 18 years old with a diagnosis of a fracture of the distal third of the radius treated with open reduction and internal fixation through a volar approach and a minimum follow up of 12 weeks. Criteria for surgery in our institution included the following fracture characteristics after a closed reduction and cast immobilization: >10° dorsal tilt, >3 mm radial shortening, >2 mm intra-articular displacement, <7° radial inclination. Exclusion criteria included loss to follow up, open fractures,
additional injuries in the ipsilateral upper extremity and stabilization with additional fixation methods such as K-wires or external fixators. Patients undergoing arthroscopy or anything but a single volar approach were also excluded. Surgery was performed in decubitus supine position with the arm abducted in extension on a surgical table under a C-arm fluoroscopic assistance and a pneumatic arm tourniquet. Regional anesthesia was used in all cases through an axillary or interscalenic block. Open reduction was done through a volar Henry approach. Reduction was assessed under fluoroscopic imaging and maintained with provisional K-wires. Definitive osteosynthesis was made with one of the following volar plates according to surgeon preferences: Variable Angle LCP Two-Column Volar Distal Radius Plate® (DePuy-Synthes, Synthes GmbH, Oberdorf, Switzerland), Variable Angle LCP Volar Rim Distal Radius Plate® (DePuy-Synthes, Synthes GmbH, Oberdorf, Switzerland), Acu-Loc 2 VDR® (Acumed LLC, Hillsboro, Oregon, USA), DVR® Crosslock plate (Biomet Orthopedics, Warsaw, Indiana, USA). A splint was used until staples/suture removal (approximately 2 weeks). Follow up protocol included visits and X-Rays 1 week postop, 4 weeks, and then every month until fracture union. Rehabilitation consultations were requested according to the surgeon criteria based on the patient needs. Data was collected from the digital clinical records and included variables such as: patient demographics, fracture characteristics (mechanism/cause of production, AO Classification [25]), time from the fracture event until surgery, surgery time, type of plate used, radiological parameters (such as radial inclination, palmar tilt, ulnar variance, depth of intra-articular step-off), range of motion (ROM), complications and need for reinterventions. For analysis purposes, radiological parameters were classified according to Sarmiento’s modification of Lidström criteria [26,27]. and calculating a punctuation based on the classification giving 3 points when “excellent”, 2 points when “good”, 1 point when “fair” and 0 points if “bad”, creating a new variable called quality score of reduction according to Sarmiento, being “excellent” when 9 points were obtained, “good” when 6–8 points, “fair” if 4–5 and “bad” if 3 or less. Variables were included in a Microsoft Excel spreadsheet (Microsoft® Excel for Mac, version 16, Microsoft Corporation, Redmond, Washington, USA). Statistical analysis was performed with IBM SPSS Statistics version 21 (SPSS inc., Chicago, Illinois, USA) for Mac®. Parametric and non-parametric tests were used as appropriate. Results were considered significant for p < 0.05. Results A total of 170 patients (63.5% female) met the inclusion criteria and were selected for the analysis. The mean age was 55.9 years [Range: 24.1–83.7; Standard Deviation (SD): 13.76]. 44.7% of the patients were 60 years old or above. 143 (84.1%) fractures were produced by low energy trauma, whereas 27 (15.9%) were caused by high energy trauma such as traffic accidents or sport injuries. High energy injuries were more frequent in younger patients (25.56% vs 3.95% p < 0.0 0 01). Fractures were classified according to AO classification and included 40 (23.5%) extraarticular fractures (2R3A), 41 (24.1%) partial articular fractures (2R3B) and 89 (52.4%) complete articular fractures (2R3C). A full categorization in the AO classification is shown in Table 1. The average time from the fracture event until surgery was 8.5 days [0–28 days; 9.74]. This time was longer in extraarticular fractures (AO-2R3A: 12.22 days) than in intraarticular fractures (AO2R3B: 7.97 days and 2R3C: 7.04 days) p = 0.018. Open reduction and internal fixation was performed on a mean time of 86.72 min [45–134 min; 18.85] and the plates used for the fixation were: LCP Volar Rim Plate (5 cases, 2.9%), LCP Two-Column Plate (107 cases, 62.9%), Acu-Loc 2 (50 cases, 29.4%) and DVR Crossloc (8 cases,
