Extract
The older population
continues to grow and, at the same time, live more active lives; as a
consequence, the incidence of distal radial fractures can be expected to
increase. There is no Level-I
clinical evidence suggesting a superior modality for treatment of distal
radial fractures. The lunate facet has a
considerable volar extension at the distal extent of the pronator quadratus
and subsequently has an important role in fracture pathomechanics and
stability. Application of a volar
plate with angular stable fixation has been used successfully in a number of
cohort studies but needs to be examined in stringent trials to determine if
there is any benefit when compared with other treatment modalities. Irritation of the
flexor pollicis longus and irritation of extensor tendons are possible
complications of fixation with a locked volar plate.
The older population
continues to grow and, at the same time, live more active lives; as a
consequence, the incidence of distal radial fractures can be expected to
increase. There is no Level-I
clinical evidence suggesting a superior modality for treatment of distal
radial fractures. The lunate facet has a
considerable volar extension at the distal extent of the pronator quadratus
and subsequently has an important role in fracture pathomechanics and
stability. Application of a volar
plate with angular stable fixation has been used successfully in a number of
cohort studies but needs to be examined in stringent trials to determine if
there is any benefit when compared with other treatment modalities. Irritation of the
flexor pollicis longus and irritation of extensor tendons are possible
complications of fixation with a locked volar plate.
The older population
continues to grow and, at the same time, live more active lives; as a
consequence, the incidence of distal radial fractures can be expected to
increase.
There is no Level-I
clinical evidence suggesting a superior modality for treatment of distal
radial fractures.
The lunate facet has a
considerable volar extension at the distal extent of the pronator quadratus
and subsequently has an important role in fracture pathomechanics and
stability.
Application of a volar
plate with angular stable fixation has been used successfully in a number of
cohort studies but needs to be examined in stringent trials to determine if
there is any benefit when compared with other treatment modalities.
Irritation of the
flexor pollicis longus and irritation of extensor tendons are possible
complications of fixation with a locked volar plate.
Interest in one of the most common injuries to the musculoskeletal
system—the distal radial fracture—has been renewed. Literature
over the past two centuries had even led some to believe that the distal
radial fracture was a solved problem. In contrast, we are now confronted with
a marked swing toward stable internal fixation being touted by some authors as
the treatment of choice for all but the most stable, aligned fractures.
Instructional courses, symposia, and skills courses worldwide are now
oversubscribed, bearing witness to these changing perspectives.
It is surprising that, despite this aggressive push toward internal
fixation, there is no convincing evidence that supports this approach in the
contemporary literature. To what can we attribute this dramatic shift in the
management of the distal radial fracture? In this review, we will attempt to
answer this question by looking in depth at a number of contributing
factors—changing epidemiologic patterns; a growing understanding of the
injury mechanism; the development of enhanced imaging techniques; novel plate
designs, especially those featuring locked screw fixation; and the impact of
patient-rated outcome assessments.
Our basic understanding of the epidemiology of the distal radial fracture
and its relationship to general health is maturing. The authors of a
prospective, multicenter epidemiologic study estimated the incidence of distal
radial fractures to be 36.8/10,000 person-years in women and 9.0/10,000
person-years in men over the age of
thirty-five1.
Examination of a 5% sample of Medicare claims data from 1986 to 1990
identified 15,000 distal forearm fractures in a cohort of 1.4 million
persons2. As life
expectancy increases, the incidence of distal radial fractures can be expected
to increase as well. On the basis of actuarial risk calculations from Medicare
data, the risk of a white woman sustaining a distal forearm fracture was
estimated to be 6% by the age of eighty years and 9% by the age of ninety
years2.
There appears to be a bimodal distribution of distal radial fractures
consisting of a younger group who sustains relatively high-energy trauma to
the upper extremity and an elderly group who sustains both high-energy
injuries and insufficiency fractures. New research has improved our
understanding of this second group. According to the 2000 United States Census
data, individuals who are sixty-five years of age or older account for 12% of
our population. This percentage is expected to balloon to almost 20%,
representing 70 million citizens, by
20303. Along with
growth of the elderly population is a trend for more individuals in this age
segment to live healthier and more active
lives4.
