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Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures
SCIENTIFIC ARTICLE
Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures Alexander Lauder, MD,* Sonya Agnew, MD,† Karim Bakri, MBBS,‡ Christopher H. Allan, MD,* Douglas P. Hanel, MD,* Jerry I. Huang, MD*
Purpose To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures. Methods All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed QuickDisabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires. Results Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43 vs 58 ), extension (46 vs 56 ), and ulnar deviation (23 vs 29 ) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture. Conclusions Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods. (J Hand Surg Am. 2015;40(8):1554e1562. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Distal radius fracture, bridge plating, distraction plate, functional outcome.
From the *Department of Orthopaedics, University of Washington, Seattle, WA; the †Division of Plastic Surgery, Northwestern University, Jesse Brown VAMC, Chicago, IL; and the ‡Division of Plastic Surgery, Mayo Clinic, Rochester, MN. Received for publication February 13, 2015; accepted in revised form May 11, 2015. J.I.H. is a consultant to Arthrex. Arthrex has no financial involvement in this project. Corresponding author: Alexander Lauder, MD, Department of Orthopaedics and Sports Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, WA 98104; e-mail: [email protected]. 0363-5023/15/4008-0005$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.05.008
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account for approximately 17% of all fractures treated in emergency rooms.1,2 There are numerous surgical techniques to treat these fractures, including percutaneous pinning, external fixation, and plate fixation.3e7 The goals of surgical treatment are anatomic reduction of the distal radius, placement of a stable construct to enable fracture healing, and restoration of normal wrist kinematics.8e12 Dorsal spanning plate fixation has been described as an effective treatment option for unstable comminuted RACTURES OF THE DISTAL RADIUS
BRIDGE PLATING DISTAL RADIUS FRACTURES
distal radius fractures, bilateral wrist fractures with metaphyseal bone loss or diaphyseal extension, and complex injuries requiring extensive soft tissue and bony reconstruction.13e15 In addition, this method allows for early weight bearing and transfer in polytrauma patients with pelvic and lower extremity fractures.13e15 The plate is temporarily fixed to the second or third metacarpal under the extensor tendons. After fracture healing is confirmed at approximately 12 weeks, the plate is removed and therapy is initiated for wrist motion and strengthening.4,5,13,16 Functional results and complications have been previously reported with percutaneous fixation, volar plating, dorsal plating, and external fixation of distal radius fractures.12,17e25 The literature on outcomes after dorsal spanning plate fixation for distal radius fractures has been limited to retrospective reviews14,26 except for one prospective series by Ruch et al27 in 2005. We hypothesized that patients treated with dorsal spanning bridge plate fixation for unilateral distal radius fractures would have functional kinematics that were not significantly different from their unaffected wrist and not have significant functional impairment in their activities of daily living or work related activities greater than 1 year after plate removal. The purpose of this study was to systematically analyze the functional and kinematic outcomes of the wrist in patients after dorsal spanning bridge plate removal for the treatment of distal radius fractures.
considered research subjects. Consent was completed at the time of the clinical follow-up visit. Study population and inclusion All available patients over age 18 years who underwent surgical treatment of a unilateral distal radius fracture at our institution with dorsal spanning bridge plate fixation during the study period with greater than 1 year of follow-up from removal of the dorsal bridge plate were included in the study and enrolled at the time of follow-up. Exclusion criteria were patients with bilateral injuries, multiple methods of fixation of the radius (ie, volar plating, dorsal plating, other methods of surgical fixation), concomitant ipsilateral elbow or hand fractures, additional injuries to the affected wrist or contralateral wrist, additional surgery on the affected wrist after removal of bridge plate for unrelated injuries, and any surgical intervention on the contralateral wrist. Patients with Kwire fixation of the radial styloid in addition to dorsal bridge plate fixation were included. All ancillary hardware was removed before or at the time of the plate removal. Surgical indications and technique Indications for use of this technique included unstable comminuted distal radius fractures, open fractures with metadiaphyseal extension and bone loss, and polytrauma patients who were thought to benefit from early weight bearing and transfer. A standardized surgical technique was used in all patients as described previously using the second metacarpal for fixation of a dorsal spanning bridge plate.13 All patients received surgical treatment from 1 of 2 authors (C.A. or D.H.).
MATERIALS AND METHODS This functional outcomes analysis was approved by our institutional review board and adhered to the Strengthening and Reporting of Observational Studies in Epidemiology guidelines, and was conducted at a large level 1 trauma center. A data inquiry was completed for all patients who underwent surgical treatment of intra-articular distal radius fractures with Current Procedural Terminology codes 25608 or 25609 treated for at our tertiary care center from January 1, 2008 to December 31, 2012. Patient medical record numbers were retrieved from this query to create a research database on a secured passwordprotected file. We performed a medical chart review to verify that patients met inclusion criteria for the study. Patients who met criteria were contacted via telephone and asked to participate in the study. We made up to 5 attempts to contact each patient. Included participants returned for a clinic visit when outcomes data were collected. Neither patients nor their insurance were billed for the visit because patients were J Hand Surg Am.