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
ARTICLE IN PRESS
JID: JINJ
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
3
Table 1 AO Classification of the fractures. Type
Group
2R3A 2R3A1 2R3A2 2R3A3 2R3B 2R3B1 2R3B2 2R3B3 2R3C 2R3C1 2R3C2 2R3C3
N 40 (23.5%) 1 (0.6%) 7 (4.1%) 32 (18.8%) 41 (24.1%) 1 (0.6%) 4 (2.4%) 36 (21.2%) 89 (52.4%) 21 (12.4%) 34 (20%) 34 (20%)
4.7%). Longer surgery times were needed for high energy fractures (85.27 vs 94.33 min, p = 0.02) and AO type 2R3C fractures (AO2R3A: 82.75 min; AO-2R3C: 89.99 min; p = 0.047). 3 surgeons performed 53% of the surgeries (more than 25 each), being the rest performed by other surgeons in the unit of trauma surgery (less than 10 fractures per surgeon). We could not find any statistical differences in the outcomes of either of the groups, although we noticed a non-significant (p = 0.08) difference in the radiological step-off (0.70 mm in the less experienced group and 0.43 mm in the more experienced). Fracture union was achieved in all cases. Radiological parameters and their classification according to Sarmiento’s modification of Lidström criteria are shown in Table 2. For statistical purposes, we calculated a punctuation based on this classification as described in materials and methods, being the mean quality score of 7.11 points out of 9 [2–9 points; 0.89]. We compared the relationship between the quality of reduction score and the AO fracture type and found poorer results in fractures AO-2R3C (AO-2R3A: 7.4 points; AO-2R3B: 7.41 points; AO-2R3C: 6.84 points; p = 0.025). We analyzed the radiological outcomes observed in patients above and below 60 years old and found that younger patients had better results regarding radial inclination (excellent results in 85.1% vs 59.21%, good results in 12.76% vs 26%, fair results in 0.1% vs 10.52%, poor results in 0.1% vs 3.9%; p = 0.001) and radial shortening (ulnar variance) (excellent results in 100% vs 88.15%; p = 0.001). Regarding range of motion (ROM), 153 patients (90%) made rehabilitation within the hospital facilities, whereas 17 (10%) didn’t need consultation with this department. At the end of the follow up (mean: 6.82 months; range: 2.8–34.1; SD: 5.19) there was a mean flexion of 63° [0–90°; 19.73], extension 57.67° [5–90°; 21.61], pronation 78.94° [40–90°] and supination 81.76° [38–90°; 8.87]. We found a weak correlation between radial shortening and the range of motion in flexion-extension (r = 0.218; p = 0.001) and again with the articular step-off (r = −0.269; p = 0.002). These results are shown in Fig. 1. No differences were found between time until surgery and ROM. We found a total of 39 complications in 36 patients (21.18%): complex regional pain syndrome (CRPS: 11 cases, 6.5%); intraarticular screw penetration (10 cases, 5.9%); tendinous rupture (5 cases; 2.9%; being in 3 patients a rupture of the extensor pollicis longus and in 2 patients a rupture of the extensor digitorum of the 2nd finger); painful or hypertrophic scar (5 cases, 2.9%); carpal tunnel syndrome (3 cases, 1.8%); painful ulnar impingement (2 cases, 1.2%); pain related to osteosynthesis hardware (1 case, 0.6%); stiffness (1 case, 0.6%) and ulnar nerve compression (1 case, 0.6%). These complications weren’t related to the experience of the surgeon, type of fracture, energy of the traumatism, time until surgery, type of implant, surgical time or radiological reduction. However, although not statistically significant we observed a
Fig. 1. Relationship between Range of Motion (ROM) in flexo-extension measured in degrees and radial shortening (according to Sarmiento’s modification of Lidström criteria: excellent: <3 mm; good: 3–6 mm; fair: 7–11 mm; poor: >12 mm) and articular step-off (excellent: 0 mm; good: 0.1–1 mm; fair 1.1–2 mm or less; poor: 2.1–3 mm).