In a large patient cohort, the mortality of persons who had sustained a
distal radial fracture was either the same as or less than that of the local
population. One interpretation of this finding is that individuals who sustain
a distal radial fracture are more active and healthier than their age-matched
counterparts5. The
self-perception of elderly people plays an important role in this increased
activity. Many elderly individuals view themselves as being in good health and
not
disabled4,6.
In addition, the proportion of older citizens living independently is growing.
A report by the United States Census Bureau stated that 23% of persons
sixty-five to seventy-four years of age and 41% of those older than
seventy-five lived
alone7.
Distal radial fracture is also frequently associated with low bone mineral
density. Some recent studies have more clearly defined our previous knowledge
of this association, especially the relationship of a prior wrist fracture
with subsequent osteoporotic fractures at other
sites8-10.
In women, the risk of a hip fracture increases 1.4 to 1.8-fold if there was a
previous wrist fracture. In older men, the risk of hip fracture increases 2.3
to
2.7-fold8,11.
Numerous studies have demonstrated increases in mortality after hip
fracture12-14.
In a similar vein, some have hypothesized that distal radial fracture in an
osteoporotic patient could be associated with decreased survival. The
existence of such a subpopulation is supported by a study demonstrating
increased mortality in a small cohort of patients, greater than sixty-five
years of age, who sustained a distal radial
fracture15. These
patients had an average of more than three comorbidities, with two of the most
frequent three being musculoskeletal and cardiac. Thus, while many older
individuals are leading more active lives, the high prevalence of osteopenia
and osteoporosis places this segment of the population at a particularly high
risk for distal radial fracture.
With today's active elderly, it can be expected that both high-energy
injuries and insufficiency fractures will occur, and results of treatment will
be confounded by the presence of agerelated osteopenia or frank osteoporosis.
The impact of distal radial fractures on society can be anticipated to
increase over time; as a result, considerable scientific, clinical, and
economic interest in the treatment of these fractures has developed.
Part of the trend toward internal fixation is due to an improved
understanding of the structural anatomy of the distal part of the radius and
the kinematics of the wrist and distal radioulnar joint. In addition, a
greater understanding of the patterns of injury is leading to treatment based
on the specifics of each individual injury.
Historical studies emphasized quantitative parameters that define an
acceptable reduction of a distal radial fracture. In 1951, Gartland and Werley
reported a landmark study on the evaluation of healed Colles fractures that
emphasized restoration of volar tilt to 11° and radial inclination to
23° to "compensate adequately for the loss of correction which will
occur" when Colles fractures are treated with closed
means16. They
defined a Colles fracture as a dorsally displaced metaphyseal fracture of the
distal part of the radius with or without articular involvement. Fractures
that settled tended to be associated with a worse functional outcome. A
subsequent study of malunited distal radial fractures compared with
anatomically healed distal radial fractures demonstrated that grip strength,
range of motion, and the ability to perform activities of daily living were
significantly worse (p < 0.05) in patients with dorsal angulation of
>12° than in those with dorsal angulation of
=10°17.
Biomechanical studies of simulated distal radial malunions have been
performed in an attempt to explain why these parameters have clinical
importance. Studies of cadavers have demonstrated an increase in radiocarpal
contact areas and pressures with radial shortening; dorsoulnar migration of
contact pressures with increased dorsal inclination; and shifts in the instant
center of rotation during pronation and supination with changes in radial
height, inclination, and dorsal
angulation18-20.
In the past, the principles of management of distal radial fractures have
focused on restoring these parameters, and restoration of global alignment is
heavily weighted in many physician-rated outcome assessments. Contemporary
investigations have focused in greater depth on the mechanism of the fracture
and its relationship to various articular injury patterns, the impact of the
fracture on carpal kinematics and the function of the distal radioulnar joint,
and the biomechanics of angular stable
fixation21-26.