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Data collection Data were collected from the patients at the study follow-up visit by 2 of the authors, an orthopedic surgical resident, and a hand fellow. Wrist motion, grip strength, and wrist extension strength were collected for both the injured wrist and the contralateral, uninjured wrist. We measured wrist range of motion using a goniometer and made strength measurements using a Baltimore Therapeutic Equipment machine (PrimusRS, Hanover, MD). Subjects completed questionnaires at the time of follow-up. These included the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) form, the Patient-Related Wrist Evaluation (PRWE) questionnaire, and the 12-item Short Form Health Survey (SF12). We collected the following information for each patient: patient demographics (age, sex, comorbidities, date of injury, date of surgery, additional injuries at the time of the r
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BRIDGE PLATING DISTAL RADIUS FRACTURES
FIGURE 1: Study enrollment. One hundred patients met inclusion criteria for the study. Eighteen patients were available for study participation after up to 5 attempts were made to contact all eligible patients.
distal radius fracture, follow-up time, fracture type, dominant wrist injury, and occupation); functional results after dorsal spanning plate removal (active wrist flexion and extension, radial and ulnar deviation, forearm pronation and supination, grip strength, and wrist extension strength); outcomes scores (QuickDASH, PRWE, and SF12 score); and complications (infection, wound problems, tendonitis, tendon rupture, hardware failure, and complex regional pain syndrome).
years after bridge plate removal. All patients sustained intra-articular multifragmentary distal radius injuries (AO 23.C3), and 11% were open fractures. Kinematic outcomes Table 2 reports kinematic comparisons for range of motion between the injured and comparison (uninjured) wrists. Wrist flexion, extension, and ulnar deviation were significantly lower in the injured wrist compared with the uninjured wrist in the total study population. Further analysis, isolating the dominant injuries and nondominant wrist injuries independently, identified significantly greater preservation of overall motion in dominant-sided wrist injuries. In dominant injuries, flexion was decreased compared with the contralateral wrist. Any perceived differences in extension, pronation, supination, ulnar deviation, and radial deviation did not reach significance. In nondominant injuries; however, extension, pronation, and ulnar deviation were significantly reduced compared with the uninjured wrist (Table 2).
Analyses and study groups Comparisons among functional outcomes between the operative and nonsurgical wrist were completed with independent paired t tests using the nonsurgical wrist for comparison. Descriptive statistics were completed with analysis of variance for means and chi-square analyses for proportions. Associations were considered significant with P < .050. Analyses were completed for the total study cohort and subgroups based on wrist dominance. Subgroup comparison analysis included dominant wrist injury and nondominant wrist injury.
Strength outcomes Table 3 lists results for grip and extension strength. Both grip strength and wrist extension strength were significantly decreased in the operative wrist compared with the contralateral wrist for the total study population. Analysis based on dominant wrist injuries showed no significant difference between grip and
RESULTS Enrollment and study population A total of 100 patients met the inclusion criteria for the study. Eighteen patients were available for study participation (Fig. 1). Table 1 lists the demographics. Follow-up averaged almost 3 years from injury and 2.7 J Hand Surg Am.
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TABLE 1.
Demographics and Fracture Characteristics in the Study Population Subgroup Study Cohort (N ¼ 18)
Dominant Wrist Injury (n ¼ 18)
Nondominant Wrist Injury (n ¼ 10)
Average
61 4
58 3
63 6
Range
29e89
44e71
29e89
13 (72)
8 (100)
5 (50)
Characteristic Age, y
Sex Male
5 (28)
0 (0)
5 (50)
Labor occupation, n (%)
Female
3 (17)
1 (13)
2 (20)
Dominant side injured, n (%)
8 (44)
8 (100)
0 (0)
Follow-up, y average (range) Since injury
2.9 0.3 (1.5e5.4)
3.0 0.4 (1.5e5.2)
2.9 0.4 (1.5e5.4)
Since bridge plate removal
2.7 0.3 (1.2e5.2)
2.7 0.4 (1.3e4.9)
2.6 0.4 (1.2e5.2)
18 (100)
8 (100)
10 (100)
Fracture characteristics, n (%) AO classification 23.C.3 Open fracture Closed fracture
2 (11)
0
2 (20)
16 (89)
8 (100)
8 (80)
0
0
0
Complications, n (%) Tendonitis Infection
0
0
0
Tendon rupture
0
0
0
2 (11)
2 (25)
0
Postoperative regional pain Results are reported as mean standard error.
extension strength between the operative and uninjured wrist. In nondominant injuries; however, both were significantly decreased (Table 3). We determined the proportional strength recovered postoperatively by dividing the strength of the injured wrist by the strength of the uninjured wrist (proportion of strength recovered ¼ strength of injured wrist / strength of uninjured wrist) at the time of follow-up. Grip strength recovered to 86% and wrist extension recovered to 78% of the uninjured wrist. Figure 2 represents a graphical analysis of dominant and nondominant injuries and identified a significant difference in both recovery of grip strength and wrist extension.
low disability at the time of follow-up. There were no significant differences in outcomes scores between dominant and nondominant injury subgroups.
Outcomes surveys Table 4 presents survey results. The SF12 results showed that the study cohort and subgroups were similar to the general population for both the physical health composite score (mean, 52) and the mental health composite score (mean, 54) and were not significantly different between study subgroups. Both the PRWE and QuickDASH means identified
DISCUSSION Distal radius fractures present a considerable burden to the United States population; they account for more than 640,000 cases annually, with an increasing incidence.28,29 Distraction bridge plating is useful for cases of unstable and comminuted distal radius fractures, bilateral wrist injuries, and polytrauma patients.13e15 Critics of this method appropriately question whether
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Complications There were no cases of tendonitis, infection, or tendon rupture in the study group. There were 2 cases of surgical site pain (defined as continued pain reported by the patient, located at the surgical or injury site). Additional findings such as temperature and sweat pattern changes were not present at the time of follow-up. Further workup for diagnosis of complex regional pain syndrome, such as the use of bone scan, was not pursued or indicated.