higher complication rate in more complex articular fractures. (AO2R3A: 15%; AO-2R3B: 17.1%; 2R3C: 25.8%; p = 0.288). Up to 10.6% (18 cases) of the patients needed a new surgery, being the procedures performed: hardware removal (11 cases, 6.5%), tendinous disruptions repairs or transfers (4 cases, 2.4%), neurolysis (2 cases, 1.2%) and new osteosynthesis (1 case, 0.6%). We noticed that the need of reintervention was associated to the type of fracture (need for re-operation: AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and the energy of the injury (low energy mechanism: 8.4%; high energy mechanism: 22.2%; p = 0.044). We couldn’t observe any relationship with any radiological measurement. Younger patients had a higher incidence of reintervention (14.9% vs 5.3%; p = 0.042). When we adjusted the results by age, and type of fracture, AO type 2R3C fractures had an odds ratio for reintervention of 3.866 (IC95% 1.18–12.63). Patients undergoing reintervention had worse functional outcomes with a decreased range of motion in flexion-extension (94.44° vs 123.83°, p = 0.007). Discussion Longer life expectancy has led to an increase in the incidence of distal radius fractures. Their treatment includes a wide variety of options from closed reduction and cast application to open reduction and internal fixation. According to Lafontaine there are five circumstances that increase the rate of secondary displacement after closed reduction [28]. These predictors of instability are: a dorsal angulation greater than 20°, intraarticular fractures, associated ulna fractures, dorsal metaphyseal comminution and age above 60 years old. However, other authors consider that the only significant risk factor for failure of closed treatment is age [29]. Despite these findings, multiple studies have suggested that clinical outcomes are not correlated with radiographic results in elderly patients [30–32]. Closed reduction and cast application has historically been the main treatment for DRF, but high incidence of malunion [4] has limited its indications to stable fractures [33]. Percutaneous fixation with kirschner wires is a good treatment for extraarticular fractures [34] but provide limited stability requiring further immobilization which may result in high rates of complications [5]. Open reduction and internal fixation restore the anatomy of the wrist and favors a faster rehabilitation with good clinical results [35]. Volar approach allows an anatomic reduction in cases with severe comminution or osteoporotic bone maintaining a correct radius length [36]. This approach avoids dorsal dissection and the
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
ARTICLE IN PRESS
JID: JINJ 4
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx Table 2 Radiological measurements and classification according to Sarmiento’s modification of Lidström criteria.
Mean Range Standard Deviation Excellent Good Fair Poor ∗
Radial shortening (ulnar variance)
Palmar tilt
Radial inclination
Articular step-off∗
−0.483 mm −6.5–5 mm 2.32 161 (94.7%) 9 (5.3%) 0 0
8.36° −10°–30° 6.80 9 (5.3%) 128 (75.3%) 2 (1.2%) 31 (18.2%)
20.12° 5–34° 5.21 125 (73.5%) 32 (18.8%) 9 (5.3%) 4 (2.4%)
0.55 mm 0–3.90 mm 0.89
AO 2R3A fractures were excluded from the analysis.
Table 3 Comparison of radiological results according to Sarmiento’s modification of Lidström criteria.
Radial shortening Radial inclination Palmar tilt
García-Cepeda et al. n = 170
Orbay et al. n = 29
Jose et al. n = 53
Lattmann et al. n = 91
−0.48 mm 20.12° 8.36°
0 mm 20° 5°
−0.15 mm 21.03° 9.51°
0.5 mm Not reported 4.6°
Table 4 Comparison of range of motion (ROM) with the results published by Duramaz et al. and Orbay et al.