Radiocarpal Stability
Biomechanical investigations have demonstrated how fractures occur and the
association of these fractures with intercarpal ligament injury. A cadaver
study21 in which a
hyperextension load was applied to the distal part of the radius demonstrated
the following sequence of events: (1) the flexor tendons are tensed, leading
to increased pressure over the carpus; (2) the palmar radiocarpal and
ulnocarpal ligaments and variable intercarpal ligaments are tensed and
rupture; (3) there is dorsal impingement of the carpus on the radial joint
surface; and (4) the dorsal aspect of the metaphysis reaches its yield point
and fractures. A separate finding was that the scaphoid impinges on the carpus
primarily with hyperextension, but there may be a considerable load on the
lunate facet (Fig. 1). In
twenty-eight of forty cadavers, the investigators identified a number of
intercarpal ligament injuries as well as different intra-articular fracture
patterns due in part to the differential impact of the scaphoid and lunate
with hyperextension.
These findings must be interpreted with caution. Because the mechanism of
injury occurs through the radioscaphoid articulation, this articulation is not
necessarily the major contributor to stability. Previous in vitro studies
suggested that radioscaphoid contact is greater than radiolunate
contact18, but
subsequent in vivo studies suggested that the radiolunate articulation accepts
a greater amount of contact than had been previously
acknowledged27.
This renewed emphasis on the importance of the radiolunate articulation
coincides with the development of a structural concept that the distal part of
the radius consists of a medial, an intermediate, and a lateral column
(Figs. 2-A and
2-B)28.
This theory emphasizes that (1) the lateral, or radial, column is an osseous
buttress for the carpus and is an attachment point for the intracapsular
ligaments; (2) the intermediate column functions in primary load transmission;
and (3) the medial, or ulnar, column serves as an axis for forearm and wrist
rotation as well as a post for secondary load transmission.
Clinical failures of volar plate fixation of the distal part of the radius
have also provided some insight into the subtleties of distal radial
anatomy29. The
volar surface of the distal part of the radius is flat until the distal end of
the pronator quadratus, where the distal rim of the radius is more anterior in
the region of both the radial styloid and the lunate facet
(Fig.
3)30.
Because of the difficulties with supporting the very distal lunate facet
fragments in the treatment of some fractures, changes have been made in a
number of volar locking plate designs.
Carpal Kinematics
It is still not clear why posttraumatic radiocarpal arthritis develops in
some patients and not in others. Residual intra-articular incongruity has been
accepted as a predictor of the development of radiographically evident
arthritis31.
However, studies with seven and fifteen-year durations of follow-up of
patients with an intra-articular fracture have demonstrated that function is
well-preserved as evaluated with validated outcome measures, despite evidence
of arthritic changes on
radiographs32,33.
The alignment of the carpus in relation to the distal radial articular
surface after healing may also be an important factor in the outcomes of
treatment of distal radial
fractures32. In a
prospective study of distal radial fractures treated with closed reduction,
external fixation, or open reduction and internal fixation, the authors found
that carpal alignment—the displacement of the capitate relative to the
longitudinal axis of the radius—was the most important predictor of
function. It is likely that the interplay between carpal kinematics and
longitudinal alignment has an important influence on fracture outcomes.
Another potential contributor to altered radiocarpal kinematics is
intercarpal ligament injury. In a study in which a hyperextension force was
applied to sixty-three cadaveric wrists until a distal radial fracture
occurred, an injury to the triangular fibrocartilage complex occurred in 63%
(forty) of the specimens, an injury to the scapholunate interosseous ligament
occurred in 32% (twenty), and an injury to the lunotriquetral ligament
occurred in 17%
(eleven)21. These
in vitro observations have been validated clinically: tears of the
scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage
complex are commonly noted during arthroscopically assisted reduction and
internal fixation of distal radial
fractures34,35.
As our understanding of carpal kinematics has advanced, it has become
evident that the carpal bones interact in an elegant and intricate pattern and
it has been suggested that these kinematics may be disrupted by articular
step-off, radiocarpal malalignment, or intercarpal ligament injury.
Recognition of these factors is an additional explanation for a growing trend
toward operative treatment of displaced fractures.
Distal Radioulnar Joint
Problems related to the distal radioulnar joint can take the form of
instability, incongruity, or late arthrosis. Studies suggest a statistical
correlation between instability of the distal radioulnar joint and worse
clinical
outcomes36,37.
