Hemiarthroplasty for irreparable distal radius fractures in the elderly:A comprehensive review

BACKGROUND Elderly patients maintaining functional independence can now be candidates for primary wrist hemiarthroplasty to manage acute irreparable distal radius fractures(DRFs).However,further investigation with long-term follow-up is required to validate these initial findings.AIM To review the literature on the outcomes of distal radius hemiarthroplasty with available implants to assess its viability as a treatment option.METHODS A comprehensive review of the literature was conducted using electronic databases,including PubMed,Medline,and Scopus.The search terms employed were"distal radius fracture","hemiarthroplasty","wrist arthroplasty",and related terminology.The search was restricted to articles published in English from 1980 until June 2023.Inclusion criteria encompassed cases or case series of DRF treated with hemiarthroplasty,providing clinical or radiographic outcomes,and published in peer-reviewed journals.RESULTS A total of 2508 articles from PubMed and 883 from Scopus were identified initially.Following screening and removal of duplicates,13 articles met the inclusion criteria.These articles,predominantly clinical retrospective studies,provided insights into hemiarthroplasty outcomes,including functional improvements and complications.Hemiarthroplasty was a treatment option for complex DRF,particularly those cases with severe comminution,intraarticular involvement,or severe osteoporosis.Functional outcomes demonstrated improvements in pain relief,wrist mobility,and grip strength,with variability across studies.Complications included implant loosening,infection,nerve injury,and stiffness,with varying incidence rates influenced by surgical techniques and implant choice.Long-term outcomes were inadequately documented,warranting further research.CONCLUSION Hemiarthroplasty is a promising treatment for irreparable DRF in the elderly.Long-term outcomes and complications require further study.

Meta-analysis of the efficacy of volar plate internal fixation versus closed reduction and external fixation in the treatment of adult distal radius fractures

Objective:To compare the efficacy of open reduction and volar locking plate internal fixation with closed reduction and external fixation in the treatment of distal radius fractures by using meta analysis.Methods:The databases of CNKI,Wanfang,Weipu,Chinese biomedical literature,Pubmed,Embase,and Cochrane Library were retrieved,and the randomized controlled studies that directly compared the efficacy of plate internal fixation and closed reduction external fixation in the treatment of distal radius fractures published publicly from the establishment of the database to April 2023 were collected.The two researchers independently screened the retrieved literature according to the inclusion and exclusion criteria,extracted data,used Cochrane risk bias assessment tool for quality assessment,and used RevMan 5.4 software for meta analysis.Results:A total of 10 randomized controlled trials were included,all of which were in English.There were 1042 patients in total,and 9 of them were rated as low risk.Meta analysis results showed that one year after the treatment of distal radius fracture with volar locking plate internal fixation,DASH score[MD=-5.64,95%CI(-7.21,-4.06),P<0.00001];One year later,PRWE score[MD=-5.90,95%CI(-8.88,-2.92),P=0.001];Palm flexion[MD=5.92,95%CI(1.29,10.55),P=0.01];Pronation[MD=2.48,95%CI(0.59,4.36),P=0.01];Postrotation[MD=4.73,95%CI(2.15,7.31),P=0.0003];Grip strength[MD=0.61,95%CI(0.12,1.10),P=0.02];palmar tilt angle[MD=9.84,95%CI(5.66,14.02),P<0.00001];Radial inclination[MD=4.33,95%CI(2.97,5.69),P<0.00001]was superior to closed reduction plaster or splint external fixation.One year later,the European Five dimensional Health Scale(EQ-5D-5L)score[MD=0.02,95%CI(-0.01,0.05),P=0.27];Back extension[MD=2.22,95%CI(-4.15,8.59),P=0.49];Ulnar deviation[MD=3.49,95%CI(-0.80,7.78),P=0.11];Radial deviation[MD=2.05,95%CI(-2.39,6.50),P=0.37];Ulnar variance[MD=-1.14,95%CI(-3.16,0.88),P=0.27];There was no significant difference in complications[MD=0.77,95%CI(0.54,1.10),P=0.16](P>0.05).Conclusion:Based on the current clinical data,internal fixation with volar locking plate is more conducive to mid-term DASH score and grip strength recovery than closed reduction plaster or splint external fixation,but there is no significant difference in the quality of life and complications of patients.For adult distal radius fractures,surgical indications should be carefully grasped,and non operative treatment should be given priority.

