Surgical interventions were all performed 5 to 7 days after the time of injury when the posttraumatic edema had completely subsided. The volar approach was ap- plied with flexor carpi radialis and median nerve pulled in the ulnar side and radial artery in the radial side. The soft tissue was carefully protected during operation. After pronator quadratus dissected longitudinally, the fracture was well exposed. With regard to the extra- articular fracture (Type A3), the temporary fixation k- wire was used immediately after the radius length, palmar tilt and radial inclination restored. For the intra- articular fractures (TypeB2, B3, C1, C2, C3), the arthros- copy technique was performed to check the articular surface anatomically restored and confirm the disappear- ance of the step-off. Locking screws were used in all the distalfracture fragments to support the articular surface. The position of the plate and correct reduction were confirmed using radiographic views. Range of motion and fracture stability were examined before skin closure. Active wrist mobilization began supervised by a physio- therapist immediately after operation.
Methods/Design: The study is randomized clinical trial with parallel groups and a blinded evaluator and involves the surgical interventions EF and VP. Patients will be randomly assigned (assignment ratio 1:1) using sealed opaque envelopes. This trial will include consecutive adult patients with an acute (up to 15 days) displaced, unstable fracture of the distal end of the radius of type A2, A3, C1, C2 or C3 by the Arbeitsgemeinschaft für Osteosynthesefragen – Association for the Study of Internal Fixation classification and type II or type III by the IDEAL 32 classification, without previous surgical treatments of the wrist. The surgical intervention assigned will be performed by three surgical specialists familiar with the techniques described. Evaluations will be performed at 2, and 8 weeks, 3, 6 and 12 months, with the primary outcomes being measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and measurement of pain (Visual Analog Pain Scale and digital algometer). Secondary outcomes will include radiographic parameters, objective functional evaluation (goniometry and dynamometry), and the rate of complications and method failure according to the intention-to-treat principle. Final postoperative evaluations (6 and 12 months) will be performed by independent blinded evaluators. For the Student ’ s t-test, a difference of 10 points in the DASH score, with a 95% confidence interval, a statistical power of 80%, and 20% sampling error results in 36 patients per group.
Various authors reported the use of additional meth- ods like Kirschner wire and/or dorsal plating in a few com- minuted fracture patterns (AO type C3) (26, 27). With the in- troduction of variable angle locking plates, there has been a decrease in the use of these additional methods of fix- ation. The adaptation of screw direction helps in engag- ing specific fracture fragments and avoiding intraarticu- lar penetration. Stanbury et al. reported the superiority of variable angle volar locking plates over fixed-angle locking plates in capturing the distal radial styloid (22). However, in our case series, three cases required additional mea- sures to stabilize the unstable distal end radiusfracture. In two cases, Kirschner wire was used to engage small radial styloid fragments that could not be engaged with the plate screws, while in the other case a cortical screw was used to reduce a lateral column bony fragment to the medial col- umn of the distal end radius (Figure 4) for the diaphyseal extension of the fracture.
Distal fractures of the radius comprise the largest por- tion of orthopaedic fractures, accounting for one sixth to one fourth of all fractures treated in clinical emer- gency departments . These fractures are more com- mon in postmenopausal women. The lifetime risk of sustaining a fracture of the distalradius is 15 % for women and 2 % for men . Among all fractures, dor- sally displaced distalradius fractures (DDDRF) are the most common. As the population is ageing, the specific incidence of this fracture type will, undoubtedly, in- crease in the coming years. In the past, many of these fractures were managed nonoperatively. However, the high incidence of malunion, associated with nonopera- tive management led to poor clinical outcomes, includ- ing pain and disability. Advances in internal fixation techniques have resulted in increased reliance on opera- tive approaches for the management of DDDRF. Closed reduction and fixation with percutaneous Kirschner wires (K-wire) has historically been the most common operative approach for distalradius fractures, providing a relatively quick and inexpensive treatmentmethod .