In vitro models have demonstrated that radial deformity affects the distal
radioulnar joint38.
Increasing dorsal angulation results in an increased torque, especially at the
extremes of supination and pronation. In addition, a 5.5-mm shift of the
instant center of rotation occurs when the radius is shortened 5 mm.
Investigators using computer models based on these data estimated increased
strains in the triangular fibrocartilage ranging from 11% to 13% with radial
shortening20.
Another in vitro study demonstrated that increases in dorsal malangulation of
the distal part of the radius result in progressive incongruity of the distal
radioulnar joint and tightness of the interosseous
membrane39. An in
vivo study, however, did not demonstrate the same change in the axis of
rotation with
malunion40. One
explanation for this discrepancy is the role of soft-tissue stabilizers about
the distal radioulnar joint and their attenuation or contracture over time.
These soft-tissue changes are generally not incorporated into biomechanical
models.
While not yet supported by adequate scientific data, it has been evident
clinically to many that instability of the distal radioulnar joint is uncommon
when the radial fracture has been reduced anatomically and supported by stable
plate fixation. When the distal interosseous membrane was divided in a cadaver
model, stability of the distal radioulnar joint was
compromised41. Some
believe that the distal radioulnar joint becomes unstable only when the distal
interosseous membrane is
injured42. Future
research is needed to determine how much influence injury to the distal
interosseous membrane has on the outcome of treatment of a distal radial
fracture.
Imaging
Improved understanding of the morphology of displaced intra-articular
distal radial fractures has been a direct result of newer imaging techniques.
Oblique standard radiographs more clearly define the dorsal lunate facet,
while measurement of the volar teardrop angle can alert the surgeon to
rotational displacement of the volar lunate
facet43. The volar
teardrop angle is formed by the intersection of the central axis of the radial
shaft and a line through the central axis of the teardrop. This angle
typically measures 70°. When the volar and dorsal articular surfaces are
injured during axial load, the volar rim hyperextends, resulting in a decrease
in this angle.
These oblique radiographic views as well as computed tomography and
three-dimensional computed tomography reconstructions have had a major impact
on decision-making, with a move toward creative intervention and internal
plate fixation, especially when the volar lunate facet is rotated
(Figs. 4-A and
4-B)44-46.
When four independent observers reviewed thirty different intra-articular
fractures on two separate occasions, the addition of a computed tomography
scan and a three-dimensional computed tomography reconstruction to the
standard radiographs led to the observers recommending operative treatment in
50% of the cases23.
Although computed tomography scanning is costly and certainly not routine in
general practice, it has become more affordable and available. Orthopaedic
surgeons in the future may find that advanced imaging studies are further
encouraging them to perform operative intervention for distal radial
fractures.
It has been long recognized that there is a correlation between the
functional outcome following a distal radial fracture and the restoration of
both the radiocarpal and the radioulnar
relationships24,31.
What has been less predictable has been the maintenance of the reduction of
fractures in osteopenic bone or fractures considered to be unstable. The
development of angular stable fixation techniques with use of implants
designed specifically for the anatomy of the distal end of the radius
theoretically improves our ability to manage these problems (Figs.
5-A, 5-B,
5-C, 5-D).
The important aspects of angular stable fixation are: (1) stability is not
achieved by the creation of friction between the plate and bone as in
traditional screw-plate fixation, but rather mechanical bridging of the bone
and load-bearing are allowed through the locked screw-plate construct; (2)
locking-head screws do not rely on the bone thread for purchase; and (3)
screws that lock into the plate prevent loosening within the implant, so early
failure of fixation with an angular stable implant will occur only if the
entire screw-plate construct pulls out from the bone or there is material
failure of the
implant25.
The concept of angular stable fixation of distal radial fractures is
actually not new as a number of different implants used over the past two
decades have involved this
technology26.
Contemporary enthusiasm for the application of these implants can be
attributed in part to the angular stable fixation but perhaps more so to the
recognition that the more prevalent dorsally displaced fractures can be
internally fixed from the palmar side.