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TABLE 2. Range of Motion (degrees) Comparison Between Study Groups
TABLE 3. Strength (kg) Comparison Between Study Groups Comparison Groups
Comparison Groups Study Groups
Operative Wrist
Uninjured Wrist
Operative Wrist
P Value
Uninjured Wrist
P Value
Total study group (N [ 18)
Total study group (N [ 18)
Grip
29 3
33 3
.013*
Wrist extension
37 8
47 7
.022*
35 5
37 5
.393
60 15
62 13
.723
Flexion
43 3
58 3
.001*
Extension
46 3
56 4
.025*
Pronation
66 4
73 3
.088
Subgroups
Supination
71 3
69 4
.424
Dominant wrist injury (n [ 8)
Ulnar deviation
23 2
29 2
.004*
Grip
Radial deviation
19 2
22 2
.102
Wrist extension
Nondominant wrist injury (n [ 10)
Subgroups Dominant wrist injury (n [ 8) Flexion
44 3
59 5
.025*
Extension
47 3
50 7
.767
Pronation
74 4
71 4
.075
Supination
70 4
73 3
.098
Ulnar deviation
26 3
30 4
.229
Radial deviation
19 3
22 3
.141
43 5
58 4
.028*
Extension
45 4
61 4
< .001*
Pronation
61 7
75 5
.035*
Supination
71 5
66 6
.099
Ulnar deviation
20 3
28 2
.004*
Radial deviation
19 3
21 2
.349
30 5
.012*
Wrist extension
19 4
29 6
.003*
patient’s contralateral uninjured wrist, for objective analysis of functional outcomes. In addition to grip strength and wrist range of motion measurements, we analyzed wrist extension strength to determine potential sequelae of plate placement underneath the wrist extensor compartment. A significant decrease in range of motion and wrist strength was identified in the total study population and when isolating nondominant wrist injuries. However, this difference was not upheld when analyzing dominant-sided wrist injuries. This suggests that rehabilitation and use of the injured wrist can result in nearly complete recovery of wrist motion and strength. Wrist flexion was the one exception, and it remained significantly reduced in both the dominant and nondominant groups. There were no cases of tendonitis, tendon rupture, or infection in this cohort despite known possible complications.14,30 These results support the safety of this surgical method with minimal adverse events. Two patients developed surgical site pain, which is in keeping with other surgical treatment methods.3e7,10 At the time of follow-up, the QuickDASH and PRWE scores indicated low disability and were similar to previous reports.27 This supports consistent patientreported outcomes for this technique (Table 5). Efforts were made to ensure the validity of the study population. The demographics of the study group were similar to that of the United States population in terms of self-reported mental and physical health with the SF12. All patients underwent the same procedure using the second metacarpal for distal
Results are reported as mean standard error. P values are reported for 2-tailed paired t tests. *Significant at P < .050.
postoperative motion and strength can be regained after immobilization of the wrist for the duration of fracture healing. There are also concerns regarding scar adhesions involving the wrist and digit extensor mechanism from placement of the bridge plate underneath the extensor compartment. Various methods of surgical fixation for distal radius fractures and their associated clinical outcomes have been described.3e7,10 However, reports of functional outcomes after treatment with the dorsal spanning bridge plate technique are limited (Table 5).5,14,26,27 Understanding functional recovery of patients treated with this method is critical for supporting surgical indications, guiding postoperative therapy, and optimizing outcomes. This investigation provides end point functional outcomes data for patients treated with distraction bridge plate fixation for distal radius fractures at greater than 1 year from implant removal. It is unique in that it used an individualized comparison group, the J Hand Surg Am.
24 5
Results are reported as mean standard error. P values are reported for 2-tailed paired t tests. *Significant at P < .050.
Nondominant wrist injury (n [ 10) Flexion
Grip
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FIGURE 2: Grip and extension strength ratios. The proportion of grip and extension strength recovered at the time of follow-up is displayed. The ratio of operative wrist strength to the uninjured wrist was determined for the total group, those with dominant wrist injuries, and those with nondominant wrist injuries. Means of subgroups were compared. Error bars display the standard errors of the mean. Differences were considered significant at P < .050.
TABLE 4.
Patient Self-Reported Outcomes Subgroups Study Cohort (N ¼ 18)
Dominant Wrist Injury (n ¼ 8)
Nondominant Wrist Injury (n ¼ 10)
P Value
Physical composite score
52 2
52 2
52 2
.998
Mental composite score
54 2
55 2
54 3
.783
PRWE
14 3
13 6
15 4
.768
QuickDASH
16 4
15 7
16 5
.865
Outcomes Survey (score) SF12
Results are reported as mean standard error.
fixation. The subgroups in the study had similar sample size, demographics, follow-up time, and fracture characteristics with one exception: All open fractures were sustained in the nondominant wrist injury group, possibly contributing to decreased motion and strength recovery. Because there were only 2 cases of open fractures in the entire group, this relation could not be statistically assessed. A limitation of this study was the small cohort population resulting from patients who were either lost or unable to follow-up. Our level 1 trauma center accepts patients from a large geographic area, and many patients were unable to travel the necessary distance to participate (Fig. 1). We attempted to minimize this limitation in small sample size by conducting J Hand Surg Am.
independent paired analyses against the best available comparison group: the patient’s own uninjured contralateral wrist. An ideal method to assess individual patient recovery would be a prospective longitudinal study using the patient’s ipsilateral wrist before injury for comparison; however, this was not practical. We thought that comparing the patient’s injured wrist with the contralateral, uninjured wrist would confer the most reliable assessment of recovery. This method did not account for inherent undiagnosed pathology of the uninjured wrist. Another possible limitation of this method was in analyzing the nondominant injured wrists against the respective comparison group, the dominant uninjured wrist, and vice versa. It may be surmised that there are differences in strength and r
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TABLE 5.