Three dimensional finite element analysis of anatomic distal radius Nitinol memory connector treating distal radius fracture

Objective: To study the memory biomechanical character of anatomic distal radius Nitinol memory connector (DRMC) in treating distal radius fracture. Methods: Establishing three dimensional model and finite element analysis, we calculated the stress in and around the fracture faces when distal radius fracture was fixated with DRMC. Results: Axial holding stress produced by holding part of DRMC on distal radius was 14.66 MPa. The maximum stress of holding part was 40-70 MPa, the minimum stress was 3-7 MPa,and the stress of compression part was 20-40 MPa. Conclusion: The distribution of stress produced by DRMC around the fracture line is reasonable, and axial holding stress can help stabilize fracture during earlier period. The existence of longitudal compression and memory effect can transfer fixated disused section into developed section and enhance fracture healing.

External fixation is more suitable for intra-articular fractures of the distal radius in elderly patients

The purpose of this study was to compare the functional outcomes, psychological impact, and complication rates associated with external fixation and volar or dorsal plating in relation to the functional parameters following treatment of intra-articular fractures of the distal radius （IFDR） in patients older than 65 years. We hypothesized that using volar or dorsal plating would improve functional outcomes, but that it would be associated with more complications and equivalent functional outcomes when compared with the external fixation group. A total of 123 consecutive patients suffering from IFDR were recruited into the study. The patients were measured for clinical, radiological, and psychosocial functioning outcomes and were followed up after I week and 3, 6 and 12 months. After 3 months, the plating group had better pronation （P = 0.001）, supination, （P = 0.047） and extension （P = 0.043） scores. These differences were somewhat attenuated by 6 months and disappeared at I year. The plating group had a greater occurrence of wound infection （P = 0.043）, tendonitis, （P = 0.024） and additional surgery compared with the external fixation group. The only TNO-AZL Adult Quality of Life scores in the plating group that were lower than those in the external fixation group were in the ＂gross motor＂ category （walking upstairs, bending over, walking 500 yards; P = 0.023）. Internal fixation was more advantageous than external fixation in the early rehabilitation period; after I year the outcomes were similar. The plating group showed significantly higher levels of wound infection and tendonitis and had a greater need for additional surgeries.

Manual reduction with traditional small splints for distal radius fracture in older patients

Objective:To investigate the effect of manual reduction with traditional small splints fixation for distal radius fractures in older patients in the emergency department.Methods:Older patients(aged at least 60 years)with distal radius fractures were enrolled in this study.The patients were randomly divided into the treatment group and the control group.The treatment group was treated with manual reduction and small splints fixation.The control group was treated with manual reduction and resin plaster fixation.Before treatment,after reduction,and 3 months after treatment,the palmar tilt angle,ulnar deviation angle,and radial length were recorded.Before treatment and 3 months after treatment,the Cooney wrist joint scores were recorded.The time of fracture healing and related adverse events during the treatment were recorded.Results:Before treatment and after reduction,there were no statistically significant differences between the two groups in palmar tilt angle,ulnar deviation angle,or radial length(P>0.05).Three months after treatment,the palmar tilt angle,ulnar deviation angle,and radial length of the treatment group were better than those of the control group(P<0.05).The Cooney wrist scores of the treatment group was significantly higher than that of the control group three months after the treatment(P<0.05).The time of fracture healing of the treatment group was shorter than that of the control group,but the difference was no statistically significant(P>0.05).Conclusions:Compared with resin plaster fixation,traditional small splints fixation for distal radius fractures in older patients have the advantages of less loss of fracture reduction and faster functional recovery.Besides,the method is simple and low cost thus,it needs to be promoted.