Theorized benefits of volar plate fixation, especially for more simple
dorsally displaced fractures, include (1) ease of anatomic reduction because
the volar cortex is often less comminuted than the dorsal side of the injury,
(2) early return of hand and upper-limb function, (3) diminished frequency and
duration of formal occupational therapy, (4) potentially less overall pain,
(5) a decreased risk of displacement, and (6) potential cost savings secondary
to a diminished need for
radiographs47,48.
Many of these benefits would be derived from the inherent stability of the
fixed-angle plate-screw construct.
Biomechanical studies have emphasized the need for placement of the
distalmost screws or pegs just beneath the subchondral bone of the articular
surface to achieve the maximum benefit of volar fixed-angle plate fixation. In
a cadaver model, when distal screw fixation was placed =4 mm proximal to
the subchondral bone, fracture displacement with cyclic loading of the
specimens doubled and rigidity at load-to-failure was reduced by
half49.
Currently, more than thirty different implant designs are produced
worldwide. The growing popularity of internal fixation has yielded numerous
options with regard to plate material, contour, and shape; locking and
nonlocking features; and cost. An estimated $2 billion in medical costs are
incurred as a result of distal radial fractures, and this is associated with a
$250 million market in medical devices aimed toward treatment of these
injuries50. A large
portion of this cost is due to fact that fixation with locked volar plates
involves machining of threaded holes in the plate and matching threaded screw
heads. This rapidly evolving industry requires careful scrutiny as these
changes are based on a limited amount of stringent clinical evidence. Case
series documenting these new technologies continue to be published and
represent possible trends in the future; however, Level-I and II evidence is
required to delineate the true benefits that these new technologies and their
additional costs confer to patients.
Over the past decade, a deliberate and profound philosophical change in
orthopaedics has redirected evaluation measures toward the patient's
self-reporting of treatment outcomes. In the late 1980s and early 1990s, a
global health survey called the Short Form-36 (SF-36) was created to collect
large cross-sectional pools of normative data with which comparisons can be
made51. Although
this scale is aimed toward measuring general health and chronic disease, it
seems to have some validity for evaluating wrist injuries. The SF-36 consists
of subscales evaluating physical role, bodily pain, social functioning, and
other components of general health. One study showed that the physical role
and mental health domains were responsive indices three months following
treatment of Colles fractures with closed
reduction52. A
subsequent study demonstrated that the physical component and mental component
summary scores were significantly lower (p < 0.01) for patients who had
intra-articular displacement of =1 mm on the most recent
radiographs53. The
findings in the latter study most likely reflect the development of arthrosis
in the wrist, as the most recent radiographs were made about two years
postinjury.
Other patient-rated evaluations have been developed. The Disabilities of
the Arm, Shoulder and Hand (DASH) questionnaire is intended to evaluate
upper-extremity outcomes, and the Patient-Rated Wrist Evaluation (PRWE) is
aimed toward disorders of the
wrist54,55.
Modified self-reporting systems such as the QuickDASH and the visual QuickDASH
recently have been
validated56,57.
In a prospective evaluation of the SF-36, DASH, and PRWE along with standard
physical performance measures for assessing recovery after distal radial
fractures treated with a variety of methods, the PRWE was found to be a more
responsive measure than the DASH and both indices were more responsive than
the SF-36. Notably, the function subscales of the PRWE were the most
responsive between the time of the initial injury and the three-month
follow-up examination, and grip strength was the most responsive physical
performance measure. The association between grip strength and the PRWE was
reaffirmed by independent
studies58.
There are important caveats with regard to the interpretation of the
results of evaluations performed with these systems. The DASH scores may be
confounded by concomitant lower-extremity
injury59. The
inability of a patient to reach a door or an inability to stabilize the trunk
and shoulder girdle may affect DASH items such as turning a key or carrying a
shopping bag. In addition, the DASH and SF-36 scores may be heavily influenced
by pain60. When
applied to disorders of the elbow, the DASH as well as the physical and mental
component scores of the SF-36 were statistically correlated (p < 0.001)
with higher pain subscale scores on the American Shoulder and Elbow Surgeons
(ASES)
evaluation61, which
requires summation of ratings for pain at its worst, at rest, during lifting,
during repetitive motions, and at
night60.
