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PubMed2006

A biomechanical comparison between two volar locking plate systems for distal radius fractures.

The biomechanical properties of two distal radius volar locking plate systems were investigated. A cadaveric model simulating distal radius fractures with dorsal comminution was selected. The biomechanical properties of fracture fixation using the Synthes volar locking T-plate and the Hand Innovation DVR plate were characterized. The average stiffness was 137.1 +/- 19.9 N/mm for the DVR group and 119.1 +/- 9.9 N/mm for the Synthes group (P = .49), and the average changes of the opening angle describing plastic deformation were 10.1 degrees +/- 4.0 degrees and 8.6 degrees +/- 13.2 degrees, respectively (P = .23). This study demonstrates that both the Synthes T-plate and Hand Innovations DVR plate fixation systems show comparable biomechanical characteristics.

Biomechanical Phenomena↗
PubMed1996

Intrafocal (Kapandji) pinning of unstable distal radius fractures: a preliminary report.

Seventeen consecutive patients (17 wrists) who underwent intrafocal pinning of unstable distal radius fractures, as described by Kapandji, were retrospectively reviewed at a mean of 42 weeks after surgery (range, 13-88 weeks). The patients were immobilized for 6 weeks postoperatively. All patients were assessed by a single physician and were asked a set of questions regarding subjective and functional status. All patients underwent physical examination of their upper extremities, and bilateral wrist PA and lateral x-rays were taken. There were 13 females and four males; the average age was 49 years. Ten dominant and seven nondominant extremities were involved. Average volar tilt on follow-up lateral wrist radiography was 7 degrees. This compares with -20 degrees at initial presentation, -12 degrees preoperatively, 6 degrees immediately postoperatively, and 10 degrees in the normal wrists. Radial shortening (average) was -2 mm at initial presentation, -1mm preoperatively, 1 mm postoperatively, 0 mm at follow-up, and 1 mm in the normal wrists. Radial inclination was 17 degrees initially, 20 degrees preoperatively, 23 degrees immediately postoperatively, 23 degrees on follow-up, and 24 degrees in the normal wrists. There was a trend for patients with osteopenic bone to lose their postoperative reduction. However, this was not statistically significant. Patients older than 65 years of age had significantly inferior radiologic results. Loss of pronation and supination averaged 2 degrees (range 0-10 degrees) compared with the uninjured wrist. Loss of dorsiflexion averaged 6.5 degrees, and palmar flexion averaged 7.6 degrees. The patients' subjective complaints were minimal. Average pain on visual analog scale (VAS) was 0.44/10. Function measured 8.64/10 (VAS). Sixteen of the patients were happy with the surgery and the outcome of their wrists. Complications included extensor tendon rupture (one patient), pin migration requiring premature removal (one patient), and initial loss of reduction requiring reoperation (one patient). Intrafocal pinning of unstable distal radius fractures provides an effective means to stabilize these complex injuries. Early follow-up suggests that the patients have a satisfactory functional outcome. The complications in this series were preventable. Intrafocal pinning should be added to the surgical armamentarium in treating distal radius fractures.

Adolescent↗
PubMed2003

Palmar tilt changes due to distal radius fractures and radiocarpal instability: a biomechanical study.

OBJECTIVE: To investigate the impact of dorsally angulated malunited distal radius fractures on the stability of the radiocarpal joint. METHODS: Eight fresh upper limb specimens from 4 human cadavers were obtained, in which radial osteotomy was performed to prepare models of Frykman I distal radius fracture. Pressure-sensitive film was applied to study the changes in the contact area distribution and the pressure load across the radiocarpal joint in response to palmar tilt variation, and the lateral radiograph of the wrist was taken at the end of pressure loading. RESULTS: When the dorsal tilt exceeded 10 degrees, the radioscaphoid and radiolunate articular contact areas were markedly decreased (P<0.01) and shifted to the dorsal aspect of the radiocarpal joint, where the pressure load was significantly increased (P<0.01). A dorsal radiocarpal subluxation was liable to occur on the sagittal plane when the dorsal tilt exceeded 40 degrees. CONCLUSION: A dorsal tilt over 10 degrees is the most primary cause of radiocarpal instability after a dorsal deformity due to distal radius fractures.

