The linear externalfixator to be used will be a radiotransparent bar with two pin fastening platforms, with one platform being proximal on the radius and the other platform distal on the second metacarpal, offered by Synthes (code – 03.304.220S). Four threaded self-drilling pins will be used with the proximal platforms that are 4.0 mm in diameter and the distal platforms that are 2.5 mm in diameter. Osteosynthesis with an externalfixator will be achieved by the following surgical technique: closed reduction of the fracture by the reduction technique employing traction and contraction manipulation; confirmation of reduction with the image intensifier; a longitudinal incision of 1.5 mm in the dorsal aspect of the forearm and 8 cm proximal from the wrist joint on the longitudinal axis of the radius; exposure of the dorsal cortex of the radius by blunt dissection, introduction of the soft tissue protector positioned at a right angle to the coronal plane of the forearm; introduction of two 4.0 mm self-drilling Schanz pins with a T-handle; double 0.01 cm incisions over the dorsal aspect of the diaphysis of the second metacarpal with a 1 cm spacing between them; dissection and exposure of the dorsal cortex of the metacarpal; placement of the soft tissue protector at a right angle to the coronal plane of the hand; introduction of two 2.5 mm self-drilling Schanz pins, with a technique similar to that for the proximal pins, in the diaphyseal region of the second metacarpal. Should the fracture be intra-articular, this surgical technique may be combined with percutaneous fixation with 1.5 or 2 mm K-wires. Where dorsal comminution is present, a bone graft may be performed with bone removed from the iliac. Open reduction with volar approach and volarlockedplate.
Treatment options for DRFs have varied between non- operative and operative, and numerous different surgical methods have been described over time. Operative treat- ment with a volar locking plate was introduced in the early 2000s, and since then the procedure has rapidly gained wide popularity. The aim of the procedure is to improve the repair of osteoporotic or comminuted frac- tures by providing a stable construction . It has also been hypothesized that reducing the fracture to the nor- mal anatomical position would produce a superior func- tional outcome . Several other operative techniques, such as dorsal plates, fragment-specific plates, external fixators, metal wires and screws, have been proposed for treating DRFs. However, none of them have been shown to be superior to any other. According to several high- quality randomized controlled trials, percutaneous tech- niques, such as externalfixator and metal wires, pro- duced similar functional outcomes when compared with a volar locking plate [14, 15].
Objectives: This study compared the clinical and radiological outcomes of two different methods for the treatment of distal radial intra-articular frac- tures. Patients and Methods: Forty-six patients with distalradius intra-arti- cular fractures were divided into two groups. Group I included 24 patients with type C fracture treated by externalfixator augmented by percutaneous K-wires. Group II included 22 patients with type C fracture treated by volarlockeddistal radial plate augmented by K-wires. Two patients had complex injuries necessitating double plating (sandwich). All patients were evaluated clinically by Mayo Wrist Score and radiologically by Sarmiento’s radiological score. Results: Both groups reported good personal satisfaction according to Mayo Wrist Score, and the results were not statistically different between the two groups. In Group I, 19 patients (79.2%) had excellent radiological out- come and five patients (20.9%) had good radiological outcome according to Sarmiento’s radiological score. In Group II, 20 patients (90.9%) had excellent outcome, and two (9.1%) had good radiological outcome; there was no or in- significant deformity. Conclusions: Complex distal radial fractures can be treated either by external fixation (ligamentotaxis) or by locked pre-contoured plating. The clinical outcome of plating and externalfixator in our study did not show any statistically significant difference. The radiological outcome had no correlation with the clinical outcome.
In cases with distal radioulnar joint subluxation, stabilization by radioulnar K wire fixation 75 was done in 5 cases in Exfix group and one case in LCP group which was removed after 3 weeks. Superficial branch of radial nerve injury occurred in one case of Exfix group which is limited by the ―Open method‖ of insertion of radial pins between the extensor carpi radialis longus and brevis 76 . One case in LCP group had median nerve neuropathy which is reduced by the surgeon‘s skill and meticulous dissection. The well padded pronator quadratus over the volarplate did not produce any tendon complications by the the hardware in long term follow up.
resulting from different treatment strategies. One might argue that the inclusion of type B fractures only might have improved the outcome; however, we feel that the concentration on one specific type entity of fracture reduced the heterogeneity of outcome measures. One limitation of this study was the sample size. It was not designed as a controlled cross-sec- tional study, and in order to be able to show non-in- feriority of this implant compared to routinely used implants a higher sample size would be necessary. However, this study showed the clinical application with a reasonable follow-up period and might there- fore serve as groundwork for future research to assess and compare different implants for the surgical treat- ment of fractures. The histological analysis of only one patient was not representative and should not be generalised. However, since none of the patients showed clinically relevant complications that led to implant removal, we feel that this implant may be safe to use in selected patients.