Other instrument measures not specifically related to the upper extremity
have also been used to evaluate outcomes after a distal radial fracture. The
Physical Activity Scale for the Elderly (PASE) instrument is a validated
measure of the overall activity and functional demand in a one-week period.
This instrument is based on a regression of a component score derived over
three days of monitoring 277 adults with a mean age of seventy-four years. The
scale ranges from 0 to 400, with a higher score indicating greater
activity62.
Treatment of a distal radial fracture with internal fixation in patients older
than sixty years of age was associated with a mean PASE score of
17763 compared with
a mean PASE score of 118 in an uninjured elderly
population64.
The emphasis on patient-rated outcomes reflects a global shift in how
operative treatments are evaluated. Rather than patients understanding their
outcomes on the basis of the surgeon's satisfaction with a procedure, surgeons
evaluate their outcomes on the basis of the patient's satisfaction with the
result. Consequently, global health, arm and wrist function, and return to
activity have supplanted traditional measures such as strength and range of
motion. Today's patients, including active elderly individuals, are demanding
outcomes that restore their perceived preinjury wrist and hand function. These
new outcome measures are arguably more accurate and reliable indicators than
traditional evaluation systems.
While yet to be reproducibly demonstrated in Level-I or II studies
regarding the outcome of volar plate fixation of simple extra-articular
fractures, there is a growing impression that, from a patient's perspective,
an early return to functional independence may be the single most important
impact of internal fixation of these fractures. By three to six months
postoperatively, there may not be any major difference between the results of
treatment modalities. This was shown to be the case in a multicenter study by
Cassidy et al., who used implantable Skeletal Repair System (SRS) cement
(Norian, Cupertino, California) for immediate fixation and encouraged motion
within ten days and compared the results with those of alternative methods
with a minimum of six weeks of
immobilization65.
The patients treated with Norian SRS cement had a significant improvement (p
< 0.05) in their SF-36 scores during that critical six weeks.
Prospective, Randomized, Controlled Trials
In a Cochrane review of randomized, controlled studies until the year 2000,
it became evident that the majority of studies suffered from methodological
deficiencies66.
Most series included a small number of patients and, as a consequence, were
unlikely to demonstrate strong evidence to support one treatment option over
another. A second criticism was that allocation concealment—i.e.,
blinding of evaluators with regard to the group to which the patients had been
randomized—was deficient in forty-two of forty-four so-called randomized
studies. As a result, it is difficult to extrapolate robust data from the
studies available prior to 2000. Despite these limitations, the authors of the
Cochrane study were able to draw one major conclusion: studies included in
their systematic review suggested that external fixation and percutaneous pin
fixation have better radiographic outcomes and may have better functional
outcomes when compared with cast immobilization.
Considering the quality of the available literature, major questions
remain: (1) Is external fixation or percutaneous pin fixation a better
intervention than closed treatment when evaluated with validated outcome
measures? (2) How does open reduction and internal fixation compare with
external fixation and percutaneous pin fixation or even closed reduction and
cast immobilization? (3) Is there a particular technique for each treatment
modality that provides superior results? (4) As most recent studies include
only a maximum of two years of follow-up, do the results of treatment endure
over the long term?
Recent randomized, controlled trials have begun to clarify some of these
questions. A series of eighty-five patients prospectively randomized to be
treated with bridging external fixation or with closed reduction and plaster
cast immobilization demonstrated statistically equivalent Gartland and Werley
functional scores after seven years of follow-up; however, radiographic
measures were significantly better in the external fixation group (p <
0.001)67. When
validated outcome scores were used to compare spanning external fixation with
closed reduction and cast immobilization of distal radial fractures without
joint incongruity in 113 patients, SF-36 bodily pain scores and
Musculoskeletal Function Assessment (MFA) scores at two years favored external
fixation; however, these trends did not reach
significance68.
In a study of fifty-seven patients, radiographic parameters after
percutaneous pin fixation were found to be significantly better than those
after closed reduction (p < 0.05); however, there was no difference in
SF-36 scores69. In
a subsequent study, although augmented external fixation and percutaneous pin
fixation resulted in similar validated outcome scores and functional outcomes
at one year, the patients treated with external fixation demonstrated better
articular congruity on radiographic
follow-up70.