Reliability of the pronator quadratus fat pad sign to predict the severity of distal radius fractures

AIM To evaluate the reliability of pronator quadratus fat pad sign to detect distal radius fracture and to predict its severity.METHODS Retrospectively we identified 89 consecutive patients(41 female, mean age 49 ± 18 years) who had X-ray(CR) and computed tomography(CT) within 24 h following distal forearm trauma. Thickness of pronator quadratus fat pad complex(PQC) was measured using lateral views(CR) and sagittal reconstructions(CT). Pearson's test was used to determine the correlation of the PQC thickness in CR and CT. A positive pronator quadratus sign(PQS) was defined as a PQC > 8.0 mm(female) or > 9.0 mm(male). Frykman classification was utilized to assess the severity of fractures.RESULTS Forty-four/89 patients(49%) had a distal radius fracture(Frykman Ⅰ n = 3, Ⅱ n = 0, Ⅲ n = 10, Ⅳ n = 5, Ⅴ n = 2, Ⅵ n = 2, Ⅶ n = 9, Ⅷ n = 13). Mean thickness of the PQC thickness can reliably be measured on X-ray views and was 7.5 ± 2.8 mm in lateral views(CR), respectively 9.4 ± 3.0 mm in sagittal reconstructions(CT), resulting in a significant correlation coefficientof 0.795. A positive PQS at CR was present in 21/44 patients(48%) with distal radius fracture and in 2/45 patients(4%) without distal radius fracture, resulting in a specificity of 96% and a sensitivity of 48% for the detection of distal radius fractures. There was no correlation between thickness of the PQC and severity of distal radius fractures.CONCLUSION A positive PQS shows high specificity but low sensitivity for detection of distal radius fractures. The PQC thickness cannot predict the severity of distal radius fractures.

Pulmonary thromboembolism after distal ulna and radius fractures surgery: A case report and a literature review

BACKGROUND Pulmonary thromboembolism(PTE)is a serious postoperative complication that can occur after a fracture.Generally,PTE is caused by the falling off of lower extremity deep vein thrombosis(LEDVT)after lower limb fracture surgery.LEDVT and PTE after upper extremity fracture surgery are very rare.PTE is one of the most common clinical causes of sudden death.Venous thromboembolism includes PTE and DVT.We experienced one case of LEDVT and PTE after distal ulna and radius fracture surgery.The purpose of our report is to raise awareness for orthopedic surgeons that PTE can occur after distal ulna and radius fracture surgery,and patients with high risk factors should be considered for prevention and treatment of thrombosis in a timely manner.CASE SUMMARY We report a 51-year-old Chinese male who had severe fractures of the left distal ulna,radius and little finger after a motorcycle accident.The patient underwent external fixation,open reduction and internal fixation.On the third post-operative day,computed tomographic pulmonary angiography showed PTE.Doppler ultrasonography showed thrombus formation in the bilateral posterior tibial veins.After a period of anticoagulation therapy,on the 25th d after the PTE,computed tomographic pulmonary angiography showed that thrombus in both sides of the pulmonary artery disappeared.Furthermore,about 4 mo after the PTE,thrombosis in the deep veins of the lower limbs disappeared.About 1 year after the surgery,X-rays showed good fracture healing,and the function of the wrist joint recovered well.CONCLUSION Though rare,PTE can occur after distal ulna and radius fracture surgery and patients with high risk factors should be considered for prevention and treatment of thrombosis in a timely manner.

Comparison of Patient Satisfaction between Brachial Plexus Block (Axillary Approach) and General Anesthesia for Surgical Treatment of Distal Radius Fractures: A Historical Cohort Study

Background: Distal radius fracture surgery is performed under general (GA) or regional anesthesia with brachial plexus block (NB). Whether anesthesia type affects patient outcomes is unclear. This study retrospectively compared patient satisfaction between GA and NB after surgery. Methods: This was a historical cohort study of 80 (34 GA and 46 NB) patients who underwent volar plate fixation of distal radius fractures. Propensity score analysis was used to generate a set of matched cases (NB) and controls (GA), yielding 14 matched patient-pairs. The simplified patient satisfaction scale was compared for primary outcomes. Secondary outcomes were anesthesia and surgery duration, hospital stay length, adverse events, postoperative analgesic requirement, and wrist range of motion (ROM) 2 weeks and 3 months postoperatively. Results: After propensity score matching, patients in almost all cases in both groups were “Satisfied” (effect size: 0.1, p = 0.572), indicating little significant difference. Significant differences in adverse events and postoperative analgesic use observed before matching disappeared after matching. Anesthesia duration and hospital stay length were significantly shorter in the NB group (effect size: -1.27 and -0.77, p = 0.00074 and p = 0.0388, respectively), as was surgery duration (effect size: -0.84, p = 0.0122) after matching. Similar to before matching, wrist ROM significantly improved in the NB group (effect size: 1.11, p = 0.0279) in the early postoperative period, but the difference disappeared at 3 months postoperatively. Conclusions: Patient satisfaction between distal radius fracture surgery under GA and NB was similar. Nerve block could help shorten hospital stay length and surgery duration and improve postoperative functional recovery.