Adult↗
PubMed1996

The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and forearm rotation.

A biomechanical cadaver study was performed to evaluate the effect of dorsally angulated distal radius fractures on the distal radioulnar joint. Frykman I distal radius fractures were simulated, and laxity measurements were taken with and without sectioning the triangular fibrocartilage complex and the interosseous membrane. The findings of this study were threefold. First, measured in terms of radial diastasis, incongruency of the distal radioulnar joint occurred with increasing dorsal tilt of the distal radius. It became most dramatic with a change of more than 20 degrees of dorsal angulation of the distal radius. This corresponds to approximately 10 degrees of dorsal tilt of the articular surface of the distal radius, as measured on an x-ray film. Second, increased dorsal angulation caused interosseous membrane tightness and limited maximum pronation and maximum supination. Third, distal radioulnar joint dislocation did not occur until both the triangular fibrocartilage complex and interosseous membrane were sectioned. These results reveal the importance of anatomic reduction of the distal radius fracture and evaluation of damaged soft tissue structures.

Biomechanical Phenomena↗
PubMed2002

Distal radius fractures in adults.

Although distal radius fractures are a common injury in the elderly and young adult population, the classification, treatment options, and assessment of outcomes of these fractures remain controversial. Since there is no uniform fracture classification system, it is difficult to compare studies. An evidence-based model of management needs to be developed.

Colles' Fracture↗
PubMed2002

Three-dimensional in vivo kinematics of the distal radioulnar joint in malunited distal radius fractures.

How malunion of the distal radius affects the kinematics of the distal radioulnar joint in vivo was evaluated. A novel computed tomography image-based technique was used to quantify radioulnar motion in both wrists of 9 patients who had unilateral malunited distal radius fractures. In the injured wrists dorsal angulation averaged 21 degrees +/- 6 degrees, radial inclination averaged 18 degrees +/- 5 degrees, and radial shortening averaged 21 +/- 3 mm. Clinically, the average range of motion of the injured wrists was 75 degrees +/- 25 degrees pronation and 73 degrees +/- 23 degrees supination. Kinematics of the radius during pronation and supination in the malunited forearms was indistinguishable from that in the uninjured forearms. In both the axis of rotation of the radius passed through the center of the ulnar head, although it shifted slightly ulnar and volar in supination and radial and dorsal during pronation. In contrast to previous in vitro biomechanical findings, there was no dorsovolar radial translation at the extremes of pronation or supination and no translation of the radius along the rotation axis. Soft tissues may play a larger role in limiting function than previously appreciated, and treatment may require correction of altered soft tissue structures as well as any abnormal bone anatomy.

Adolescent↗
PubMed2004

Complications of treating distal radius fractures with external fixation: a community experience.

OBJECTIVE: To analyze the immediate postoperative complications associated with treating distal radius fractures with external fixation. DESIGN: A retrospective chart review of data obtained from 24 consecutive patients who were treated with small AO external fixators in 1997. SETTING: Two community medical centers. INTERVENTION: Preoperative and postoperative radiograph measurements were taken of radial inclination, radial tilt, and radial length, and fractures were classified according to the AO system. Patient charts were reviewed to document demographics, type of fixator used, open or percutaneous technique for pin placement, use of augmentation, additional operations, and complications. MAIN OUTCOME MEASUREMENTS: Complications associated with treating distal radius fractures with one type of external fixator. RESULTS: Sixteen of the 24 patients had complications: 5 with neuropathies of the median or superficial radial nerve, 9 with pin track infections, 2 with pin loosening, one with a nonunion, 2 with malunion, and 4 patients each with radial shortening, loss of radial tilt, collapse of ulnar border or volar intercalated segment instability (VISI) of the lunate and rotatory subluxation of the scaphoid. CONCLUSIONS: Postoperative complications following distal radius fractures treated with external fixation are common. Their effect, however, on long term functional results and patient satisfaction is negligible, with the exception of those patients with complications intrinsic to the fracture itself, i.e., nonunion, malunion or carpal malalignment.