In two Canadian studies, open reduction and internal fixation was compared
with external fixation for displaced, unstable intra-articular fractures. One
of these was a prospective, randomized, controlled trial in which dorsal
pi-plate fixation was compared with external fixation with limited reduction
and pin fixation in sixty-two
patients71. There
were no significant differences in DASH scores or SF-36 scores; however, the
pi-plate group had significantly weaker grip strength and a higher number of
complications, especially tendinitis and the need for hardware removal (p =
0.004). In the other study, a prospective randomized trial, external fixation
with indirect reduction and percutaneous pin fixation was compared with open
reduction and internal fixation in 179
patients72;
although MFA and SF-36 scores at two years were statistically equivalent
between the groups, external fixation yielded better outcomes at the six-month
interval. The authors concluded that, if articular congruity can be
established through indirect means, external fixation may be preferable
because of an earlier return of function. What is unclear is when occupational
therapy was initiated for the internal fixation group and whether this factor
may have affected the study results.
The authors72
also contended that, because outcome scores and functional results appear
stable after one year, there is no need to pursue a two to five-year
follow-up. Although primary outcomes may become stable, potential midterm
complications of volar plate techniques such as irritation of the flexor
pollicis longus by the implants or carpal tunnel syndrome may become apparent
in the future. Despite evidence that validated outcome scores may not change
after the one-year mark, midterm follow-up may have independent value and
should continue to be performed and reported.
Studies comparing locked volar plate fixation with external fixation are
ongoing and may help to distinguish whether a locked volar plate provides
additional benefit. One case-control study comparing use of a volar
fixed-angle plate with external fixation in thirty-two patients demonstrated
better radiographic outcomes with use of the plate (p < 0.05) but no
difference in the DASH or PRWE
scores73.
From these studies, the following inferences can be made regarding plates:
(1) external fixation augmented with percutaneous pin fixation yields better
radiographic results than closed reduction or percutaneous pin fixation alone;
(2) internal fixation yields radiographic results and two-year clinical
results that are comparable with those of augmented external fixation; and (3)
because internal fixation yields radiographic results that are comparable with
those of external fixation, internal fixation can be expected to provide
radiographic results that are better than those of closed reduction or
percutaneous pin fixation. Although these studies have yielded useful data, a
large, long-term, prospective, randomized, controlled trial in which validated
outcome measures are used to compare different treatment modalities is needed
to test the assumption that strict anatomic reduction by open reduction and
plate fixation better supports the intermediate column, improves carpal
mechanics, and as a result decreases radiocarpal arthrosis. Until that study
is completed, there is little Level-I evidence to suggest that any form of
internal fixation with a plate is superior to augmented external fixation for
the majority of unstable extra-articular or intra-articular fractures.
Biomechanics
A second approach to determining which types of treatment might be most
beneficial for patients with a distal radial fracture is the use of
biomechanical models to compare different fixation methods. The overlying
premise is that the fixation device with the most robust biomechanical
properties will be superior to other methods. It is important to recognize
that this premise has philosophical and practical limitations; however, these
studies still possess some value.
Two biomechanical studies in which a cadaver distal radial fracture model
was subjected to physiologic loads have demonstrated that enhancing external
fixation with Kirschner wires improves stability only to a
point74,75.
This enhancement is substantially lessened when there is a more complex
intra-articular fracture. The studies showed that, when augmented external
fixation is used for complex intra-articular fractures, it is less stable than
small-plate-and-pin fixation directly applied to the fracture fragments.
Biomechanical studies have also been done to evaluate different types of
internal fixation devices. In two studies, plates applied on the volar surface
with use of angular stable fixation screws or pegs that lock into the plate
were compared with alternative plate-fixation techniques in an extra-articular
fracture
model76,77.
The fixed-angle plates demonstrated increased single load to failure and
increased stiffness during cyclic loading when compared with dorsal plates and
volar plates without fixed-angle support. In another study, fixed-angle volar
plate fixation was compared with the use of small plates applied directly on
the fracture fragments in an intra-articular fracture
model78. When the
constructs were subjected to cyclical loading and single load to failure, the
stiffnesses of the two types of fixation were similar in most cases. However,
specific fixation of the dorsal ulnar fragment with additional orthogonal
fixation from the radial side added significant stiffness (p < 0.05) when
compared with that provided by a fixed-angle volar plate alone.