Ulnar nerve injury associated with displaced distal radius fracture:Two case reports

BACKGROUND Ulnar nerve injury subsequent to a fracture of the distal radius is extremely rare compared to median nerve injury.Treatment of ulnar nerve injury after closed distal radial fracture is controversial.Reasonable surgical planning and careful postoperative management can improve the prognosis of patients.CASE SUMMARY We report two cases of ulnar nerve injury subsequent to fracture of the distal radius.Both patients were admitted to hospital.Both patients had persistent ulnar nerve compression syndromes.The first patient achieved rapid recovery by early nerve decompression surgery,while the second patient had no recovery at 2-3 mo after injury and had more severe symptoms.At 10 wk after injury,the second patient agreed to nerve decompression surgery.The second patient finally achieved a successful outcome after nerve decompression and neurolysis,although she still has residual symptoms.CONCLUSION For patients with ulnar nerve compression syndrome related to acute wrist fracture,if symptoms persist and signs of recovery are not observed,early release is necessary to prevent permanent neurological damage.

Small splints versus plate fixation for distal radius fractures: A meta- analysis and systematical analysis

Objective:Evaluate the efficacy,safety and economy of small splints and plate in the treatment of distal radius fractures(DRFs).Methods:Seven electronic databases,including PubMed,EMBASE,Cochrane Library,sinomed,CNKI,VIP and Wanfang,were searched for the original study.Literature was screened according to the inclusion and exclusion criteria,and the methodological quality of the included studies was evaluated by Cochrane risk bias assessment tool.The software Revman 5.4 was used for data analysis.Results:A total of 19 studies were included in the study.The clinical effective rate of the plate group[RR=0.96,95%CI(0.93,0.99),P=0.007],Radial inclination[MD=-1.85,95%CI(-2.93,-0.77),P=0.0008],Ulnar inclination[MD=-2.49,95%CI(-3.95,-1.04),P=0.0007],relative height of radius[MD=-1.63,95%CI(-2.40,-0.86),P<0.0001]were better than those in small splints group.There was no significant difference in fracture healing time[MD=-4.39,95%CI(-9.07,0.28),P=0.07]and complications[RR=1.57,95%CI(0.98,2.52),P=0.06]between the two groups.In terms of treatment cost[MD=-2.83,95%CI(-3.37,-2.30),P<0.00001],the small splint group was better than the plate treatment group.Conclusion:Compared with small splints therapy,plate internal fixation has advantages in clinical effective rate and imaging scores.There is no significant difference in fracture healing time and complications between the two groups.In terms of treatment cost,small splint therapy is better than plate therapy.Clinical treatment should be selected and formulated according to the individual situation,demands and clinical practice of patients.

Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction:Results of the SLA-VER noninferiority trial

BACKGROUND Distal radius fractures(DRFs)are a common challenge in orthopaedic trauma care,yet for those fractures that are treated nonoperatively,strong evidence to guide cast treatment is still lacking.AIM To compare the efficacy of below elbow cast(BEC)and above elbow cast(AEC)in maintaining reduction of manipulated DRFs.METHODS We conducted a prospective,monocentric,randomized,parallel-group,open label,blinded,noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs.Two hundred and eighty patients>18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period.Noninferiority thresholds were defined as a 2 mm difference for radial length(RL),a 3°difference for radial inclination(RI),and volar tilt(VT).The trial is registered at Clinicaltrials.gov(NCT03468023).RESULTS One hundred and forty-three patients were treated with BEC,and 137 were treated with AEC.The mean time of immobilization was 33 d.The mean loss of RL,RI,and VT was 1.59 mm,2.83°,and 4.11°for BEC and 1.63 mm,2.54°,and VT loss were respectively 0.04 mm(95%CI:-0.36-0.44),-0.29°(95%CI:-1.03-0.45),and 0.59°(95%CI:-1.39-2.57),and they were all below the prefixed noninferiority thresholds.The rate of loss of reduction was similar.CONCLUSION BEC performs as well as AEC in maintaining the reduction of a manipulated DRF.Being more comfortable to patients,BEC may be preferable for nonoperative treatment of DRFs.