Adult↗
PubMed2005

[Effects of circumferential rigid wrist orthoses in rehabilitation of patients with radius fracture at typical site].

BACKGROUND: The use of orthoses is a questionable rehabilitation method for patients with the distal radius fracture at typical site. The aim of this study was to compare the effects of the rehabilitation on patients with radius fracture at the typical site, who wore circumferential static wrist orthoses, with those who did not wear them. METHODS: Thirty patients were divided into 3 equal groups, 2 experimental groups, and 1 control group. The patients in the experimental groups were given the rehabilitation program of wearing serially manufactured (off-the-shelf), as well as custom-fit orthoses. Those in the control group did not wear wrist orthoses. Evaluation parameters were pain, edema, the range of the wrist motion, the quality of cylindrical, spherical, and pinch-spherical grasp, the strength of pinch and hand grasp, and patient's assessment of the effects of rehabilitation. RESULTS: No significant difference in the effects of rehabilitation on the patients in experimental groups as opposed to control group was found. Patients in the first experimental group, and in control group were more satisfied with the effects of rehabilitation, as opposed to the patients in the second experimental group (p<0.05). CONCLUSION: The effects of circumferential static wrist orthoses in the rehabilitation of patients with distal radius fracture at the typical site were not clinically significant. There was no significant difference between the custom and off-the-shelf orthoses.

Aged↗
PubMed2006

Volar versus dorsal plating in the management of intra-articular distal radius fractures.

PURPOSE: To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures. METHODS: This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score. RESULTS: Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score. Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one. CONCLUSIONS: Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.

Bone Plates↗
PubMed1996

Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility.

The Frykman, Melone, Mayo, and AO classification systems for distal radius fractures were evaluated for interobserver reliability and intraobserver reproducibility in a clinical setting using initial plain radiographs. Two attending orthopedic hand surgeons and two attending radiologists classified 55 sets of distal radius fractures. kappa-statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer. Interobserver agreement was rated as moderate for the Mayo classification and fair for the Frykman, Melone, and AO classifications. Intraobserver agreement was substantial for only one of four observers for each of the Frykman, Melone, and Mayo, while the remaining three observers achieved only fair to moderate reproducibility. Intraobserver agreement for the AO classification was fair for all four of the observers. Neither interobserver or intraobserver agreement was affected by combining similar subclasses in the Melone classification or by reducing the number of categories in the AO system from 27 to 9. However, further reducing the AO system to its three main types brought agreement to the "substantial" level. No difference was found in interobserver agreement between the first and second readings or in interobserver or intraobserver agreement between orthopedic hand surgeons and radiologists. Understanding the limitations of fracture classifications based solely on plain radiographs can help avoid undue reliance on them. Given the low degree of interobserver and intraobserver agreement for each of the distal radius fracture classifications in this study, their use as the sole means for determining the direction of treatment or for the direct comparison of results among different studies is not warranted.

Adult↗
PubMed1999

[The operative therapy of distal unstable radius fractures with dorsal and palmar plates. A retrospective study with respect to the DASH-score system].

The distal radius fracture is the most common human skeletal injury. Predominantly woman in the 6th to 7th decade are found. There is a high correlation to the post menopause high turn over osteoporosis and its negative calcium balance. Due to the various multifactoral radius fracture combinations is a detailed classification with its correlated treatment important. The operative intervention in the past played a secondary roll. The newest concepts demand an exact reconstruction of the articulating surfaces through closed reposition and K-wire support, screw osteosynthesis, external fixation and its combinated forms. The posttraumatical joint changes with secondary palmar and dorsal dislocation of the radius base after reduction caused the exact therapy scheme with respect to the AO-classification to be developed. In the clinic and policlinic Oskar-Helene-Heim of the Free University in Berlin 213 patients were surgicly treated on distal radius fractures either from volar or dorsaly with a plate osteosynthesis between 1988-1998. In cases of multidirectionional fractures with compression of the articular surfaces we combined a bicortal bone block or spongiosa to support and to avoid the secondary dislocation and thus arthrosis. The study was divided in three sections, beginning with the clinical inspection. Further followed the X-ray evaluation and the assessment of the DASH-scores.

Aged↗
PubMed2000

The role of osteoporosis in distal radius fractures.

