Very few reports in the literature have studied the treatment of these complex fractures. The sample size of this study is not very large, but it is similar to previously reported series. Despite some points of weakness (inho- mogeneous samples with respect to the type of fracture, age and plates used), our study seems to demonstrate the effectiveness of volar long plating for treating distalradiusfractures that extend proximally to the radial diaphysis. Conflict of interest The authors declare that they have no conflict of interest related to the publication of this manuscript.
We report a case of an 80-year-old previously healthy Japanese female patient who was able to walk on her own. She fell down and was taken to our hospital. There were cut wounds measuring approximately 5 cm on the palmar side of both wrists (Figure 1A and B) and radiographs showed bilateral distalradiusfractures. The right side was classified as A3 according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and the left side was A1 (Figure 2A,B,C and D). She was diagnosed with bilateral open distalradiusfractures and we performed
Fractures of distalradius are most common fractures of the upper extremity forming about 17 % of all fractures. Distal radial fractures have a bimodal age distribution, consisting of a younger patients sustaining injury due to relatively high-energy trauma and an elderly patients sustaining low energy trauma. Around 50-70 % of the distalradiusfractures are associated with distal ulna fractures following a rise in the high energy trauma in recent years. The treatment of distalradius fracture has seen a tremendous evolution from cast immobilization through Kirschner wire fixation to internal fixation with various plates. The significance of distal ulna fractures is often not appreciated and treated inadequately in comparison to its larger counterpart; the radius.
Distalradiusfractures are one of the most common upper extremity injuries, accounting for about 8–15 % of all skeletal injuries treated by orthopedic surgeons [1–3]. Late- diagnosed fractures are frequently complicated with many sequelae; among them, malunion and post-traumatic wrist arthritis due to post-traumatic distalradius deformity are most frequently seen [4–6]. Common deformities follow- ing an extra-articular distalradius fracture include loss of the normal volar tilt of the articular surface in the saggital plane, decreased ulnar inclination in the frontal plane, and loss of length relative to the ulna . Post-traumatic deformity results in alteration of normal anatomy, biome- chanics of distalradius, and functional impairment in hand and wrist [6–8]. Many surgical modalities in the treatment of acute fractures of the distalradius have been proposed [9, 10]. Intramedullary nailing is currently used to treat unstable extra-articular fractures of the distalradius . Bearing the advantages of allowing load transfer across the fracture site and lessening soft-tissue dissection, intrame- dullary fixation can be used to stabilize the fracture bones through a less invasive approach and maintain periosteal vascular blood supply to promote fracture healing . The purposes of this retrospective study were to describe our experience with mini-open osteotomy, local bone grafting, and fracture stabilization with the intramedullary nail
Minimally displaced fractures of the distalradius are usu- ally treated non-operatively while displaced fractures are treated either with closed reduction and immobilization with cast, percutaneous pinning or external fixation or, especially when intraarticular, with open reduction and internal fixation. Recently, the use of internal fixation for displaced fractures, which is probably the most costly and technically demanding treatment method, has been widely increasing. Thus, estimating the incidence of frac- tures classified according to articular involvement and fracture displacement would be of importance in deter- mining costs and resource allocation for these injuries. Moreover, distalradiusfractures may result in prolonged pain and functional impairment . Complications such as persistent neuropathy of median, ulnar or radial nerve and fracture malunion have been reported in 1 out of 3 patients . In this respect, fracture severity charac- teristics may be of importance. Previous Scandinavian studies of fracture incidence presented the proportions of fractures classified according to the methods of Older and Frykman [4,6,13,14]. The AO system (Arbeitsgemein- schaft fur Osteosyntesfrage) of fracture classification is
Distalradiusfractures are one of the most common fractures, and biomechanical models are used to validate and develop novel treatment methods. Recent research suggests that the distal fracture fragment is smaller than observed in previous studies. Based on this data, an improved fracture model was developed. We were able to show that the biomechanical parameters assessed through biomechanical fracture models are sensitive to the position of the extra-articular comminuted fracture. The degree of sensitivity is dependent on the type of osteosynthetic device used. Consequently the fracture model introduced here should be used as the new gold standard for future research until more studies on fracture location have been done.
Our study has certain limitations. Certainly, the sam- ple size was limited and the overall follow-up was around 1 year. However, we feel that despite the limited number, our study is valuable for the following reasons: 1. It represents a single-surgeon experience for surgery and two experienced surgeons for follow-up. 2. In all pa- tients, we waited to submit the clinical result after com- pletion of physical functioning and return to work. In distalradiusfractures, this is achievable within 3 months after injury. 3. We were pleased with the radiolucency of the implant, allowing for proper assessment of healing in every X-ray on follow-up. In this respect, radius frac- tures differ from other injuries, such as tibial or femur shaft fractures.