Fixed-angle volar plates can adequately stabilize artic- ular fragments and both volar and dorsal comminution, even in osteoporotic bone [8, 9]. Optimal positioning of the plate, with screws and pins placed in the subchondral position, restores radial length and radial and palmar tilt, acting as an internal fixator; indirect reduction of the dorsal aspect of the radius avoids damaging bone vascularity in comminuted fractures, reducing or avoiding the need for bone grafting. Using long plates, the metaphyseal and distal diaphyseal fracture is bypassed and the plate fixed proximally with at least three screws in the healthy diaphyseal bone. In multifragmented and highly commi- nuted fractures, multiple wire loops or single cortical screws can be used to improve stability and the reduction of the metadiaphyseal part of the radius. The rationale behind this technique is to obtain optimal stability of the fracture, restoring radial length and correct radioulnar and radiocarpal relationships, avoiding interference with soft tissues, and allowing an early functional recovery. As the plate is positioned deep and covered by muscles, interfer- ence with tendons is rare; elsewhere, there is no need to remove the hardware. Associated ulnar head fractures are treated with percutaneous pin fixation or ORIF depending on the stability of the fracture [10, 11]. In our cases, this technique led to the consolidation of all fractures except one that needed a secondary bone grafting. Optimal reduction was achieved in most cases (16 out of 21); in particular, restoration of radial length was obtained in all cases with average ulnar variance of 0°. Two patients healed with an articular step; clinical results were graded as good and fair. No case showed loss of reduction during the treatment. Imperfect reduction was found to be associated with higher DASH scores (P = 0.0006). A clinical evalu- ation revealed satisfactory results in 19 cases out of 21. Two cases had poor results—one associated with articular incongruity and one due to radioulnar synosthosis. The latter case was operated on 12 months from the first intervention with almost complete recovery of forearm rotation. Extra-articular A3 fractures showed better results than articular C2 and C3 fractures, but no significant dif- ferences were noted among these two groups (P = 0.2). Associated ulnar fractures are generally the consequence of a high-energy trauma; despite that, they did not produce significant effects on the outcome (P = 0.4). Even though the fractures appeared extremely comminuted in some cases, bone grafts or substitutes were never used. In C3 fractures with multiple small articular fragments, adequate fixation with periarticular plates may be difficult and, in
Modified De Palma technique of percutaneous pinning The modified De Palma fixation technique of percutane- ous pinning was used in which the fracture of the radius was fixed using the ulna as a support . Two to four Kirschner wires (1.5 to 2.0 mm) were introduced with the aid of fluoroscopy by means of stab incisions on the ulnar face of the distal region of the forearm, 2 to 4 cm proxi- mal to the ulnar styloid process. In piercing through the two cortical walls of the ulna, we directed the convergent pins towards the styloid process of the radius in the coro- nal plane (figure 1C and 1D), with diverging directions (dorsal and volar) in the sagittal plane. When more than two pins were used for fixation of joint fragments, they were introduced tangentially to the joint surface of the radius (figure 1D). The pins were curved and cut close to the skin, and were protected with a bandage containing sterilized gauze. We then applied a cast that was extended above the elbow at 90 degrees with the forearm and wrist in neutral position (figure 1E). During postoperative fol- low-up, evaluations and rebandaging were performed every week. The cast and pins were retained for four to eight weeks, and the decision on when to remove them was based on radiographically demonstrated fracture consolidation. (Figure 1)
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 lockedvolar 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.
Our meta-analysis showed that in treating dis- tal radial fractures, volar locking plate and per- cutaneous fixation yielded similar outcomes. Although volar locking plates have the advan- tage of supination and grip strength at 3 and 6 months postoperatively, this was not reflected in the functional outcome. In contrast, percuta- neous fixation is quicker to perform than volar locking plate fixation. Over the past decade, there has been a shift in the surgical approach for treatment of distal radial fractures in favor of open reduction and internal fixation, to achieve anatomical reconstruction of the frac- tured bone. By pooling and analyzing the origi- nal data provided by the corresponding author, our results suggested that if early grip strength and supination rehabilitation are important, volar locking plate fixation is an alternative method. Otherwise, percutaneous fixation is an ideal treatment. In contrast, the results of grip strength were not presented although the authors mentioned that the data on grip strength were collected in one recently pub- lished meta-analysis , and the grip strength data were analyzed with incorrect raw data in the other meta-analysis . We believe that our results are correct and precise.