Our study was designed to establish whether the degree of osteoporosis of the distal forearm affects the outcome of distal radius fractures in elderly women. We assessed the Gartland and Werley score, wrist mobility, grip strength, ulnar variance, radial inclination and palmar tilt of both wrists in 27 postmenopausal women who had sustained a unilateral distal radius fracture following a simple fall. Bone mineral density of the contralateral uninjured wrist and mid-tibial ultrasound velocity were measured. The Gartland and Werley score, wrist mobility, loss of grip strength and the radiological results of the fractured wrist did not correlate with bone mineral density of the uninjured distal radius or with mid-tibial ultrasound velocity. These results may indicate that the influence of osteoporosis on the radiological and clinical outcome in distal radius fractures is not very important.

Aged↗
PubMed1998

Long-term results of the external fixation of distal radius fractures.

OBJECTIVE: To evaluate the long-term results of external fixation of distal radius fractures. METHODS: A retrospective follow-up study (median follow-up, 5.3 years) of 49 patients with 50 distal radius fractures treated with an external fixator was carried out. An external fixator (Minifixator, Stratec Medical, Waldenburg, Switzerland) was used. The operative procedure is described in detail. A personal evaluation including clinical and radiologic assessment of both wrists was performed. RESULTS: The functional results, including the parameters strength, daily activities, range of motion, and presence of pain, as well as an anatomic score, the presence of osteoarthritis, the quality of reduction, and complications were recorded. Functional and anatomic results indicated excellent to good ratings in more than 80% of the cases. CONCLUSION: The external fixator is a versatile tool in the treatment of intra-articular and extra-articular fractures of the distal radius. The rate of algodystrophy (reflex sympathetic dystrophy) was 6%, and wrist stiffness was not found in our series.

Adult↗
PubMed2000

[Plate osteosynthesis of distal radius fractures--incidence, indications and results].

UNLABELLED: From 1.1.95 to 31.12.98 133 distal radius fractures were treated surgically. Internal fixation with a plate was carried out in 34 fractures (25%). 17 plates were placed dorsally, 16 plates on the volar aspect and one fracture was treated with a combined dorsal and volar plate. 29/34 fractures (87%) were reviewed 1 year after surgery. All fractures healed without further surgery. No infection occurred. 15 implants were removed. 23/29 (79%) internal fixations showed a good or excellent result, 6/29 (21%) a fair result. These 6 patients had in common: an intraarticular fracture (5), a volar tilt (5), a postoperative algodystrophy (5) or a secondary dorsal displacement (2). IN CONCLUSION: One fourth of all surgically treated distal radius fractures underwent plate osteosynthesis with about 80% of good or excellent results. Dorsal plate osteosynthesis showed better results than volar plate fixation. An additional, temporary external fixator in fractures with radial shortening proved a reliable help intraoperatively. Secondary displacement in these fractures did not occur.

Adolescent↗
PubMed1992

[Malposition of healed distal radius fracture. Indications, technique and timing of correction].

Typical complications of distal radius fractures include post-traumatic malalignment in about 20%. This is associated with ulno-carpal pain and impaired wrist function. Various corrective procedures have been recommended. Between 1972 and 1986, 96 patients with posttraumatic disorders after distal radius fractures underwent surgical treatment. Three different procedures were carried out: simple corrective osteotomy of the distal radius, combined correction of the radius and ulna, as well as isolated correction of the ulna (distal resection, step-cut osteotomy, hemiresection arthroplasty). 83 (86.5%) of the patients were followed up for an average of 7 years postoperatively. The functional results were evaluated according to Lidström. Excellent and good results were found in 58 (69.9%), fair in 20 (24.1%) and bad results in 5 (6.0%). The best results were mostly seen in cases with a short interval between trauma and corrective procedure. Distal ulna resection has not been performed in our department since 1986 because of poor results and concommitant wrist-instability. We recommend combined correction procedures in those patients with painful deformities within a period of no more than six to nine months after trauma. The indication should also take individual aspects such as profession, age, activities, complaints, and radiological findings into account. Signs of osteoarthrosis and wrist disorders due to severe soft tissue problems are contra-indications to any of the aforementioned correction procedures.