Flexion Extension Pronation Supination
García-Cepeda et al. n = 170
Duramaz et al. n = 114
Orbay et al. n = 29
63° 57.67° 78.94° 81.76°
68° 64° 72° 71°
59° 57° 90° 78°
devascularization of its fragments at the same time that prevents harm to the extensor tendons by dorsal plates [6,8,9]. Most of the patients (63.5%) were females in the present series, mean age reached 55.9 years, and 84.1% of the fractures were the result of a low energy trauma (fall from standing height). These results are similar to those described by other studies which confirm that DRF rise with age, are more common in female and are usually caused by low energy impacts [3]. This is due to the increased fragility caused by osteoporosis. Our observed radiological results (ulnar variance, palmar tilt and radial inclination) did not differ with those reported in other publications [6,37,38]. and are described in Table 3. As expected, quality of reduction was significantly better in extraarticular and partial articular fractures than in complete articular fractures. Range of motion achieved after follow up has been summarized and compared to the results obtained by other authors such as Duramaz [39]. and Orbay [8]. in Table 4, in which we can’t account major differences. Overall satisfaction on discharge from the clinics was high with most of the patients not referring disabilities for their routine activities despite the lack of final degrees in the range of motion. We could not find differences in range of motion when comparing the fractures in our sample according to the AO classification. Our study suggests that a better anatomical reduction of a DRF (radial shortening and articular step-off) is associated with a better range of motion (flexion-extension) [13,14]. Batra et al. also found a relationship between ulnar variance and functional outcomes, considering radial shortening as the most important factor affecting functional outcome [40]. while Trumble et al. described the close correlation between postoperative step-off and functional outcomes in 1994 [21]. The average time from the fracture event until surgery was 8.5 days. This time was longer in extraarticular fractures (AO-2R3A: 12.22 days) than in intraarticular fractures (AO-2R3B: 7.97 days and 2R3C: 7.04 days). The reason for this relies on our indication for surgery, where we always attempt an initial treatment with closed reduction and cast application. Decision for surgery is taken when
a correct reduction is not achieved or when secondary displacement of the fracture happens. According to our data, there were no clinical or statistically significant differences when comparing early vs delayed osteosynthesis regarding radiological or functional outcomes. These results don’t differ to the published by Yamashita et al. [41]. who described no differences in radiological outcomes of a group of patients treated within the first day when comparing them to those undergoing surgery after one week. In their study, they identified differences in ROM during the first 12 weeks of follow up, however, these differences were not significant when follow up was extended to 48 weeks. We couldn’t find any publication regarding the optimal timing for internal fixation in DRF. We found that longer surgery times were needed for high energy fractures and AO type 2R3C fractures, which we think is due to the higher severity of these fractures. We didn’t notice any differences in the results when comparing the experience of the surgeon. However, we need to take into account that this is a retrospective study. Randomization could have avoided bias: perhaps more experience surgeons tend to perform more complex surgeries. The rate of complications in our sample is as high as 21.18%, ranging the reported complications by other authors from 8% to 39% [7,23,42–44]. The most common observed complication was CRPS (6.5%), which is close to the results outlined by Roh et al. [45]. involving 8.8% of patients. The pathophysiology for this is still unclear, but DRF are closely related to the diagnosis of CRPS. Vitamin C may prevent the development of this terrific syndrome [46] while bisphosphonates may reduce the pain associated to the disease [47]. Regarding extensor tendon ruptures, we found an incidence of 2.9%, slightly higher than the 1.7% detailed in the systematic review by Bentohami et al. [48]. 1.7% of our complications were ruptures of the extensor pollicis longus, similar to 1.4% described by Arora [23]. Tendon injuries may be produced by too distally positioned plates, poor dorsal reduction or long screws that protrude in the dorsal cortex [49,50]. Radioscopic skyline view obtained intraoperatively may prevent this protrusion [51]. Intraarticular screws are the result of hardware mispositioning and loss