Literature Review of Functional Outcomes Associated With Bridge Plate Fixation Functional Results (degrees)
Study Ruch et al
27
Dodds et al35
Level of Evidence
Size, Technique, Follow-Up
Radial Ulnar Flexion Extension Pronation Supination Deviation Deviation
IV: prospective cohort
22 pts, avg age 55 y, 3rd metacarpal, 24.8 mo follow-up, avg 12 mo functional results
57
IV: retrospective 25 pts, avg age 54.6 y, review second metacarpal, 6.6 mo follow-up and functional results
46
65
77
76
Grip Strength
Complications and DASH
69% (contralateral) 3/22 infection 3/22 extensor lag DASH (24.8 mo): 11.5
42
76
69
14
18
0/25 EPL entrapment 0/25 extensor tendon rupture 0/25 infection
3/25 hardware failure DASH: N/A Richard et al
26
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IV: retrospective 33 pts, avg age 70 y, review second metacarpal (12 pts), third metacarpal (21 pts), 11.8 mo follow-up and functional results
Mithani et al36 IV: case series
Hanel et al14
8 pts, avg age 68 y, third metacarpal volar plate, used for prior nonunion, final followup time not reported
IV: retrospective 134 pts, second and third chart review metacarpal, follow-up not obtained
46
50
79
77
10/33 digital stiffness DASH (11.8 mo): 32
36
40
79
72
1/8 persistent pain DASH (final): 27.6
2/134 wound healing 5/134 hardware failure 2/134 malunion 2/134 nonunion 2/134 deep infection 2/134 extensor tendon adhesions 1/134 EPL rupture DASH: N/A (Continued)
BRIDGE PLATING DISTAL RADIUS FRACTURES
J Hand Surg Am.
0/25 radial sensory nerve injury
Pt, patient; avg, average; ECRL, extensor carpi radialis longus; EPL, extensor pollicus longus; N/A, not available; CRPS, complex regional pain syndrome.
75 80 65 45 1 pt case report, third metacarpal, 4 y functional results IV: case report Burke et al4
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range of motion between dominant and nondominant wrists at baseline, before injury, which biases this type of comparison. However, there is no evidenced-based consensus that supports this speculation.31e33 Recent data suggest that no baseline differences exist in strength or motion based on wrist dominance and that grip strength ratios, as used in this study, correlate well with DASH scores.34 Despite these limitations, we used self-reported validated functional outcomes questionnaires to supplement the results. Future studies performed in a prospective, randomized, controlled fashion are needed to compare the results of this method definitively with other surgical techniques for the treatment of distal radius fractures.
DASH: N/A
No complications
DASH: N/A
No complications 30 10 60 70 35 45
IV: retrospective 1 pt case report via chart case report review, second metacarpal, 12 mo functional results Hanel et al
13
IV: retrospective 62 pts via chart review, chart review second metacarpal Hanel et al
13
Study
TABLE 5.
DASH: N/A
No CRPS, 1/62 ECRL rupture, 1/62 hardware failure, 0/62 postoperative digit stiffness
Grip Strength Radial Ulnar Flexion Extension Pronation Supination Deviation Deviation Size, Technique, Follow-Up Level of Evidence
Functional Results (degrees)
Literature Review of Functional Outcomes Associated With Bridge Plate Fixation (Continued)
Complications and DASH
BRIDGE PLATING DISTAL RADIUS FRACTURES
ACKNOWLEDGMENT The University of Washington Department of Orthopaedics Resident Research Grant was awarded to one of the authors (A.L.) for this project. The sponsor had no role in development of the study design, data collection, or analysis. REFERENCES 1. Graff S, Jupiter J. Fracture of the distal radius: classification of treatment and indications for external fixation. Injury. 1994;25(suppl 4):S-D14-25. 2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691e697. 3. Behrens F, Johnson W. Unilateral external fixation: methods to increase and reduce frame stiffness. Clin Orthop Relat Res. 1989;241:48e56. 4. Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998;2(4):248e252. 5. Ginn TA, Ruch DS, Yang CC, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 pt 1):29e36. 6. Konrath GA, Bahler S. Open reduction and internal fixation of unstable distal radius fractures: results using the trimed fixation system. J Orthop Trauma. 2002;16(8):578e585. 7. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(2):205e215. 8. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208e210. 9. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am. 1990;15(5):721e727. 10. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3): CD003209. 11. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am. 2004;29(6): 1128e1138. 12. Obert L, Rey PB, Uhring J, et al. Fixation of distal radius fractures in adults: a review. Orthop Traumatol Surg Res. 2013;99(2):216e234. 13. Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius fractures: the Harborview method. Clin Orthop Relat Res. 2006;445:91e99. 14. Hanel DP, Ruhlman SD, Katolik LI, Allan CH. Complications associated with distraction plate fixation of wrist fractures. Hand Clin. 2010;26(2):237e243.
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15. Wolf JC, Weil WM, Hanel DP, Trumble TE. A biomechanic comparison of an internal radiocarpal-spanning 2.4-mm locking plate and external fixation in a model of distal radius fractures. J Hand Surg Am. 2006;31(10):1578e1586. 16. Ryu JY, Cooney WP 3rd, Askew LJ, An KN, Chao EY. Functional ranges of motion of the wrist joint. J Hand Surg Am. 1991;16(3): 409e419. 17. Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W. Combined Kirschner wire fixation in the treatment of Colles fracture: a prospective, controlled trial. Arch Orthop Trauma Surg. 1999;119(3-4):171e178. 18. Brady O, Rice J, Nicholson P, Kelly E, O’Rourke SK. The unstable distal radial fracture one year post Kapandji intrafocal pinning. Injury. 1999;30(4):251e255. 19. Fernandez JJ, Gruen GS, Herndon JH. Outcome of distal radius fractures using the short form 36 health survey. Clin Orthop Relat Res. 1997;(341):36e41. 20. 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(5): 316e322. 21. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006;(445): 58e67. 22. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A metaanalysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6): 1185e1199. 23. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87(6):829e836. 24. Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am. 1997;79(9):1303e1312. 25. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable
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Vol. 40, August 2015
Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures Alexander Lauder, MD,* Sonya Agnew, MD,† Karim Bakri, MBBS,‡ Christopher H. Allan, MD,* Douglas P. Hanel, MD,* Jerry I. Huang, MD*
Purpose To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures. Methods All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed QuickDisabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires. Results Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43 vs 58 ), extension (46 vs 56 ), and ulnar deviation (23 vs 29 ) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture. Conclusions Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods. (J Hand Surg Am. 2015;40(8):1554e1562. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Distal radius fracture, bridge plating, distraction plate, functional outcome.