Adolescent↗
PubMed2004

[Clinical results after surgeries of intraarticular distal radius fractures].

UNLABELLED: The aim of the study was to evaluate treatment results of intraarticular distal radius fractures using the combined method and to compare it to other methods. MATERIAL AND METHODS: Between 2000 and 2003 we evaluated clinical results of 105 patients with intraarticular fracture of distal radius. Thirty-five patients underwent the repair of intraarticular fracture according to combined method (using Kirschner wires and external fixator), 30 patients - only with Kirschner wires and 40 patients - only with external fixator. Results were evaluated clinically and rentgenologically. The evaluation was made by scoring system according to J. J. Gartland and C. W. Werley (modified by A. Sarmiento). X-ray pictures were evaluated every 2 weeks till the 6(th) week ant after 6 months. RESULTS: Using combined method, treatment results were good and very good for 28 patients, and satisfactory for 7 patients. In case when Kirschner wires were used, good and very good results were found in 17 patients, and satisfactory - in 13 ones. When only external fixators were used, good and very good results were observed in 26 patients and satisfactory - in 14 patients. There was statistically significant difference between the groups (p<0.05). CONCLUSIONS: Better clinical treatment results of intraarticular distal radius fractures were achieved when combined method (using Kirschner wires and external fixator) was applied. Using other methods of treatment we observed more cases of secondary dislocations.

Adult↗
PubMed2004

[Do fixed-angle T-plates offer advantages for distal radius fractures in elderly patients?].

In the treatment of distal radius fractures, plate osteosynthesis using fixed-angle T-plates has become more common. Higher stability often allows functional aftertreatment in metaphyseal and articular fractures. So far it remains unclear whether these advantages also apply to elderly patients who commonly suffer from osteoporosis and reduced cooperativeness. Therefore, we evaluated the radiological loss of correction during fracture consolidation in patients aged more than 70 years. Fixed-angle plates were used in 44 patients (mean age: 79.4 years) while conventional T-plates were used in 30 patients (mean age: 78.2 years). Postoperative immobilization for 6 weeks by plaster or external fixator was performed in all patients. The loss of correction was significantly lower for fixed-angle plates (4.6% vs 40.0%). As a result of this study, we have gradually reduced immobilization in favor of early functional treatment. In a recent study fixed-angle plates so far seemed to permit stable fracture fixation. Our results underline the advantage of stable fixation in displaced fractures of the distal radius even in osteoporotic bone of elderly patients.

Aged↗
PubMed2005

A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures.

PURPOSE: External fixation and open reduction and internal fixation have been the traditional techniques for surgical fixation of unstable distal radius fractures. The existing literature has not identified which is superior, primarily because of the lack of comparative trials. We performed a comprehensive systematic review and meta-analysis of the current literature on external fixation and internal fixation of distal radius fractures to determine the dominant strategy based on available scientific evidence. METHODS: We searched MEDLINE and EMBASE for English-language articles published between 1980 and 2004 that satisfied predetermined inclusion and exclusion criteria. The outcomes of internal and external fixation were compared using continuous measures of grip strength, wrist range of motion, and radiographic alignment and categoric measures of pain, physician-rated outcome scales, and complication rates. Outcomes were pooled by random-effects meta-analysis and meta-regression analysis was used to control for patient age, presence of intra-articular fracture, duration of follow-up period, and date of publication. Sensitivity analyses were used to test the stability of the meta-analysis results under different assumptions. RESULTS: Forty-six articles were included in the review with 28 (917 patients) external fixation studies and 18 (603 patients) internal fixation studies. Meta-analysis did not detect clinically or statistically significant differences in pooled grip strength, wrist range of motion, radiographic alignment, pain, and physician-rated outcomes between the 2 treatment arms. There were higher rates of infection, hardware failure, and neuritis with external fixation and higher rates of tendon complications and early hardware removal with internal fixation. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis. CONCLUSIONS: The current literature offers no evidence to support the use of internal fixation over external fixation for unstable distal radius fractures. Comparative trials using appropriately sensitive and validated outcome measurements are needed to guide treatment decisions.

Bone Plates↗