When using SDLS pre-drilling is not required and hence screw length cannot be measured directly during the oper- ation. Therefore, distal screw length has to be determined prior to surgery. The authors are not aware of any study assessing screw length preoperatively. Preoperative screw length assessment based on posterior-anterior (pa) radio- graphs appears possible, if the following two prerequisites are met: First, radius width (measured from pa radio- graphs) correlates to radius depth, i.e. distal screw length. Second, the distal screw orientation is known. Ljungquist et al.  have shown recently that the lunate depth can be used as a predictor. Due to its dependency on a pre- operative CT image, we chose to use the distalradius width, which can be measured easily on regular radio- graphs. Measurements should be conducted on true pa ra- diographs centered on the distalradius, as outlined in a previous study . This study showed a high correlation between distalradius width and depth. This indicates a possible correlation between distal pa-radius width and distal screw length, in case the screw orientation is known. The use of a drill-guide block could standardize distal screw orientation.
Locking compress plate (LCP), which is lightweight, comfortable and convenient for patients to ambulate , is very attractive to be used as external fixators in the treatment of distal tibial fracture, especially compared with conventional external fixators. LCP has been suc- cessfully used in open or closed distal tibial fractures and shown good rates of union and ankle-joint motion [8–11] due to the use of angular stable anchoring of screws in the plate, which enables LCP to stabilize the short distal tibial segment without spanning the ankle joint. However, the stability of LCP as an externalfixator was questioned by several studies [12 – 14] based on the fact that stiffness of compression and torsion of plate would be significantly reduced when the distance be- tween the plate and the bone surface was above 5 mm . A poor stability of externalfixator may cause exces- sive interfragmentary movements during weight-bearing functional exercises, prolonging the healing period and causing delayed union or nonunion of the bone fragments.
In the present study, the SF-36 was administered for self-completion by patients two, six and ten years post- operatively. The final follow-up results of PCS and MCS in our study did not show any statistically significant changes compared to the follow-ups at two and six years postoperatively. The results of the SF-36 questionnaire at the two-, six- and ten-year follow-ups compared with sex- and age-matched norms for the United States popu- lation and with data of an Austrian control group showed no significant changes in the PCS and MCS but there was a significant difference for the MH subscale (p = 0.045). In this subscale we found deterioration for our ten-year follow-up results compared to the Austrian norm, but no difference in comparison with the US norm population. The reason for this might ultimately be found in differences between the two health care sys- tems. There was a decrease over time for the VT sub- scale that can be explained by the aging of our cohort.
Donor site morbidity, especially at the iliac crest, has been well described and minor complications such as persistent pain at the harvest site, superficial sensory nerve injury, superficial hematoma or seroma and superficial infection have been reported . Moreover, a volar approach is easier than a dorsal approach and the reduction of the volar cortex is simple because of less comminution and the advantage of direct vision . The present study showed that a corrective osteotomy using a volar locking plate without the use of bone grafting could effectively produce a significant improvement in wrist function in patients treated for extra-articular distalradius malunion. We obtained an excellent correction of deformity based on radiographic parameters, with low morbidity and no non- unions, hardware failure or need for hardware removal. Our results are in line with those reported by Mahmoud et al. , who treated 30 malunited dorsally-angulated radii using fixed-angle volar locking plates without bone graft- ing, obtaining at a mean 18-month follow-up radiological evidence of union, correction of the deformity, and clinical and functional improvement in all cases. In particular, the improvement in the DASH and Mayo scores obtained in the present study was 28.5 and 42.8 points, respectively, compared with the 21.6 and 22.7 points reported by Mahmoud et al. . These differences in functional out- come can probably be explained by the longer follow-up period of the present research. Favorable results have also been reported in numerous studies following volar locking plates with additional bone graft [18, 19]. The volar approach and the use of locking plates is an extremely effective and safe technique; in fact, the use of fixed-angle locking plates reduces the risk of postoperative bone dis- placement, and requires a shorter immobilization time [20, 21]. Moreover, the mechanical strength provided by this construct does not necessarily require the use of bone grafting. We therefore believe that the volar approach and locking plate, without necessarily the use of bone grafting, is an effective technique for addressing symptomatic and even severe deformities of the distalradius, and should be preferred especially in elderly patients with poor bone
Use of this plate enables early joint mobilization with stable fixation construct owing to its close forming near articular margin and availability of different screw directions; proving its biomechanical superiorities. As well, the use of volar approach poses minimal soft tissue trauma and good space for implant placement, avoiding the pitfalls of the dorsal approach like irritation of extensor tendon e and possibly late tendon ruptures (Schnur and Change, With volar approach the large volar fragment, small fragment near the lunate fossa, the radial styloid and the ulnar fragment of the distalradius should be fixed with buttressing itself and with the use of spatially oriented small threaded screws as and when necessary. Separate screws, k- wires or tension band should be utilized to fix the radial or ulnar styloid fractures and unstable DRUJ. The very absence of fracture fragment displacement and shortening in our case is related to the proper plate placement within 2mm of the articular margin and securing each fragment with accurate placement of fixation screws.