From the *Department of Orthopaedics, University of Washington, Seattle, WA; the †Division of Plastic Surgery, Northwestern University, Jesse Brown VAMC, Chicago, IL; and the ‡Division of Plastic Surgery, Mayo Clinic, Rochester, MN. Received for publication February 13, 2015; accepted in revised form May 11, 2015. J.I.H. is a consultant to Arthrex. Arthrex has no financial involvement in this project. Corresponding author: Alexander Lauder, MD, Department of Orthopaedics and Sports Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, WA 98104; e-mail: [email protected]. 0363-5023/15/4008-0005$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.05.008
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account for approximately 17% of all fractures treated in emergency rooms.1,2 There are numerous surgical techniques to treat these fractures, including percutaneous pinning, external fixation, and plate fixation.3e7 The goals of surgical treatment are anatomic reduction of the distal radius, placement of a stable construct to enable fracture healing, and restoration of normal wrist kinematics.8e12 Dorsal spanning plate fixation has been described as an effective treatment option for unstable comminuted RACTURES OF THE DISTAL RADIUS
BRIDGE PLATING DISTAL RADIUS FRACTURES
distal radius fractures, bilateral wrist fractures with metaphyseal bone loss or diaphyseal extension, and complex injuries requiring extensive soft tissue and bony reconstruction.13e15 In addition, this method allows for early weight bearing and transfer in polytrauma patients with pelvic and lower extremity fractures.13e15 The plate is temporarily fixed to the second or third metacarpal under the extensor tendons. After fracture healing is confirmed at approximately 12 weeks, the plate is removed and therapy is initiated for wrist motion and strengthening.4,5,13,16 Functional results and complications have been previously reported with percutaneous fixation, volar plating, dorsal plating, and external fixation of distal radius fractures.12,17e25 The literature on outcomes after dorsal spanning plate fixation for distal radius fractures has been limited to retrospective reviews14,26 except for one prospective series by Ruch et al27 in 2005. We hypothesized that patients treated with dorsal spanning bridge plate fixation for unilateral distal radius fractures would have functional kinematics that were not significantly different from their unaffected wrist and not have significant functional impairment in their activities of daily living or work related activities greater than 1 year after plate removal. The purpose of this study was to systematically analyze the functional and kinematic outcomes of the wrist in patients after dorsal spanning bridge plate removal for the treatment of distal radius fractures.
considered research subjects. Consent was completed at the time of the clinical follow-up visit. Study population and inclusion All available patients over age 18 years who underwent surgical treatment of a unilateral distal radius fracture at our institution with dorsal spanning bridge plate fixation during the study period with greater than 1 year of follow-up from removal of the dorsal bridge plate were included in the study and enrolled at the time of follow-up. Exclusion criteria were patients with bilateral injuries, multiple methods of fixation of the radius (ie, volar plating, dorsal plating, other methods of surgical fixation), concomitant ipsilateral elbow or hand fractures, additional injuries to the affected wrist or contralateral wrist, additional surgery on the affected wrist after removal of bridge plate for unrelated injuries, and any surgical intervention on the contralateral wrist. Patients with Kwire fixation of the radial styloid in addition to dorsal bridge plate fixation were included. All ancillary hardware was removed before or at the time of the plate removal. Surgical indications and technique Indications for use of this technique included unstable comminuted distal radius fractures, open fractures with metadiaphyseal extension and bone loss, and polytrauma patients who were thought to benefit from early weight bearing and transfer. A standardized surgical technique was used in all patients as described previously using the second metacarpal for fixation of a dorsal spanning bridge plate.13 All patients received surgical treatment from 1 of 2 authors (C.A. or D.H.).
MATERIALS AND METHODS This functional outcomes analysis was approved by our institutional review board and adhered to the Strengthening and Reporting of Observational Studies in Epidemiology guidelines, and was conducted at a large level 1 trauma center. A data inquiry was completed for all patients who underwent surgical treatment of intra-articular distal radius fractures with Current Procedural Terminology codes 25608 or 25609 treated for at our tertiary care center from January 1, 2008 to December 31, 2012. Patient medical record numbers were retrieved from this query to create a research database on a secured passwordprotected file. We performed a medical chart review to verify that patients met inclusion criteria for the study. Patients who met criteria were contacted via telephone and asked to participate in the study. We made up to 5 attempts to contact each patient. Included participants returned for a clinic visit when outcomes data were collected. Neither patients nor their insurance were billed for the visit because patients were J Hand Surg Am.