There is also a large body of literature on a new generation of treatment/management methods, examples being 1) plating systems involving new materials and/or new designs, such as variable- angle volar locking plate [32,33], a carbon fiber- reinforced poly (etheretherketone) (PEEK) volarplate , and a bioresorbable dorsal locking plate ; 2) intramedullary fixation (IM) devices, such as a non-bridging cross-pin fixator , the MICRONAIL ® device (Wright Medical Technology, Arlington, TN, USA) , the DRS System (Conventus Orthopedics, Maple Grove, MN, USA), the WRx Wrist Pin (Sonoma Orthopedic Products, Inc., Santa Rosa, CA, USA), the photodynamic bone stabilization system (PBSS) (IlluminOss ® ; IlluminOss Medical, Inc., East Providence, RI, USA) ), and a threaded, cannulated pin (T-Pin; Union Surgical LLC, Philadelphia, PA, USA) ; 3) hybrid plating and IM devices, such as the Dorsal Nail Plate ® (Hand Innovations LLC, Miami, FL, USA) ; and 4) local administration of recombinant
Fractures of the distalradius are common [1–3]. The increasing incidence of these injuries may be attributed to an aging population (osteoporotic fractures) and the growing participation in outdoor pursuits (higher energy fractures) [4, 5]. Whereas a large number of these fractures are managed non-operatively, the number of patients who undergo surgical management is considerable. Over the past 30 years, the surgical treatment of distalradius frac- ture has shifted from cast immobilization to numerous surgical options such as the use of external fixation and volar locking plates [6–9]. There are distinctive differences in these two surgical techniques and postoperative reha- bilitation protocols. Previously some authors have com- pared volarlocked plating with external fixation, but there is still insufficient evidence regarding which gives the best outcome [10–14].
fragments in fractures with major joint involvement. Excessive distraction of the hardware, to obtain satisfactory reduction, can result in delayed union, nonunion, complex regional pain syndrome (CRPS) or digital stiffness [3, 4]. Despite the fact that randomized trials do not provide strong evidence regarding the type of surgical intervention that is the most appropriate treatment for fractures of the distalradius in adults, superior functional and radiological results of ORIF with respect to external fixation have been reported recently . Standard straight plates result in optimal diaphyseal stabilization but may be inadequate for fixing metaphyseal and epiphyseal fractures. When posi- tioned on the volar aspect of the radius, straight plates are too bulky and may create attritional damage to flexor tendons; they need to be bent to follow the radial volar inclination, and are not sufficiently wide to adequately fix the epiphysis and capture small articular pieces for such fractures. A new technique described by Ginn et al.  involves ‘‘bridging’’ the fracture using a standard 3.5 mm plate applied dorsally and fixed in distraction from the radius to the third metacarpal shaft distally. The distraction plate technique also uses the concept of ligamentotaxis and, like external fixation, is especially indicated for intra- articular fractures with small, comminuted fragments which may be difficult to manage with plates or other nonbridging methods; when distraction fails to obtain adequate reduction, the use of bone grafts, K-wires and supplementary screws are included in the procedure. The hardware is removed after radiographic evidence of con- solidation (mean time: 124 days) and wrist motion has been initiated. Excellent clinical and radiographical results are reported with this technique . Disadvantages of this method include the long period of immobilization of the wrist, the need for a second operation to remove the Fig. 3 Radioulnar synostosis at 9 months after osteosynthesis (Syn-
Background Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at 12-month follow-up using a newplate made of carbon-fiber-reinforced polyethere- therketon for the treatment of distalradius fractures. Materials and methods We included 40 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 21 fractures were type C1, 9 were type C2, 2 were type C3, 2 were type B1 and 6 were type B2.
In conclusion, the evidence for using VLDRPs for the treatment of distalradius fractures is still a matter of debate and in addition to efficacy; costs and adverse effects should be taken into account. However, our study showed that in the short-term, the functional, clinical and radiological outcomes were superior in the VLDRP group in comparison to other treatment methods. We strongly believe we should concentrate on the early outcomes of distalradiusfracturetreatment with VLDRPs and not resign ourselves to the fact that “after time, they are all the same”. Therefore, the results of this study could encourage the judicial use of VLDRPs for the treatment of distalradius fractures. Future studies should focus on cost savings gained by earlier return to ADLs.