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
of reduction that usually appears in comminuted fractures. Our reported incidence of intra-articular screws was of 5,9%, higher than those described by other authors (0,5–1,3%) [23,44,52] which we can’t relate to the experience of the surgeons performing the surgeries as mentioned before. In 2001 Kumar et all published how to perform intraoperative tangential radioscopic views to avoid intraarticular penetration [53]. We found a non-significant higher complication rate in complex intraarticular fractures (AO-2R3C). Thorninger et al. revealed significant results, which could be explained as more severe fractures could have more complications [54]. The need for reintervention was 10.6%. Our results are slightly higher than those published in other series, which are close to 7.5% [55,56]. Need for hardware removal could be related to intraarticular screws, tendon rupture or tendon irritation. Younger patients had a higher incidence of reintervention compared to those above 60 years old (14.9% vs 5.3%), although no differences were assessed in radiological results or complications. This difference could be based on different lifestyles, as younger patients tend to develop more demanding activities for work or sports. We observed that the need for reintervention was associated to the type of fracture and the energy of the injury, as complete articular fractures and high energy traumatism resulted in a higher revision rate. When we adjusted the results by age and mechanism of injury, which could act as confusion factors, we still found that the odds ratio for reintervention in complete articular fractures (AO-2R3C) was of 3.866. To our knowledge this is the first study which shows a correlation between the articular step-off and the range of motion in the treatment of DRF with volar locking plates, and one of the publications with a wider sample describing radiological outcomes. The limitations of our study correspond to its retrospective design, lack or randomization and follow up time. We could not obtain a contralateral radiography for measuring radiological parameters in the uninjured limb, however, none of the studies mentioned in our publication take these measurements into account.
Conclusions Radial shortening and articular step-off were the most important predictors for postoperative range of motion in our cases. Worse radiological outcomes were observed in complete articular fractures and those affecting elder population. The results of our study suggest that although radiological and functional results are good or excellent in most cases, the incidence of complications and need for reintervention still remains noticeable. The need for a new surgery was higher in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes. Attempt to close reduction, cast and follow up of distal radius fractures instead of early intervention hasn’t shown to be related to the outcomes.
Compliance with ethical standards All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
Declaration of Competing Interest
5
References [1] Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin 2012;28:113–25. doi:10.1016/j.hcl.2012.02.001. [2] Figl M, Weninger P, Jurkowitsch J, Hofbauer M, Schauer J, Leixnering M. Unstable distal radius fractures in the elderly patient–volar fixed-angle plate osteosynthesis prevents secondary loss of reduction. J Trauma 2010;68:992–8. doi:10.1097/TA.0b013e3181b99f71. [3] Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,0 0 0 adults: the influence of age and gender. J Bone Joint Surg Br 1998;80:243–8. [4] Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006;88:1944–51. doi:10.2106/JBJS.D.02520. [5] Handoll HHG, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev 20 07:CD0 06080. doi:10. 10 02/14651858.CD0 06080.pub2. [6] Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg 2004;29:96–102. [7] Quadlbauer S, Pezzei C, Jurkowitsch J, Kolmayr B, Keuchel T, Simon D, et al. Early rehabilitation of distal radius fractures stabilized by volar locking plate: a prospective randomized pilot study. J Wrist Surg 2017;6:102–12. doi:10.1055/ s- 0036- 1587317. [8] Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27:205–15. [9] Jupiter JB, Ring D, Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg 2002;27:714–23. [10] Khatri K, Sharma V, Farooque K, Tiwari V. Surgical treatment of unstable distal radius fractures with a volar variable-angle locking plate: clinical and radiological outcomes. Arch Trauma Res 2016;5:e25174. doi:10.5812/atr.25174. [11] Abramo A, Kopylov P, Geijer M, Tägil M. Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Acta Orthop 2009;80:478–85. doi:10.3109/ 17453670903171875. [12] Catalano LW, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am 1997;79:1290–302. [13] Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am 2013;95:1737–44. doi:10.2106/JBJS.L.00232. [14] Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am 2009;91:1837–46. doi:10.2106/JBJS.H. 01478. [15] Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, et al. American academy of orthopaedic surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011;93:775–8. doi:10.2106/JBJS.938ebo. [16] Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159–71. [17] null Graham. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997;5:270–81. [18] Murray J, Gross L. Treatment of distal radius fractures: aaos appropriate use criteria summary. J Am Acad Orthop Surg 2013;21:502–5 n.d. [19] Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68:647–59. [20] Pogue DJ, Viegas SF, Patterson RM, Peterson PD, Jenkins DK, Sweo TD, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg 1990;15:721–7. [21] Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19:325–40. doi:10.1016/0363- 5023(94)90028- 0. [22] Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop 2009;467:1612– 20. doi:10.10 07/s11999-0 08-0660-2. [23] Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma 2007;21:316–22. doi:10.1097/BOT. 0b013e318059b993. [24] Haug LCP, Deml C, Blauth M, Arora R. Dorsal screw penetration following implant removal after volar locked plating of distal radius fracture. Arch Orthop Trauma Surg 2011;131:1279–82. doi:10.10 07/s0 0402- 011- 1300- y. [25] Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018;32(Suppl 1):S1– 170. doi:10.1097/BOT.0 0 0 0 0 0 0 0 0 0 0 01063. [26] Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures. Functional bracing in supination. J Bone Joint Surg Am 1975;57:311–17. [27] Gauresh V. Distal end radius fractures: evaluation of results of various treatments and assessment of treatment choice. Chin J Traumatol 2014;17:214–19. doi:10.3760/cma.j.issn.10 08-1275.2014.04.0 06. [28] Lafontaine M, Delince P, Hardy D, Simons M. [Instability of fractures of the lower end of the radius: apropos of a series of 167 cases]. Acta Orthop Belg 1989;55:203–16.
None. Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106
JID: JINJ 6
ARTICLE IN PRESS
[m5G;February 26, 2020;13:19]
I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al. / Injury xxx (xxxx) xxx
[29] Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg 2004;29:1128–38. doi:10.1016/j.jhsa.20 04.06.0 08. [30] Jaremko JL, Lambert RGW, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol 2007;62:65–72. doi:10.1016/j.crad. 2006.08.013. [31] Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg 20 0 0;25:19–28. doi:10.1053/jhsu.20 0 0.jhsu025a0 019. [32] Anzarut A, Johnson JA, Rowe BH, Lambert RGW, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg 2004;29:1121–7. doi:10.1016/j.jhsa.20 04.07.0 02. [33] Fernandez DL. Closed manipulation and casting of distal radius fractures. Hand Clin 2005;21:307–16. doi:10.1016/j.hcl.2005.02.004. [34] Mah ET, Atkinson RN. Percutaneous kirschner wire stabilisation following closed reduction of Colles’ fractures. J Hand Surg Edinb Scotl 1992;17:55–62. [35] Park JH, Hagopian J, Ilyas AM. Variable-angle locking screw volar plating of distal radius fractures. Hand Clin 2010;26:373–80 vi. doi:10.1016/j.hcl.2010.04. 003. [36] Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg 2005;30:1185–99. doi:10.1016/j.jhsa.2005.08.009. [37] Jose A, Suranigi SM, Deniese PN, Babu AT, Rengasamy K, Najimudeen S. Unstable distal radius fractures treated by volar locking anatomical plates. J Clin Diagn Res JCDR 2017;11:RC04–8. doi:10.7860/JCDR/2017/24114.9261. [38] Lattmann T, Dietrich M, Meier C, Kilgus M, Platz A. Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius. J Hand Surg 2008;33:1135–43. doi:10.1016/j.jhsa.2008.03.016. [39] Duramaz A, Bilgili MG, Karaali E, Bayram B, Zirog˘ lu N, Kural C. Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: a comparison of functional and radiological outcomes. Ulus Travma Ve Acil Cerrahi Derg Turk J Trauma Emerg Surg TJTES 2018;24:255–62. doi:10.5505/tjtes.2017.35837. [40] Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury 2002;33:499–502. [41] Yamashita K, Zenke Y, Sakai A, Oshige T, Moritani S, Maehara T. Comparison of functional outcome between early and delayed internal fixation using volar locking plate for distal radius fractures. J UOEH 2015;37:111–19. doi:10.7888/ juoeh.37.111. [42] Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146–53. doi:10.2106/JBJS.J.01597. [43] Erhart S, Toth S, Kaiser P, Kastenberger T, Deml C, Arora R. Comparison of volarly and dorsally displaced distal radius fracture treated by volar locking plate fixation. Arch Orthop Trauma Surg 2018;138:879–85. doi:10.1007/ s00402- 018- 2925- x.