Our study has been conducted in locally to assess the functional outcome of unstabledistalradius fracture in adults treated with palmer T-plate Osteosynthesis. Palmer T- plate can be the choice of implant for fixation of unstabledistalradiusfractures. Use palmer T- plate provides the best mode of anatomical reduction and in addition to this their buttress modes reduces and stabilize vertical shear intra-articular fractures through an antiglide effect . The purpose for conducting this study is to achieve a validated data by assessing the postoperative range of motion by the use of validated DASH score (Disability of Arm, Shoulder and Hand) and assessment of degree of flexion & extension at wrist post operatively. Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH & confirming its usefulness across the whole extremity [12,13]. A very strong correlation was noted between DASH & other scoring systems making it reliable in evaluating a subjective outcome. Range of flexion and extension which is most important function of wrist is evaluated.
This study has some limitations. First of all, it has to be clearly stated that the results seen in this very short duration of follow-up might change with a longer fol- low-up term. However, concerning about the functional outcomes of cited studies above that have shown no dif- ferences up to 1 year of follow-up, it is doubtful whether the pronation strength or other functional parameters will be changed during the further postoperative time period [4, 12, 18, 19]. This study did not examine pro- nation strengths in relation to the dominant arm side, which can potentially be influenced by a PQ repair or not, and moreover, the quality of fracture reduction or plate positioning was ignored. A power analysis has not been performed a priori, as, during the planning of the study, no comparable studies have been published.
So, in cases with metaphyseal comminution the fracture actually takes long time to consolidate. So in cases with metaphyseal comminution, the externalfixator has to be kept for a longer time or there should be addition of cancellolus bone graft to avoid metaphyseal collapse.Residual dorsal angulation can precipitate ulnar impaction, midcarpal instability and altered stress concentration which may lead to early arthritis. Porter, in his study, felt that loss of function did not occur until at least 20 degrees of palmar tilt was lost.
6 destruction of the blood supply to bone (MIPO -minimally invasive plate osteosynthesis). Systems such as the Less Invasive Stabilization System (LISS) , Point Contact Fixator (PC-Fix) and Schuhlis systems used principles of external fixation, internally and locking technology theory. What resulted in 2000 was the Locking Compression Plate (LCP) (Fig.11) with a Combi hole so that the techniques of conventional and locked screw technology could be used in one plate.
gested that use of VLPs led to faster recovery. No difference was observed in functional out- come, radiological findings, and complication rates at 1 year. The need for reoperation was more common with VLP use. Compared with the findings reported by Li , other studies showed similar outcomes. Moreover, Li’s study included 6 articles, while our study included 10 RCTs.
The volar variable angle locking plate is not a panacea for distal end radiusfractures. The inability to decipher the articular anatomy of the distal end radius and the poor re- duction of the fracture will lead to poor results with this newer implant. Complications such as hardware promi- nence, loss of reduction, and tendon irritation are similar to those found with other volar plates. The overall com- plication rate in our study was 21.7%, which is comparable to that reported by Jagodzinski et al. in a bicentric study on distalradius variable angle locking plates (28). They re- ported a complication rate of 19.6%, although the major- ity had screw misplacement, while Kawasaki et al. had no reported cases of screw misplacement (29). In our study, there was only one case of screw misplacement because extra care was taken to prevent this complication since it could have resulted in longer fluoroscopy time. However, no effort was made to calculate the resultant extra fluo- roscopy exposure. The smaller sample size in our study could also be the reason for only a single case of such a com- plication.