Materials and methods We performed a systematic review to evaluate the demographics, clinical profile, treatment and outcome of flexor tendon rupture following volarplate fixation of distalradiusfracture. Electronic searches of the MEDLINE, EMBASE, and Cochrane dat- abases for systematic reviews and conference proceedings were performed. Studies were included if they reported flexor tendon rupture (partial or complete) as a complica- tion of distalradiusfracture plating (all levels of evidence). Result Our search yielded 21 studies. There were 12 case reports and 9 clinical studies. A total of 47 cases were reported. There were 11 males and 23 females (n = 16 studies). The mean age was 61 years old (range 30–85). The median interval between the surgery and flexor tendon rupture was 9 months (interquartile range, 6–26 months). Twenty-nine plates were locking and 15 were nonlocking (n = 20 studies). FPL was the most commonly ruptured tendon (n = 27 cases, 57 %), with FDP to index finger being the second most common (n = 7 cases, 15 %). Palmaris longus tendon graft and primary end-to-end repair were the most common surgical methods used in cases of FPL tendon rupture.
Many studies reviewing various methods of fixation look at radiographic parameters that affect outcome, however few if any have looked at surgeon grade or time to surgery as we have. In a large radiographic study, Mackenney et al. showed that age over 80 years; metaphyseal comminution and positive ulna variance were the main predictors of instability. This and poor radio-carpal alignment were shown to be associated with poor outcome . However this study did not look at results after fixation with a volar locking plate, which has specific design applications for use in osteo- porotic unstable fracture patterns. We chose not to assess radiographic parameters such as residual intra- articular step, correction of normal distal radial anat- omy and presence of post traumatic osteoarthritis as we were interested purely in patient centered outcome and these radiographic features have consistently been Table 3 Time to Fracture Union with varying fracture type
the ulna head is the key to obtaining normal wrist biome- chanics. A wrist with a normal motion has about 120° of wrist flexion and extension, 50° of wrist radial and ulnar deviation, and 150° of forearm rotation. The radius carries 80 % of the axial load through the wrist, and the distal ulna only 20 % . Malalignment of the distalradius due to an osseous deformity affects the normal load transmission, causing a limitation in the extension-flexion arc of motion. Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Authors such as Fernandez  have descri- bed the traditional treatment of osteotomy and dorsal plating with bone graft for dorsal angulated malunions. These techniques guarantee good restoration of the anat- omy and relieve pain, but have sometimes been associated with irritation or rupture of extensor tendons. Volar fixed- angled plates have added a new approach to the treatment of distalradius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function . The aim of this study is to report the outcomes of a cohort of patients affected by symptomatic dorsally malunited extra- articular fractures of the distalradius who underwent cor- rective osteotomy using a volar locking plate without additional bone graft.
Introduction: Fractures of distal femur are one of the most prevalent fractures encountered in high-velocity trauma which are associated with high morbidity and mortality if not managed well. The isolated fracture can itself lead to complications such as Acute Respiratory Distress Syndrome (ARDS) and pulmonary embolism (PE). This necessitates early stabilization of fractures. Open reduction and internal fixation (ORIF) with locking compression plate is the treatment of choice for closed fractures of the distal femur. Distal femur anatomic contoured locking compression plate (LCP) has shown to give one of the best results regarding recovery, fracture union, return to work and the functional outcome. We present our experience of management of distal femur fracture at our centre.
Several limitations remain. The use of isolated radii (without ulna and the surrounding soft tissue) may over- simplify the biomechanical situation; however, it is the method typically employed in biomechanical testing and eliminates confounding factors [21, 32, 33]. A simple uniaxial loading in compression was used; while this will still cause shear loads and moments, the varying in-vivo loading patterns due to different hand postures will not be fully represented . Finally, only one extra-articular fracture type (AO-23-A3) was tested. Whether similar results can be obtained for intra-articular fractures needs to be investigated, but we assume that more complex fracture patterns require the use of individually oriented screws. This would prevent the use of a drill guide block (which sets a predefined axis for every screw) and thus the use of screws with predetermined lengths.
The mean total costs per patient from a NHS perspective was calculated adding the cost of inpatient stay, outpatient visit, consultations, medication, equipment, and intervention costs for all patients where response data were available. Respondents who failed to complete individual items of the EQ-5D were not allocated a utility index score. From the overall sample, missing data represented 7.07%. The complete data analysis was based on 278 patients. For those cases in which either resource usage or quality of life data was unavailable, we addressed missingness using multiple imputations via chained equations (Little and Rubin, 2002) assuming missing at random and using STATA 12. Missing cost data were predicted in terms of QALYs, treatment received, length of stay, age, gender, job status, patient’s self -reported health status, PRWE score, and Disability of the Arm, Shoulder and Hand score. Missing QALYs data were predicted in terms of this same list (excluding QALYs), plus each of the cost items. In order to remove implausible data, missing cost data were constrained to be positive. A total of 10 imputations were created to stabilise the results. The reported cost-effectiveness results were synthesized based on all imputed datasets.