Dynamic External Fixator Combined with Volar Locking Plate Fixation for the Treatment of AO Type C3 Distal Radius Fractures

Background: AO type C3 distal radius fracture (DRF) is the most difficult-to-treat fracture type because of a tendency to shorten and collapse. The purpose of this study is to investigate the clinical and radiographic outcomes of comminuted intra-articular DRFs treated with a dynamic external fixator combined with a volar locking plate (VLP). Methods: Eleven patients (mean age, 61 years) with comminuted intra-articular DRFs were treated with a dynamic type of external fixator combined with a VLP. Following reduction and fixation with a VLP, the dynamic external fixator was applied and the distal ball joint of the fixator was aligned with the lunate-capitate line. The ball joint was unlocked approximately 2 weeks after surgery to allow wrist mobilization. The fixator was removed 3 - 6 weeks (mean, 5 weeks) after surgery. Consequently, clinical and radiographic assessments were carried out at the final follow-up. Results: At the final follow-up, the mean range values of wrist extension and flexion were 76&deg;and 64&deg;, respectively. Compared with the contralateral side, the mean grip strength was 84%. The mean Modified Mayo Wrist Score and the Disabilities of the Arm, Shoulder and Hand score were 88 and 9, respectively. No significant differences in the radiographic parameters exist between after surgery and final follow-up. Conclusions: This study indicated that the dynamic wrist fixator combined with a VLP is effective for the treatment of AO type C3 DRFs.

Distal Radius Fracture: What Does the Patient Want?

Distal radius fractures are common and while historically most have been treated nonoperatively the frequency with which distal radius fractures are treated surgically is increasing. Criteria for considering surgical treatment are often based on radiographic appearance of the fracture. Less often discussed is patient preference: what do patients want. We investigated responses of a general population when presented with various treatment options following a hypothetical distal radius fracture. Many respondents chose nonoperative treatment even when told that surgery might result in a better outcome. This information can help during the shared decision-making process when discussing treatment options with a patient who presents with a distal radius fracture.

Robert Jones bandage versus cast in the treatment of distal radius fracture in children:A randomized controlled trial

Purpose:The present study aimed to treat fractures of the distal end of the radius in children with Robert Jones(RJ)bandage.The objective was to compare this treatment modality with the cast regarding the frequency of the complication occurrence,child comfortability,and family satisfaction.Methods:The study was a randomized controlled non-inferiority clinical trial including children with recent(less than 5 days)fractures at the distal end of the radius OTA/AO 23-A2,which is usually treated conservatively.Those with open fractures,pathological fracture,severely displaced fracture that needs reduction or multiple injuries were excluded.The participants were divided randomly into 2 groups according to the treatment modalities.Group 1 was treated by plaster of Paris cast(the control group).and Group 2 by modified RJ bandage(the trial group).The difference between the 2 groups was found by the Chi-squared test.The difference was considered statistically significant when the p value was less than 0.05.Results:There were 150 children(aged 2-12 years,any gender)included in the study,75 in each group.The complications occured in 5(3.3%)cases only,pressure sores of 3 cases in Group 1 and fracture displacement of 2 cases in Group 2.There was no statistically significant difference in the rate of complication occurrence between both modalities of treatment(p=0.649).Children treated by RJ bandages were more comfortable than those treated by the cast(97.3%vs.73.3%,p<0.001)with a statistically significant difference between them.Contrary to that,the families were more satisfied with the cast than RJ bandage(88.0%vs.81.3%),but without a statistically significant difference(p=0.257).Conclusion:RJ bandage is a non-inferior alternative to the cast for the treatment of fractures at the distal end of the radius that can be treated conservatively in children.