When an individual falls forward fall on pronated forearm with the hand and wrist in extension, bending of the metaphyseal bone because the weight of the body is transmitted along the long axis of the radius. Also the hard diaphyseal bone causes impaction of cancellous metaphyseal bone that result in metaphyseal collapse. During the fall, compressive forces over the dorsal cortex and tensile stress acting over the volar cortex result in volar and dorsal cortical bone disruption. When there is a supination of distal end of radius with respect of the radial diaphysis, a dorsal displacement fracture occurs. In about fifty to sixty percent of distalradiusfractures, associated ulnar styloid fractures. Also ulnar styloid fractures may be associated with triangular fibrocartilage disruption which may sometimes be an isolated finding.
This study has several potential shortcomings. First, this is a retrospective study, which has its drawbacks such as selection bias and limited clinical data. Second, due to lack of a very good or excellent inter- and intra-observer repro- ducibility in the existing classifications of distalradiusfractures , AO subclassifications based on X-ray and/ or CT scans may also have inconsistencies, leading to changes in our conclusion. Ma et al. described that X-ray results might be false negative in diagnosis of die-punch fracture. The X-ray-missed diagnosis rate was 11.1%, and the misdiagnosis rate was 15.6% . Third, the issue of how to avoid variability in ROM measurement still cannot be completely solved. Hohmann et al. reported there was accurate, valid, and reliable use of a goniometer according to a standardized protocol advised by the American Soci- ety for Hand Therapists . Therefore, we used the goni- ometer to measure wrist ROM following the standard guideline to reduce variability. And we supported that clinical examination comparing between the injured and uninjured contralateral sides was a reasonable way to re- duce individual differences in the assessment of objective indicators of wrist function after distalradiusfractures.
Distalradiusfractures (DRFs) are the most common fractures encountered in orthopedic practice and ac- count for 20% of all fractures seen in the emergency room (1). Following near anatomic close reduction and cast immobilization, various factors can cause second- ary displacement of the fracture fragments, including shortening, angle of reduction (dorsal angulation), and articular congruence. These factors determine the treat- ment outcomes of DRFs. In young adults, the fractures are typically the result of high-energy injuries such as motor accidentsor fall from height. In contrast, most of the DRFs in the elderly occur from low-energy injuries such as fall from a standing height or on an outstretched hand (2, 3). Management of DRFs is still controversial and may be influenced by the initial fracture classification (4). Even though numerous classification systems have been proposed e.g., Frykman, Mayo, Melone, and AO, the evaluation and management of these fracture is yet con-
Broadly speaking, aspects of distalradiusfractures (DRFs) covered in the literature may be grouped into three categories. In the first category are studies of aspects on which there is widespread agreement. Three such aspects are recognized. The first is etiology, with the preponderance of DRFs being the result of either low-energy incidents, such as using an outstretched hand to break a fall from a slippery floor or a road pavement, or high-energy trauma, such as falling from a height > 1 m in a bicycle, ski, or motor vehicle accident [1-8]. The second is incidence, with DRFs being the most common fracture cases seen in emergency rooms, trauma centers, and general orthopaedic practices [9- 11]. Furthermore, there is a sizeable number of cases of distalradius fragility fractures, which occasionally present in severely osteoporotic patients . The third comprises the most common complications, examples being damage to the median nerve, neuritis, and marked depreciation in many hand functions, such as grip strength and range of motion [4,13]. In the second category are studies of aspects on which there is much controversy, such as fracture classification schemes for complicated cases (such as comminuted fractures), reliability of a given scheme, and the most appropriate treatment/management modality for a given combination of patient and fracture pattern [14,15]. In the third category are studies on aspects that have received little attention, such as detailed epidemiological studies, prediction of clinical outcome for a given combination of
We assessed the error associated with radiographic inter- pretation of acute distalradiusfractures and whether the errors associated with measurements were small enough for measurements to be used confidently in fracture man- agement. We investigated the intra- and inter-observer re- liability of eight anatomic parameters in skeletally mature patients with an acute distalradius fracture using digitised radiographs. This investigation extends and updates the work of Kreder et al.  by using a larger sample of radio- graphs (30 acute fractures) and the computerised images and measurement procedures used in current practice. The majority of choices regarding treatment for distal ra- dius fractures occur in the acute period. This investigation utilized radiographs of acute distalradiusfractures in con- trast to the healed distal fracture radiographs utilized by Kreder et al. .
