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Comparison of AO Type-B and Type-C Volar Shearing Fractures of the Distal Part of the Radius
J. Sebastiaan Souer, MD1; David Ring, MD, PhD1; Jesse B. Jupiter, MD1; Stefan Matschke, MD2; Laurent Audige, PhD3; Marta Marent-Huber3
1 Massachusetts General Hospital, Yawkey 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
2 BG-Unfallklinik, Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany
3 AO Clinical Investigation and Documentation, Stettbachstrasse 10, CH-8600 Zurich/Dübendorf, Switzerland
View Disclosures and Other Information
The AOCID Prospective ORIF Distal Radius Study Group includes Dr. Beate Hanson, AOCID, Dübendorf, Switzerland; Dr. D. Rikli, Kantonspital, Luzern, Switzerland; Prof. H.R. Siebert, Diakonie-Krankenhaus, Schwäbisch Hall, Germany; Dr. D.A. Campbell, St. James' University Hospital, Leeds, Great Britain; Dr. L.-C. Teoh, Singapore General Hospital, Singapore; Dr. F. Torretta, Istituto Ortopedico Gaetano Pini, Milano, Italy; Dr. G. Lauri, Centro Traumatologico Ortopedico, Firenze, Italy; Dr. W. Hintringer, Krankenanstaltenverbund Korneuburg-Stockerau, Austria; Dr. H. Drobetz, Unfallabteilung Krankenhaus Neunkirchen, Austria; Dr. M. Plecko, Abteilung Unfallchirurgie, UKH, Graz, Austria; Prof. A. Wentzensen, BG-Unfallklinik, Ludwigshafen, Germany; Prof. D. Höntzsch, BG- Unfallklinik, Tübingen, Germany; Prof. R.H. Neugebauer, Krankenhaus der Barmherzigen Brüder, Regensburg, Germany; Prof. N.P. Haas, Charité, Berlin, Germany; Prof. K.E. Rehm, Chirurgische Universitätsklinik, Köln, Germany; Prof. K.H. Winker, HELIOS Klinikum Unfallchirurgie, Erfurt, Germany; Prof. W. Ertel, Universitätsklinik Benjamin Franklin, Berlin, Germany; Dr. Chr. Sommer, Rätisches Kantons- und Regionalspital, Chur, Switzerland; Prof. M. Wagner, Wilhelminenspital, Wien, Austria; and Prof. S.P. Chow, Queen Mary Hospital, Hong Kong.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from AO Clinical Investigation and Documentation (AOCID). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 (in total) or a commitment or agreement to provide such benefits from commercial entities (Small Bone Innovations, Smith and Nephew Richards, Wright Medical, Tornier, Acumed, Joint Active Systems, Biomet, Stryker, DePuy, Hand Innovations, Skeletal Dynamics, Illuminos, and Mimedex).

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2605-2611. doi: 10.2106/JBJS.H.01479
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Abstract

Background: Fractures of the volar articular margin of the distal part of the radius with volar radiocarpal subluxation (volar shearing, or Barton, fractures) can be accompanied by a fracture of the dorsal metaphyseal cortex. We tested the null hypothesis that there is no difference in wrist function or health status after open reduction and plate-and-screw fixation between volar shearing fractures with a dorsal cortical fracture (complete articular, AO Type C) and those without a dorsal cortical fracture (partial articular, AO Type B).

Methods: In a multicenter cohort study, fifty-seven patients with a volar marginal shearing fracture of the distal part of the radius and volar radiocarpal subluxation were followed for at least one year following plate-and-screw fixation. Thirty-seven patients who also had a dorsal metaphyseal cortical fracture (Type-C fracture) were compared with twenty patients who had a partial articular (Type-B) fracture. The two cohorts were analyzed for differences in wrist and forearm motion, grip strength, pain, and the Gartland and Werley, Disabilities of the Arm, Shoulder and Hand (DASH), and Short Form-36 (SF-36) scores at six, twelve, and twenty-four months postoperatively. Differences in mean values and their change over time were determined.

Results: There were no significant differences between patients with a Type-B fracture and those with a Type-C fracture with respect to motion, grip strength, or the Gartland and Werley or DASH score at any time point. At six months after the surgery, the patients with a Type-B volar shearing fracture reported a mean score for pain in motion of 0.5 point on a 10-point visual analogue scale compared with 2.2 points for patients with a Type-C fracture (difference in means, 1.7 points [95% confidence interval, 0.7 to 2.6 points]; p < 0.001), but no significant difference was seen at twelve or twenty-four months.