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Data collection Data were collected from the patients at the study follow-up visit by 2 of the authors, an orthopedic surgical resident, and a hand fellow. Wrist motion, grip strength, and wrist extension strength were collected for both the injured wrist and the contralateral, uninjured wrist. We measured wrist range of motion using a goniometer and made strength measurements using a Baltimore Therapeutic Equipment machine (PrimusRS, Hanover, MD). Subjects completed questionnaires at the time of follow-up. These included the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) form, the Patient-Related Wrist Evaluation (PRWE) questionnaire, and the 12-item Short Form Health Survey (SF12). We collected the following information for each patient: patient demographics (age, sex, comorbidities, date of injury, date of surgery, additional injuries at the time of the r
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BRIDGE PLATING DISTAL RADIUS FRACTURES
FIGURE 1: Study enrollment. One hundred patients met inclusion criteria for the study. Eighteen patients were available for study participation after up to 5 attempts were made to contact all eligible patients.
distal radius fracture, follow-up time, fracture type, dominant wrist injury, and occupation); functional results after dorsal spanning plate removal (active wrist flexion and extension, radial and ulnar deviation, forearm pronation and supination, grip strength, and wrist extension strength); outcomes scores (QuickDASH, PRWE, and SF12 score); and complications (infection, wound problems, tendonitis, tendon rupture, hardware failure, and complex regional pain syndrome).
years after bridge plate removal. All patients sustained intra-articular multifragmentary distal radius injuries (AO 23.C3), and 11% were open fractures. Kinematic outcomes Table 2 reports kinematic comparisons for range of motion between the injured and comparison (uninjured) wrists. Wrist flexion, extension, and ulnar deviation were significantly lower in the injured wrist compared with the uninjured wrist in the total study population. Further analysis, isolating the dominant injuries and nondominant wrist injuries independently, identified significantly greater preservation of overall motion in dominant-sided wrist injuries. In dominant injuries, flexion was decreased compared with the contralateral wrist. Any perceived differences in extension, pronation, supination, ulnar deviation, and radial deviation did not reach significance. In nondominant injuries; however, extension, pronation, and ulnar deviation were significantly reduced compared with the uninjured wrist (Table 2).
Analyses and study groups Comparisons among functional outcomes between the operative and nonsurgical wrist were completed with independent paired t tests using the nonsurgical wrist for comparison. Descriptive statistics were completed with analysis of variance for means and chi-square analyses for proportions. Associations were considered significant with P < .050. Analyses were completed for the total study cohort and subgroups based on wrist dominance. Subgroup comparison analysis included dominant wrist injury and nondominant wrist injury.
Strength outcomes Table 3 lists results for grip and extension strength. Both grip strength and wrist extension strength were significantly decreased in the operative wrist compared with the contralateral wrist for the total study population. Analysis based on dominant wrist injuries showed no significant difference between grip and
RESULTS Enrollment and study population A total of 100 patients met the inclusion criteria for the study. Eighteen patients were available for study participation (Fig. 1). Table 1 lists the demographics. Follow-up averaged almost 3 years from injury and 2.7 J Hand Surg Am.
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TABLE 1.
Demographics and Fracture Characteristics in the Study Population Subgroup Study Cohort (N ¼ 18)
Dominant Wrist Injury (n ¼ 18)
Nondominant Wrist Injury (n ¼ 10)
Average
61 4
58 3
63 6
Range
29e89
44e71
29e89
13 (72)
8 (100)
5 (50)
Characteristic Age, y
Sex Male
5 (28)
0 (0)
5 (50)
Labor occupation, n (%)
Female
3 (17)
1 (13)
2 (20)
Dominant side injured, n (%)
8 (44)
8 (100)
0 (0)
Follow-up, y average (range) Since injury
2.9 0.3 (1.5e5.4)
3.0 0.4 (1.5e5.2)
2.9 0.4 (1.5e5.4)
Since bridge plate removal
2.7 0.3 (1.2e5.2)
2.7 0.4 (1.3e4.9)
2.6 0.4 (1.2e5.2)
18 (100)
8 (100)
10 (100)
Fracture characteristics, n (%) AO classification 23.C.3 Open fracture Closed fracture
2 (11)
0
2 (20)
16 (89)
8 (100)
8 (80)
0
0
0
Complications, n (%) Tendonitis Infection
0
0
0
Tendon rupture
0
0
0
2 (11)
2 (25)
0
Postoperative regional pain Results are reported as mean standard error.
extension strength between the operative and uninjured wrist. In nondominant injuries; however, both were significantly decreased (Table 3). We determined the proportional strength recovered postoperatively by dividing the strength of the injured wrist by the strength of the uninjured wrist (proportion of strength recovered ¼ strength of injured wrist / strength of uninjured wrist) at the time of follow-up. Grip strength recovered to 86% and wrist extension recovered to 78% of the uninjured wrist. Figure 2 represents a graphical analysis of dominant and nondominant injuries and identified a significant difference in both recovery of grip strength and wrist extension.
low disability at the time of follow-up. There were no significant differences in outcomes scores between dominant and nondominant injury subgroups.
Outcomes surveys Table 4 presents survey results. The SF12 results showed that the study cohort and subgroups were similar to the general population for both the physical health composite score (mean, 52) and the mental health composite score (mean, 54) and were not significantly different between study subgroups. Both the PRWE and QuickDASH means identified
DISCUSSION Distal radius fractures present a considerable burden to the United States population; they account for more than 640,000 cases annually, with an increasing incidence.28,29 Distraction bridge plating is useful for cases of unstable and comminuted distal radius fractures, bilateral wrist injuries, and polytrauma patients.13e15 Critics of this method appropriately question whether
J Hand Surg Am.
Complications There were no cases of tendonitis, infection, or tendon rupture in the study group. There were 2 cases of surgical site pain (defined as continued pain reported by the patient, located at the surgical or injury site). Additional findings such as temperature and sweat pattern changes were not present at the time of follow-up. Further workup for diagnosis of complex regional pain syndrome, such as the use of bone scan, was not pursued or indicated.
