In Reply:

Abstract

We would like to thank the author for his interest and the comments made concerning our article.1Kim J.K. Park J.S. Shin S.J. Bae H. Kim S.-Y. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function.J Hand Surg Am. 2014; 39: 2246-2250Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The author commented that repairing brachioradialis (BR) during volar plate fixation of distal radius fracture (DRF) would be better than the method we described (releasing the BR without repair) in 3 respects. First, the author raised a concern that we did not release the BR attached to the proximal fracture fragment. However, this is the result of a misunderstanding. We do release the BR attached to the proximal fracture fragment and have experienced no difficulty elevating the BR in the proximal fragment, although we release the BR tendon transversely. Second, the author pointed out that releasing the BR without repair would adversely affect elbow flexion strength. However, previous biomechanical studies showed that BR attachment to the distal fracture fragment contributes little to total elbow flexion strength,2Murray W.M. Delp S.L. Buchanan T.S. Variation of muscle moment arms with elbow and forearm position.J Biomech. 1995; 28: 513-525Abstract Full Text PDF PubMed Scopus (290) Google Scholar, 3Tirrell T.F. Franko O.I. Bhola S. Hentzen E.R. Abrams R.A. Lieber R.L. Functional consequence of distal brachioradialis tendon release: a biomechanical study.J Hand Surg Am. 2013; 38: 920-926Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar and our study also demonstrated no difference between patients whose BR was released or preserved in terms of elbow flexion strength.1Kim J.K. Park J.S. Shin S.J. Bae H. Kim S.-Y. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function.J Hand Surg Am. 2014; 39: 2246-2250Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Consequently, we believe that although the BR is repaired after release, this cannot provide more elbow flexion strength than an intact BR. Third, the author stated that BR repair is required for repair of the pronator quadratus (PQ). However, it is difficult to repair the PQ at the radial septum of the radius despite BR repair, because the muscle fascia of the PQ is not strong enough to hold sutures.4Nho J.H. Gong H.S. Song C.H. Wi S.M. Lee Y.H. Baek G.H. Examination of the pronator quadratus muscle during hardware removal procedures after volar plating for distal radius fractures.Clin Orthop Surg. 2014; 6: 267-272Crossref PubMed Scopus (5) Google Scholar In addition, some studies have shown that PQ repair after volar plate fixation of DRF provided no functional advantage in terms of wrist range of motion, grip strength, and Disabilities of the Hand, Arm, and Shoulder score and visual analog score at 1 year.5Hershman S.H. Immerman I. Bechtel C. Lekic N. Paksima N. Egol K.A. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures.J Orthop Trauma. 2013; 27: 130-133Crossref PubMed Scopus (59) Google Scholar, 6Tosti R. Ilyas A.M. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures.J Hand Surg Am. 2013; 38: 1678-1684Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The author also mentioned that PQ repair is necessary to prevent flexor tendon complications after volar plate fixation of DRF; however, this is not supported by published evidence. Although we usually do not repair the PQ, we have rarely encountered flexor tendon complications.1Kim J.K. Park J.S. Shin S.J. Bae H. Kim S.-Y. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function.J Hand Surg Am. 2014; 39: 2246-2250Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar On the other hand, those who routinely repair the PQ still report flexor tendon complications.7Arora R. Lutz M. Hennerbichler A. Krappinger D. Espen D. Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate.J Orthop Trauma. 2007; 21: 316-322Crossref PubMed Scopus (416) Google Scholar, 8Soong M. Earp B.E. Bishop G. Leung A. Blazar P. Volar locking plate implant prominence and flexor tendon rupture.J Bone Joint Surg Am. 2011; 93: 328-335Crossref PubMed Scopus (191) Google Scholar Based on a literature review, we believe that flexor tendon complications after volar plate fixation of DRF are not related to PQ repair, but rather to plate position and prominence.6Tosti R. Ilyas A.M. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures.J Hand Surg Am. 2013; 38: 1678-1684Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 9White B.D. Nydick J.A. Karsky D. Williams B.D. Hess A.V. Stone J.D. Incidence and clinical outcomes of tendon rupture following distal radius fracture.J Hand Surg Am. 2012; 37: 2035-2040Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar It is reasonable for the author to be concerned regarding nonrepair of the BR after its release during volar plate fixation of DRF, because the need for such repair remains debatable. We hope that further biomechanical studies and randomized clinical trials will address and resolve this issue. Regarding “The Effect of Brachioradialis Release During Distal Radius Fracture Fixation on Elbow Flexion Strength and Wrist Function”Journal of Hand SurgeryVol. 40Issue 4PreviewWith great interest, we have read the article by Kim et al.1 Their conclusion that “Release of the BR [brachioradialis] during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function” is attractive, because it means that we could save time and simplify the surgical procedure for distal radius fractures. Full-Text PDF