Conclusions: Volar shearing fractures are usually complete articular, Type-C injuries. Patients with a Type-C volar shearing fracture experience more pain during early recovery, but ultimately their outcome is comparable with that for patients with a Type-B (partial articular) volar shearing fracture.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    Topics

    fracture ; radius
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    References

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    David Ring, MD
    Posted on December 02, 2009
    Dr. Ring responds to Mr. Rogers and colleagues
    Massachusetts General Hospital

    We appreciate the interest in our work. Mr. Rogers and colleagues raise some important questions about distal radius fractures. I will attempt to clarify these points on behalf of my co-authors.

    1. None of the patients in this series were diagnosed with distal radioulnar joint (DRUJ) instability and none had secondary procedures for problems at the DRUJ. These problems are uncommon in volar shearing fractures. DRUJ problems also seem particularly uncommon after distal radius fracture in general these days, whether due to better realignment or some other factor (1). Finally, there is not a reliable definition or measure of DRUJ instability, and it seems that pain is often ascribed to instability by convention rather than by objective measurement.

    2. Evidence suggests that variations in rehabilitation do not have much effect on outcome (2). Rehabilitation was not standardized in the multiple international participating sites in this study.

    3. The relationship between anatomy and function in the distal radius is not as well understood as we would like to think. In any case, these patients were all treated with open reduction and internal fixation and had only slight residual malalignment after treatment (see Table 2 in the manuscript).

    4. With the advent of plates with locking screws, the quality of the bone is much less frequently an issue. None of the patients in the series experienced loss of fixation, loss of alignment, or any complication related to osteoporosis.

    References

    1. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB; AOCID Prospective ORIF Distal Radius Study Group. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830-8.

    2. Lozano-Calderón SA, Souer S, Mudgal C, Jupiter JB, Ring D. Wrist mobilization following volar plate fixation of fractures of the distal part of the radius. J Bone Joint Surg Am. 2008;90:1297-304.

    Benedict A. Rogers, MA, MSc, MRCGP, FRCS(Orth)
    Posted on November 24, 2009
    Comparison of AO Type-B and Type-C Volar Shearing Fractures of the Distal Part of the Radius
    Easy Surrey Hospital, Redhill, United Kingdom

    To the Editor:

    We read with interest the November 2009 article by Souer et al. (1) entitled, “Comparison of AO Type-B and Type-C Volar Shearing Fractures of the Distal Part of the Radius” and would like to make the following points:

    1. Previous studies suggest a statistical correlation between instability of the distal radioulnar joint (DRUJ) and worse clinical outcomes (2-4). No assessment has been detailed in this study of DRUJ instability, and indeed the AO classification does clearly differentiate involvement of the DRUJ. Do the authors feel that DRUJ instability is a possible confounding factor in the outcome of these fractures?

    2. An advice and exercise program improves the outcome for adults following distal radius fracture (5) and the methods section gives no detail of the physiotherapy regimen used. Did all of the patients have a similar rehabilitation program?

    3. It is recognized that a correlation exists between functional outcome and the restoration of the radiocarpal and radioulnar relationships (6,7). Further, carpal alignment in relation to the distal radial articular surface after healing may also be an important factor in the outcomes of treatment of distal radial fractures (8). As this study provides no direct evaluation of carpal alignment following treatment, such as the scapholunate angle, do the authors consider carpal alignment a significant factor in wrist function?

    4. The relative bone mineral density (BMD) of each of the three treatment arms studied is not provided in the results. While the quantification of BMD may be superfluous in routine clinical practice, for a clinical study evaluating different fracture patterns should the results be matched for BMD (9)? Specifically, should the reader assume all patients had normal bone mineral density and, if so, is this assumption a valid one?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Souer JS, Ring D, Jupiter JB, Matschke S, Audige L, Marent-Huber M; AOCID Prospective ORIF Distal Radius Study Group. Comparison of AO Type-B and Type-C volar shearing fractures of the distal part of the radius. J Bone Joint Surg Am. 2009;91:2605-11.

    2. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;376:229-35.

    3. Lindau T, Aspenberg P. The radioulnar joint in distal radial fractures. Acta Orthop Scand. 2002;73:579-88.

    4. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioulnar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002;73:151-6.

    5. Kay S, McMahon M, Stiller K. An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial. Aust J Physiother. 2008;54:253-9.

    6. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951;33:895-907.

    7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59.

    8. Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79:1290-302.

    9. Nordvall H, Glanberg-Persson G, Lysholm J. Are distal radius fractures due to fragility or to falls? A consecutive case-control study of bone mineral density, tendency to fall, risk factors for osteoporosis, and health-related quality of life. Acta Orthop. 2007;78:271-7.

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