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TABLE 2. Range of Motion (degrees) Comparison Between Study Groups
TABLE 3. Strength (kg) Comparison Between Study Groups Comparison Groups
Comparison Groups Study Groups
Operative Wrist
Uninjured Wrist
Operative Wrist
P Value
Uninjured Wrist
P Value
Total study group (N [ 18)
Total study group (N [ 18)
Grip
29 3
33 3
.013*
Wrist extension
37 8
47 7
.022*
35 5
37 5
.393
60 15
62 13
.723
Flexion
43 3
58 3
.001*
Extension
46 3
56 4
.025*
Pronation
66 4
73 3
.088
Subgroups
Supination
71 3
69 4
.424
Dominant wrist injury (n [ 8)
Ulnar deviation
23 2
29 2
.004*
Grip
Radial deviation
19 2
22 2
.102
Wrist extension
Nondominant wrist injury (n [ 10)
Subgroups Dominant wrist injury (n [ 8) Flexion
44 3
59 5
.025*
Extension
47 3
50 7
.767
Pronation
74 4
71 4
.075
Supination
70 4
73 3
.098
Ulnar deviation
26 3
30 4
.229
Radial deviation
19 3
22 3
.141
43 5
58 4
.028*
Extension
45 4
61 4
< .001*
Pronation
61 7
75 5
.035*
Supination
71 5
66 6
.099
Ulnar deviation
20 3
28 2
.004*
Radial deviation
19 3
21 2
.349
30 5
.012*
Wrist extension
19 4
29 6
.003*
patient’s contralateral uninjured wrist, for objective analysis of functional outcomes. In addition to grip strength and wrist range of motion measurements, we analyzed wrist extension strength to determine potential sequelae of plate placement underneath the wrist extensor compartment. A significant decrease in range of motion and wrist strength was identified in the total study population and when isolating nondominant wrist injuries. However, this difference was not upheld when analyzing dominant-sided wrist injuries. This suggests that rehabilitation and use of the injured wrist can result in nearly complete recovery of wrist motion and strength. Wrist flexion was the one exception, and it remained significantly reduced in both the dominant and nondominant groups. There were no cases of tendonitis, tendon rupture, or infection in this cohort despite known possible complications.14,30 These results support the safety of this surgical method with minimal adverse events. Two patients developed surgical site pain, which is in keeping with other surgical treatment methods.3e7,10 At the time of follow-up, the QuickDASH and PRWE scores indicated low disability and were similar to previous reports.27 This supports consistent patientreported outcomes for this technique (Table 5). Efforts were made to ensure the validity of the study population. The demographics of the study group were similar to that of the United States population in terms of self-reported mental and physical health with the SF12. All patients underwent the same procedure using the second metacarpal for distal
Results are reported as mean standard error. P values are reported for 2-tailed paired t tests. *Significant at P < .050.
postoperative motion and strength can be regained after immobilization of the wrist for the duration of fracture healing. There are also concerns regarding scar adhesions involving the wrist and digit extensor mechanism from placement of the bridge plate underneath the extensor compartment. Various methods of surgical fixation for distal radius fractures and their associated clinical outcomes have been described.3e7,10 However, reports of functional outcomes after treatment with the dorsal spanning bridge plate technique are limited (Table 5).5,14,26,27 Understanding functional recovery of patients treated with this method is critical for supporting surgical indications, guiding postoperative therapy, and optimizing outcomes. This investigation provides end point functional outcomes data for patients treated with distraction bridge plate fixation for distal radius fractures at greater than 1 year from implant removal. It is unique in that it used an individualized comparison group, the J Hand Surg Am.
24 5
Results are reported as mean standard error. P values are reported for 2-tailed paired t tests. *Significant at P < .050.
Nondominant wrist injury (n [ 10) Flexion
Grip
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FIGURE 2: Grip and extension strength ratios. The proportion of grip and extension strength recovered at the time of follow-up is displayed. The ratio of operative wrist strength to the uninjured wrist was determined for the total group, those with dominant wrist injuries, and those with nondominant wrist injuries. Means of subgroups were compared. Error bars display the standard errors of the mean. Differences were considered significant at P < .050.
TABLE 4.
Patient Self-Reported Outcomes Subgroups Study Cohort (N ¼ 18)
Dominant Wrist Injury (n ¼ 8)
Nondominant Wrist Injury (n ¼ 10)
P Value
Physical composite score
52 2
52 2
52 2
.998
Mental composite score
54 2
55 2
54 3
.783
PRWE
14 3
13 6
15 4
.768
QuickDASH
16 4
15 7
16 5
.865
Outcomes Survey (score) SF12
Results are reported as mean standard error.
fixation. The subgroups in the study had similar sample size, demographics, follow-up time, and fracture characteristics with one exception: All open fractures were sustained in the nondominant wrist injury group, possibly contributing to decreased motion and strength recovery. Because there were only 2 cases of open fractures in the entire group, this relation could not be statistically assessed. A limitation of this study was the small cohort population resulting from patients who were either lost or unable to follow-up. Our level 1 trauma center accepts patients from a large geographic area, and many patients were unable to travel the necessary distance to participate (Fig. 1). We attempted to minimize this limitation in small sample size by conducting J Hand Surg Am.
independent paired analyses against the best available comparison group: the patient’s own uninjured contralateral wrist. An ideal method to assess individual patient recovery would be a prospective longitudinal study using the patient’s ipsilateral wrist before injury for comparison; however, this was not practical. We thought that comparing the patient’s injured wrist with the contralateral, uninjured wrist would confer the most reliable assessment of recovery. This method did not account for inherent undiagnosed pathology of the uninjured wrist. Another possible limitation of this method was in analyzing the nondominant injured wrists against the respective comparison group, the dominant uninjured wrist, and vice versa. It may be surmised that there are differences in strength and r
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TABLE 5.