[44] Soong M, van Leerdam R, Guitton TG, Got C, Katarincic J, Ring D. Fracture of the distal radius: risk factors for complications after locked volar plate fixation. J Hand Surg 2011;36:3–9. doi:10.1016/j.jhsa.2010.09.033. [45] Roh YH, Lee BK, Noh JH, Baek JR, Oh JH, Gong HS, et al. Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture. Arch Orthop Trauma Surg 2014;134:1775–81. doi:10.10 07/s0 0402- 014- 2094- 5. [46] Aïm F, Klouche S, Frison A, Bauer T, Hardy P. Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: a systematic review and meta-analysis. Orthop Traumatol Surg Res OTSR 2017;103:465–70. doi:10.1016/j.otsr.2016.12.021. [47] Chevreau M, Romand X, Gaudin P, Juvin R, Baillet A. Bisphosphonates for treatment of complex regional pain syndrome type 1: a systematic literature review and meta-analysis of randomized controlled trials versus placebo. Jt Bone Spine Rev Rhum 2017;84:393–9. doi:10.1016/j.jbspin.2017.03.009. [48] Bentohami A, de Burlet K, de Korte N, van den Bekerom MPJ, Goslings JC, Schep NWL. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol 2014;39:745–54. doi:10.1177/1753193413511936. [49] Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 2011;93:328–35. doi:10.2106/JBJS.J.00193. [50] Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop 2006;445:58–67. doi:10.1097/01.blo. 0 0 0 0205891.96575.0f. [51] Riddick AP, Hickey B, White SP. Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation. J Hand Surg Eur Vol 2012;37:407–11. doi:10.1177/1753193411426809. [52] Esenwein P, Sonderegger J, Gruenert J, Ellenrieder B, Tawfik J, Jakubietz M. Complications following palmar plate fixation of distal radius fractures: a review of 665 cases. Arch Orthop Trauma Surg 2013;133:1155–62. doi:10.1007/ s00402- 013- 1766- x. [53] Kumar D, Breakwell L, Deshmukh SC, Singh BK. Tangential views of the articular surface of the distal radius-aid to open reduction and internal fixation of fractures. Injury 2001;32:783–6. [54] Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury 2017;48:1104–9. doi:10.1016/j.injury.2017.03.008. [55] Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg 2006;31:359–65. doi:10.1016/j.jhsa.2005.10.010. [56] Johnson NA, Cutler L, Dias JJ, Ullah AS, Wildin CJ, Bhowal B. Complications after volar locking plate fixation of distal radius fractures. Injury 2014;45:528– 33. doi:10.1016/j.injury.2013.10.003.
Please cite this article as: I. García-Cepeda, I. Aguado-Maestro and I. De Blas-Sanz et al., Radiological results of surgical management of fracture of the distal radius treated with volar locking plates, Injury, https://doi.org/10.1016/j.injury.2020.02.106