Treatment of type C3 distal radius fracture resulted from high-energy injuries by volar plate in combination with external fixator

Background With a type C3 distal radius fracture it is extremely difficult to maintain the reduction and to restore congruity of the articular surface because the support for the volar and dorsal bone cortex has been lost. An external fixator crossing wrist in combination with Kirschner wire （K-wire） fixation was popularly used by most studies in recent years. But loss of reduction often occurred especially in the volar sides. Methods A total of 30 cases of type C3 distal radius fracture were treated by a volar buttress plate combined with a transarticular external fixator and other techniques such as K-wire fixation and bone grafting if necessary. The postoperative volar tilt angles, ulnar inclinations, radial heights, range of motion, grip strength and complications were recorded to assess the therapeutic effects. Results Of the 30 patients, 27 patients were followed up for 12-29 （mean 18） months and all fractures healed in 8-13 weeks after surgery （mean 10 weeks）. The wrist function was excellent in 8 cases, good in 16 cases and fair in 3 cases according to the Sarmiento scoring system （modified by Stewart）. Conclusions For type C3 comminuted fracture with severe volar and dorsal instability, fixation by volar buttress plate combined with transarticular external fixator should be adopted. Dorsal instability could be further stabilized by other techniques such as Kirschner wire fixation, and bone grafting.

Effect of fixing distal radius fracture with volar locking palmar plates while preserving pronator quadratus

Background L-shaped incision of pronator quadratus （PQ） muscle along its radial and distal borders was always taken for distal radius fractures reduction and internal fixation.Repair of the PQ muscle was always recommended at the end of operation for some instructive reasons.But repair of PQ is not satisfied because of poor quality of muscle and fascial tissues which may cause pain or impede forearm pronation and supination for post-operative scarring around PQ.Inserting the locking palmar plate to pass under the pronator quadratus muscle and the locking screws are inserted through miniincisions in pronator quadratus in some patients with distal radius fractures is a reasonable technique which can preserve the pronator quadratus.The purpose of this study was to evaluate and compare the clinical effects after volar plating of the distal radius fractures while preserving the pronator quadratus and pronator quadratus repair.Methods Between September 2010 and April 2012,65 patients （42 males and 23 females; aged 20-68 years and a mean age of 42.5 years） with distal radius fracture underwent open reduction and internal fixation using the volar locking palmar plates （Depuy or Smith companies）.The patients were classified as 23A-2 through 23C-3 according to the Orthopaedic Trauma Association （OTA） classifications.All surgeries were completed by the same trained team.The volar locking palmar plates of distal radius performed with preserving pronator quadratus group involved 30 patients including 19 males and 11 females and performed with pronator quadratus repair group involved 35 patients including 23 males and 12 females.We compared the two groups for wrist pain,forearm range of motion,grip strength,pedoperative complications and wrist functional recovery score.Results The minimum follow-up for the whole cohort was one year.The differences between the two groups were significant with regard to wrist pain,forearm range of motion,grip strength and wrist function at 1,2,and 6 weeks postoperatively,but insignificant at 6 and 12 months postoperatively.No significant differences were found in the pedoperative complications and radiographs postoperatively.Conclusions Preservation of the pronator quadratus muscle is a satisfactory method for the treatment of majority of the fractures of the distal radius with volar locking palmar plates,as this technique can yield better early wrist function and shorten the rehabilitation.

Use of mineralized collagen bone graft substitutes and dorsal locking plate in treatment of elder metaphyseal comminuted distal radius fracture

Bone graft may be needed to fill bone defect in elderly patients with a metaphyseal comminuted distal radius fracture. In this retrospective, nonrandomized, single-surgeon study, we evaluated the clinical and radiologic outcomes of using both dorsal locking plates with or without augmentation with mineralized collagen （MC） bone graft for elderly patients with dorsally metaphyseal comminuted radius fractures. Patients in group 1 （n = 12） were treated with dorsal locking plates with MC bone graft application into the metaphyseal bone defect, and those in group 2 （n - 12） only with dorsal locking plates. Clinical and radiologic parameters were determined at three and 12 months after surgery. At final follow-up, no significant difference was noted between the 2 groups in terms of palmar tilt and radial inclination （p - 0.80）; however, ulnar variance increased significantly in the group 2 treated with dorsal locking plates without augmentation （p〈0.05）. Functionally, there was no significant difference between the groups. Our preliminary study suggests that combination of MC as bone-graft substitutes and dorsal locking plates may be a usefully alternative for elderly patients with metaphyseal comminuted distal radius fracture.