Although there is a dearth of strict prospective, randomized studies or
biomechanical data indicating clear superiority of one treatment modality over
another, there continues to be a strong push toward anatomic reduction and
internal fixation especially on the volar side with use of angular stable
fixation. It is remarkable that this trend toward internal fixation is so
strongly driven without clear scientific evidence supporting it.
As the method of internal fixation of distal radial fractures changes, the
frequency and types of complications as well as our treatment of complications
can be expected to change as well. Complications of distal radial fractures
include compressive neuropathy, malunion, tendon rupture, radioulnar and
radiocarpal arthrosis, pain syndromes, and finger stiffness. Other
complications include flexor or extensor tendon entrapment in the fracture or
the distal radioulnar joint and the development of palmar fascial
nodules79.
Although the use of volar plates and low-profile dorsal plates may limit
tendon irritation, these techniques do not entirely eliminate the problem.
With volar plate fixation, irritation of the flexor carpi radialis and flexor
pollicis longus tendon by the plate itself as well as dorsal tendon irritation
from screw prominence have been
reported80. Early
in the experience with the use of volar plates, frank rupture of the extensor
pollicis longus was reported in two
patients81. No
cases of extensor tenosynovitis were observed in two series of patients
treated with a low-profile dorsal plate; however, superficial extensor
retinacular scarring requiring extensor pollicis longus tenolysis and two
cases of metaphyseal screw loosening requiring removal were
reported82,83.
There has also been increased attention on the possibility of ischemic
contracture of the pronator quadratus as a potential complication leading to
limited forearm rotation after distal radial fracture, or specifically after
fixation with a volar plate and tight repair of the pronator quadratus.
Although this entity was considered theoretical in the past, case reports have
documented both isolated pronator quadratus compartment syndrome and
compartment syndrome associated with a minimally displaced distal radial
fracture84,85.
Isolated pronator quadratus compartment syndrome presents as pain with passive
supination and pronation. In theory, ischemic injury could lead to contracture
and limited supination.
An important caveat is that, while use of a locked volar plate is an
acceptable treatment for distal radial fractures, there are fracture patterns
that are not amenable to these techniques. As mentioned previously, small
volar lip fractures are important to recognize and can be a source of fixation
failure. Loss of fixation of the volar lunate facet was documented in two
independent
reports24,80.
A locked volar plate augmented with a second radial buttress plate provides a
stiffer construct than does a volar plate alone and may have utility in the
treatment of a fracture with severe metaphyseal
comminution86.
Double-plate fixation was reported to have acceptable outcomes at two years
postoperatively; however, plate removal was common in that
cohort87. Some
surgeons have utilized a distraction plate technique, with use of a long
3.5-mm plate spanning the radial shaft to the long finger metacarpal, for
fractures with severe metaphyseal-diaphyseal
comminution88. Use
of a volar plate when other techniques are more suitable could result in poor
outcomes.
The advent of volar plate fixation has also influenced treatment of distal
radial malunion. Traditionally, a nonlocking plate was applied in a buttress
mode to support the osteotomy site and bone
graft89. The choice
of a volar or dorsal buttress was based on the direction of the malunion. With
volar locking constructs, an osteotomy can be performed through a volar
approach, even for dorsally angulated malunions. In a case series of dorsally
angular distal radial malunions treated with a fixed-angle volar plate and
followed for one year, DASH scores were comparable with those following
internal fixation of acute distal radial
fractures90.
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fixation, and now internal fixation has begun to supplant all other treatment
modalities. Novel fields of research, epidemiologic and sociologic changes,
and new implant designs are driving this new trend toward plate fixation.
However, the future of treatment of distal radial fractures depends on solid
research. There is a need for well-designed clinical, biomechanical, and
cost-benefit studies to compare locking plate systems with other treatments.
Ultimately, the current enthusiasm for volar fixed-angle plates should be
tempered until outcomes and advantages are securely validated by hard
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