Literature Review of Functional Outcomes Associated With Bridge Plate Fixation Functional Results (degrees)
Study Ruch et al
27
Dodds et al35
Level of Evidence
Size, Technique, Follow-Up
Radial Ulnar Flexion Extension Pronation Supination Deviation Deviation
IV: prospective cohort
22 pts, avg age 55 y, 3rd metacarpal, 24.8 mo follow-up, avg 12 mo functional results
57
IV: retrospective 25 pts, avg age 54.6 y, review second metacarpal, 6.6 mo follow-up and functional results
46
65
77
76
Grip Strength
Complications and DASH
69% (contralateral) 3/22 infection 3/22 extensor lag DASH (24.8 mo): 11.5
42
76
69
14
18
0/25 EPL entrapment 0/25 extensor tendon rupture 0/25 infection
3/25 hardware failure DASH: N/A Richard et al
26
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IV: retrospective 33 pts, avg age 70 y, review second metacarpal (12 pts), third metacarpal (21 pts), 11.8 mo follow-up and functional results
Mithani et al36 IV: case series
Hanel et al14
8 pts, avg age 68 y, third metacarpal volar plate, used for prior nonunion, final followup time not reported
IV: retrospective 134 pts, second and third chart review metacarpal, follow-up not obtained
46
50
79
77
10/33 digital stiffness DASH (11.8 mo): 32
36
40
79
72
1/8 persistent pain DASH (final): 27.6
2/134 wound healing 5/134 hardware failure 2/134 malunion 2/134 nonunion 2/134 deep infection 2/134 extensor tendon adhesions 1/134 EPL rupture DASH: N/A (Continued)
BRIDGE PLATING DISTAL RADIUS FRACTURES
J Hand Surg Am.
0/25 radial sensory nerve injury
Pt, patient; avg, average; ECRL, extensor carpi radialis longus; EPL, extensor pollicus longus; N/A, not available; CRPS, complex regional pain syndrome.
75 80 65 45 1 pt case report, third metacarpal, 4 y functional results IV: case report Burke et al4
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range of motion between dominant and nondominant wrists at baseline, before injury, which biases this type of comparison. However, there is no evidenced-based consensus that supports this speculation.31e33 Recent data suggest that no baseline differences exist in strength or motion based on wrist dominance and that grip strength ratios, as used in this study, correlate well with DASH scores.34 Despite these limitations, we used self-reported validated functional outcomes questionnaires to supplement the results. Future studies performed in a prospective, randomized, controlled fashion are needed to compare the results of this method definitively with other surgical techniques for the treatment of distal radius fractures.
DASH: N/A
No complications
DASH: N/A
No complications 30 10 60 70 35 45
IV: retrospective 1 pt case report via chart case report review, second metacarpal, 12 mo functional results Hanel et al
13
IV: retrospective 62 pts via chart review, chart review second metacarpal Hanel et al
13
Study
TABLE 5.
DASH: N/A
No CRPS, 1/62 ECRL rupture, 1/62 hardware failure, 0/62 postoperative digit stiffness
Grip Strength Radial Ulnar Flexion Extension Pronation Supination Deviation Deviation Size, Technique, Follow-Up Level of Evidence
Functional Results (degrees)
Literature Review of Functional Outcomes Associated With Bridge Plate Fixation (Continued)
Complications and DASH
BRIDGE PLATING DISTAL RADIUS FRACTURES
ACKNOWLEDGMENT The University of Washington Department of Orthopaedics Resident Research Grant was awarded to one of the authors (A.L.) for this project. The sponsor had no role in development of the study design, data collection, or analysis. REFERENCES 1. Graff S, Jupiter J. Fracture of the distal radius: classification of treatment and indications for external fixation. Injury. 1994;25(suppl 4):S-D14-25. 2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691e697. 3. Behrens F, Johnson W. Unilateral external fixation: methods to increase and reduce frame stiffness. Clin Orthop Relat Res. 1989;241:48e56. 4. Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998;2(4):248e252. 5. Ginn TA, Ruch DS, Yang CC, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 pt 1):29e36. 6. Konrath GA, Bahler S. Open reduction and internal fixation of unstable distal radius fractures: results using the trimed fixation system. J Orthop Trauma. 2002;16(8):578e585. 7. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(2):205e215. 8. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208e210. 9. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am. 1990;15(5):721e727. 10. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3): CD003209. 11. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am. 2004;29(6): 1128e1138. 12. Obert L, Rey PB, Uhring J, et al. Fixation of distal radius fractures in adults: a review. Orthop Traumatol Surg Res. 2013;99(2):216e234. 13. Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius fractures: the Harborview method. Clin Orthop Relat Res. 2006;445:91e99. 14. Hanel DP, Ruhlman SD, Katolik LI, Allan CH. Complications associated with distraction plate fixation of wrist fractures. Hand Clin. 2010;26(2):237e243.
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15. Wolf JC, Weil WM, Hanel DP, Trumble TE. A biomechanic comparison of an internal radiocarpal-spanning 2.4-mm locking plate and external fixation in a model of distal radius fractures. J Hand Surg Am. 2006;31(10):1578e1586. 16. Ryu JY, Cooney WP 3rd, Askew LJ, An KN, Chao EY. Functional ranges of motion of the wrist joint. J Hand Surg Am. 1991;16(3): 409e419. 17. Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W. Combined Kirschner wire fixation in the treatment of Colles fracture: a prospective, controlled trial. Arch Orthop Trauma Surg. 1999;119(3-4):171e178. 18. Brady O, Rice J, Nicholson P, Kelly E, O’Rourke SK. The unstable distal radial fracture one year post Kapandji intrafocal pinning. Injury. 1999;30(4):251e255. 19. Fernandez JJ, Gruen GS, Herndon JH. Outcome of distal radius fractures using the short form 36 health survey. Clin Orthop Relat Res. 1997;(341):36e41. 20. 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(5): 316e322. 21. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006;(445): 58e67. 22. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A metaanalysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6): 1185e1199. 23. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87(6):829e836. 24. Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am. 1997;79(9):1303e1312. 25. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable
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