Distal end radius fractures： evaluation of results of various treatments and assessment of treatment choice

Objective：The rapid expansion of knowledge regarding the functional anatomy of hand and wrist,increasing functional demands of senior citizens and improved methodologies of achieving and maintaining anatomic restoration of distal radius fractures has generated a renewed interest in addressing these fractures in a more precise manner.The purpose of our study was to evaluate the difference in patients function among those treated by 1） closed reduction and Plaster of Paris cast,2） distractor application,or 3） open reduction and internal fixation with a volar plate,and to assess the treatment choice for each particular fracture type.Methods：A prospective study was carried out on 60 patients with fractures of the distal end radius.Fractures were classified according to the AO classification into type A （extra-articular）,type B （partial articular） and type C （complete articular）.After initial evaluation patients were taken up for either conservative or operative treatment and were followed up for two years.Results：Anatomical results were evaluated according to the Sarmiento＇s modification of Lindstrom Criteria,which showed that excellent results were more frequent with open reduction and internal fixation using the plating technique.Clinical and functional results were evaluated according to the demerit point system of Gartland and Werley with Sarmiento modification,which was revealed to relate with the type of treatment techniques.Conclusion：There is no customized solution for all the fractures of the distal radius.The choice of treatment should be based on the fracture type,the patient＇s characteristics,the patient＇s demands and the treating surgeon＇s experience and preference.

A comparative study of variable angle volar plate and bridging external fixator with K-wire augmentation in comminuted distal radius fractures

Purpose:Comminuted intraarticular distal radial fractures are difficult to treat conservatively and require operative treatment.This study compared the functional outcomes between variable angle volar plating and external fixator with K-wire augmentation in open reduction and internal fixation.Methods:A total of 62 adult patients with comminuted intraarticular distal radius fracture were randomized into 2 groups:volar plate group and external fixator group.These patients aged between 18 and 60 years had unilateral fractures,and agreed to be included in the study.Patients with a history of fracture,bilateral fracture,associated other injuries,delayed injury for more than 2 weeks,open fracture,pre-existing arthrosis or disability,psychiatric illness and pathological fracture were excluded.Patients were followed up at 6 weeks,3 months,6 months and 1 year.The assessment of pain,functional activity,range of motion and grip strength was done at each stage of follow-up.The pain and functional activities were assessed by patient rated wrist evaluation(PRWE)score and disabilities of the arm,shoulder and hand(DASH)score.Results:Patients in volar plate group had superior PRWE score and DASH score at each stage of followup.At 1 year follow-up,the mean PRWE score were 7.48 for volar plate group and 7.35 for external fixator group;while the mean DASH score was 4.65 for volar plate group and 5.61 for external fixator group.They had better flexion and extension range of movement.They also had better pronation and supination range of motion at initial follow-up,however the difference get attenuated by 1 year.Volar plate group had significantly better grip strength than external fixator group.Complication rates were higher in external fixation group.Conclusion:Fixation with variable angle volar plate results in early wrist mobilization,better range of movement,less pain and disability and early return of function.

Do we really need to repair the pronator quadratus after distal radius plating?

Purpose:Fractures of distal radius are one of the common orthopaedic injuries.Placing the plate on volar surface requires release of underlying pronator quadratus(PQ)muscle.No consensus is present in the literature about the repair or not of the PQ.The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications.Methods:Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated.Demographic data,operative notes and physical therapy records were retrieved.Patients were divided into group A where PQ repair was done and group B where no repair was done.Functional data such as range of motion(ROM),grip strength,visual analogue scale(VAS)score and disabilities of arm,shoulder and hand(DASH)score at 4 weeks,3 months,6 months and finial follow-up were retrieved.Results:Totally 63 patients(n=29 in group A and n=34 in group B)with the mean age of 51.64 years were examined.Patients were followed up for a mean of 35.2 months(range 27.2-47.1 months)in group A and 38.6 months(range 28.6-51.0 months)in group B.Though functional outcome of the affected limb was not significantly different between two groups after 3 months,PQ repair did affect the recovery at an early stage.Repair group had significantly better ROM(p=0.0383)and VAS score at 4 weeks(p=0.017)while grip strength(p=0.014)was significantly better at 3 months.Conclusions:Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.