Complex articular fractures of the distalradius represent an increasing challenge for surgeons and for the design of new surgical implants. The popularity of lockedvolar plat- ing continues to grow however, previous reports of suc- cessful outcomes concentrate on radiographic and surgeon orientated measures of success. Several reports use the Gartland and Werley score to evaluate outcomes after distalradiusfracture. Although widely used, this tool has not been validated and has been criticised heavily [13-15]. The patient rated wrist evaluation score has been shown to be much more sensitive to recovery after distalradiusfracture than the two more commonly used Table 1 Patient and injury characteristics, early post-operative assessment (6 months)
Under local or general anesthesia and control of tourni- quet in supine position, modified Henry approach was used to make a 10–12-cm longitudinal incision along the course of the flexor carpi radialis (FCR). FCR tendon, the flexor pollicis longus tendon, and radial nerve were retracted ulnarly, and brachioradialis and radial blood vessels were retracted radially. Then, pronator quadratus muscle was elevated from its radial origin and retracted ulnarly to expose the fracture fragments. Every fragment was reduced and re-confirmed under the fluoroscopic guidance. As for impacted fragments into the articular surface or metaphysis, periosteum elevator is introduced to elevate the fragments. Autogenous bone graft or allograft was applied to fill the bone detect, if necessary. Temporary fixation with K-wires was used to stabilize the reduced fragments. 2.4 mm or 3.5 mm T-shape
High functional outcomes (near preinjury ROM, minor values of the QuickDASH indicating a very low level of upper extremity disability, excellent results of the Mayo- Wrist-Score in >93 % of the patients) were seen at the latest follow-up in both groups, even though without dif- ferences among each other. Trosti and Ilyas  also per- formed a prospective evaluation of pronator quadratus repair versus no repair following volarplate fixation with a minimum follow-up of 12 months. They even found no significantly different results between groups accord- ing to ROM at the wrist, DASH scores, grip strength, and VAS scores. These findings as well as the results of the present study compare favorably to those of other recently published studies [21, 22]. In a retrospective study with a 3-month follow-up, Ahsan et al.  found no differences in ROM and grip strength in 108 patients with complete and incomplete PQ repair. Hershman et al.  examined the outcome effects in 112 patients treated with or without PQ repair after a follow-up of 1 year. They found no differences in pronation, pain and DASH scores and, therefore, concluded that there is no advan- tage in repairing the PQ muscle during volar plating of distalradius fractures.
erative methods (8, 9, 16, 17). However, in few selected intra- articular scapular fractures, the best outcome is usually ob- tained with open reduction and internal fixation (16, 17). They are often associated with poly-trauma, which takes the immediate attention away from scapula and hence other life threatening injuries are treated first (8, 9). Surgi- cal indications are there in the literature that include the unstable shoulder joint based on multiple disruptions of the superior shoulder suspensory complex (SSSC) (18-20), ‘medialization of glenoid’ (medial/lateral (M/L) displace- ment) by 10 - 25 mm (21, 22), angular deformity (21, 22), shortening > 25 mm as defined by Jones et al. (22) (a mea- sure of medialization of the glenoid), displaced fracture of the glenoid with intra-articular step-off or gap between 2 and 10 mm, and 20% - 30% involvement of the articular surface or instability of the glenohumeral joint(4, 7, 23-25). There are many published papers that describe different operative approaches and fixation techniques for scapula fractures (7, 24, 25). Ideberg’s classification (3) is the most
One of the most important structures is the triangular fibrocartilage complex (TFCC), a term coined by Palmer and Werner. It arises from the ulnar aspect of the lunate fossa of the radius and courses ulnarward to insert into the base of the ulnar styloid. It also flows distally, where it is joined by fibers arising from the ulnar aspect of the ulnar styloid and inserts distally into the triquetrum, hamate, and base of the fifth metacarpal. In the center of the complex is the triangular fibrocartilage (TFC) proper 34 . The periphery of the TFC is thickest, usually measuring 5 mm, and is the portion best suited to bear tensile loads. The rim is well vascularized and therefore has good healing potential.