This study was reviewed and approved by our regional ethical review committee. Over a 12 month period, we treated 21 patients with complex type C distalradiusfractures using locked volar plating. Plating was under- taken by or under the supervision of one of two consul- tant orthopaedic surgeons with a specialist interest in upper limb surgery. Patients who were unfit for surgery, unable to give informed consent or who had low func- tional demands were not included. Fracture classifica- tion was performed preoperatively and confirmed at the time of surgery using the AO classification system . Post-operative assessment involved a wound check at 2 weeks with routine radiographic imaging, a further appointment at 6 weeks at which point formal referral for physiotherapy was made and another outpatient visit at 3 months. Patients were invited for a further clinical assessment at 6 months and all of the patients accepted this offer.
In 1975 SARMIENTO introduced functional cast bracing to distalradiusfractures and immobilized the patient in supination. He modified the GARTLAND & WERLEY system of evaluation. The AO – ASIF group developed techniques of open reduction and internal fixation and external fixation. They applied their principles to distalradiusfractures like k wire pinning, plating and external fixators. They introduced AO minifixator for the distalradius.
The only factor that was associated with a poorer functional outcome was the development of a post- operative complication. The 27 patients with a post- operative complication had both DASH and MAYO scores considerably worse than the other patients, and those with what we classed as a major complication (10 patients) had a much worse functional score. The two patients who acutely developed post operative carpal tunnel syndrome were both females under the age of 60 years. Neither had preoperative symptoms. One had a 23-C2 type fracture whilst the other had a 23-A2 frac- ture. Ring et al. suggested that younger women with sig- nificantly translated fractures may be at higher risk of carpal tunnel syndrome however, other authors have not advocated the need for carpal tunnel decompression as a routine in any fracture type, age group or gender [2,27-30]. Whether to routinely perform carpal tunnel decompression in certain patients remains controversial and it remains our policy to select patients on a case- by-case basis.
the small size or incomplete evaluation of these RCTs makes the results inconsistent. Recently, a systematic review  regarding volar locking plates and K-wire/pin fixation in the manage- ment of distalradiusfractures has been pub- lished. Regrettably, the systematic review was not based on RCTs, which only provided level 2 evidence. Another two meta-analyses [10, 11] were performed based on RCTs, however, meth- odological flaws in the process of data manage- ment, make the results imprecise. Thus, wheth- er surgical treatment of distal radial fractures with a volar locking plate improves clinical out- comes when compared with percutaneous Kirschner wires remains controversial.
Conclusion: Volar locking compression plate is the implant of choice in Comminuted Intraarticular distalradiusFractures. Use of locked volar plate predictably yields better patient reported outcome as per DASH scoring system and Sarmiento’s modification of Lidstorm’s crtiria for radiological outcome and allows earlier range of wrist motion which yields accelerated return of function necessary for our Indian population.
simple, minimally invasive technique to maintain the reduction in extra and intra articular fractures. Clinical guidelines from the American Academy of Orthopaedic Surgeons (AAOS) moderately recommend an anatomically stable surgical fixation, instead of cast fixation, to be followed by early wrist motion for treatment of patients with displaced distalradiusfractures. 4 Radial length is a radiological parameter that
Fractures of the distalradius are encountered mainly in postmenopausal women, but may occur in any sub- ject with osteoporosis (1). A variety of management op- tions have been devised. Since the outcome of treatment appears to depend to a large extent, on bone density (2, 3), this factor should be taken into account when choos- ing the most suitable management strategy for each pa- tient. However, distalradiusfractures are very common and frequently occur when full imaging facilities are not available. As a result, the medical staff on duty will rarely be able to determine bone quality as a guide for treat- ment planning. In the absence of more sophisticated techniques, many physicians will look at standard radio- graphs and intuitively use the cortical thickness of the distalradius as a rough indicator of bone density. This ap- proach was first described, for the femoral diaphysis, by Barnett and Nordin (4). Similarly, the cortical thickness of the humerus has been used to estimate osteoporosis (5, 6).
7. Shukla R, Jain RK, Sharma NK, et al. External fixation versus volar locking plate for displaced intra-articular distalradiusfractures, a prospective randomized comparative study of the functional outcomes. J orthop traumatol. 2014; 15(4):265-70. 8. Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distalradius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury.2000; 31(2):75-9.