Unstable Extra-articular Fractures Research Articles

Closed Reduction & Pinning of unstable Extraarticular fracture Distal Radius (How many K-wires needed?) Systematic Review

Closed Reduction & Pinning of unstable Extraarticular fracture Distal Radius (How many K-wires needed?) Systematic Review

Comparison of functional outcome of extra-articular distal radius fractures treated by volar locking plate versus percutaneous pinning in adults-a retrospective study

<p><strong>Background</strong>: Distal radius fractures are one of the most common fractures in an adult population and accounts for 17.5% of all the fractures. The management of distal radius fractures remains debatable despite the availability of different methods of treatment. The aim of this study is to assess the functional outcomes of extra-articular distal radius fractures treated with percutaneous pinning or internal fixation with volar locking plate in adults.</p><p><strong>Methods: </strong>A retrospective study of 40 patients diagnosed with distal radius fracture with AO classification were treated either with percutaneous pinning (n=20) or open reduction and internal fixation with volar locking plate (n=20) were included in study. DASH score and radiographs at 6<sup>th</sup> month was assessed for functional outcome and radiological union.</p><p><strong>Results: </strong>Mean age in plate group was 40 and 45 years in K wire group. The mean passive wrist ROM at the final follow-up evaluation in plate group was 63.8<sup>o</sup> extension and 70.5<sup>o </sup>flexion, 81.7<sup>o</sup> supination and 79<sup>o</sup> pronation, compared with 56.75<sup>o</sup> extension and 65.25<sup>o</sup> flexion, 74.7<sup>o</sup> supination and 85.5<sup>o</sup> pronation in patients treated with K wire group. Patients with plate group and K wire group had DASH score of 19.85 and 18.49 respectively (p=0.07) at 6 months follow-up.</p><p><strong>Conclusions:</strong> The use of ORIF with plate resulted in stable fixation of the unstable extraarticular fractures, allowing early post-surgical wrist motion and has good radiological outcome whereas K wire also has advantages of being minimal invasive, reduced hospital stay and minimal cost.</p>

How Many Screws Are Needed for Reliable Stability of Extra-articular Nonosteoporotic Distal Radius Fractures Fixed with Volar Locking Plates?

BackgroundWe hypothesized that volar locking pate fixation using a minimum number of screws—four in the distal row and two in the shaft of the plate—will provide sufficient stability for unstable extra-articular fractures of the distal radius. We aimed to compare the biomechanical properties of different numbers and locations of screws in volar locking plate fixation and describe the clinical and radiological outcome of plate fixation using a minimum number of screws for distal radius fractures.MethodsWe divided 48 artificial radius fracture bones into four groups (group A–D) based on the number and location of screws used for fixation with volar locking plates. The artificial bone models were subjected to axial compression and volar bending load with a force of 250 N and 80 N, respectively, for 1,000 cycles at a frequency of 1 Hz. We also retrospectively reviewed 42 patients with unstable, extra-articular, distal radius fractures who were treated with volar locking plate fixation using a minimum number of screws.ResultsGroup A (seven distal screws and three proximal screws) had the highest mean stiffness: 303.7 N/mm under axial compression and 61.1 N/mm under volar bending. Compared with group A, group D (four screws in the distal part and two screws in the shaft) showed significantly lower stiffness; therefore, group D was considered inferior in terms of stability. However, in the fatigue test, neither deformation of the metal plate nor detachment or breakage of the metal screws was observed in all groups. In the clinical study, all fractures united without displacement and satisfactory clinical outcome was obtained.ConclusionsIn the dorsally comminuted, extra-articular, nonosteoporotic distal radius fractures, the minimum number of screws—four in the distal row and two in the shaft—in volar locking plate fixation can provide sufficient stability. Further biomechanical studies involving osteoporotic bone will be necessary to confirm the results because volar plate fixation is most commonly used in patients with osteoporosis.

Minimally invasive internal fixation for extra-articular distal radius fracture: Comparison between volar plate and intramedullary nail

IntroductionThere are numerous internal fixation techniques for distal radius fracture, using pins, plates or nails. Some authors have developed minimally invasive procedures. The aim of the present study was to compare two minimally invasive internal fixation techniques for unstable extra-articular distal radius fracture in women over 50 years of age: volar plate (minimally invasive plate osteosynthesis: MIPO), and intramedullary nail. HypothesesThe main study hypothesis was that the incision scar left by minimally invasive internal fixation is smaller using MIPO than an intramedullary nail. The secondary hypotheses were that the two techniques do not differ in terms of pain, functional score, strength, range of motion and radiologic indices. Material and methodThe series comprised nineteen A2.2 and one A2.1 fractures in 20 female patients with a mean age of 72 years. The first 10 (group 1) received minimally invasive internal fixation of the distal radius by MIPO, and the other 10 (group 2) by intramedullary nail locked onto the distal radius epiphysis and diaphysis. ResultsThe main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail (mean, 14.3mm vs. 32.8mm). Some of the secondary hypotheses were also confirmed: there were no differences between the two techniques in terms of pain at 6 months, QuickDASH, PRWE (Patient-Reported Wrist Evaluation), range of motion or ulnar variance; two were not confirmed: pain at 6 weeks was less with intramedullary nails, and palmar slope was better with MIPO. Discussion and conclusionThe main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail. In conclusion, the present findings showed that internal fixation of unstable extra-articular fracture in over 50-year-olds gave better clinical results at 6 weeks using an intramedullary nail, while MIPO required smaller incision. Level of evidenceIII, retrospective study.

Volar locking plate fixation (Ellis plate) of intra-articular distal radius fractures: Prospective randomized study

Background: Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed volar plate for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose: The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with compound fracture of distal radius grade III and above. Patients and Methods: This prospective randomized study comprised 60 patients with displaced intra-articular (Frykman type IV-VIII) distal end radius fractures treated with volar locking plates. The patients were followed up at 2nd week, 6th week, 12 week, 6 months and 1 year after surgery. The assessment of pain, range of motion, grip strength and activity were assessed at each follow-up visit and scored according to the Green and O’Brien scoring system. Results: At the end of 1 years, In volar plate group out of 60 patients, excellent result was achieved in 08 patients (13%), good in 48 patients (80%), fair in 04 patients (7%). No poor outcome seen. Conclusions: Irrespective of the direction and amount of initial displacement, a great majority of intra articular fractures of the distal radius can be managed with a fixed angle volar plate through a single volar approach.

Tension band wiring for treatment of extra articular fracture of the base of first metacarpal.

Eleven patients with unstable extra-articular fractures of the base of the first metacarpal with angulations more than 30° uncorrected by closed reduction were treated by open reduction and tension band fixation. Ten men and one woman with a mean age of 36.18years. Fall on a stretched hand was the cause in eight while a punch in two and trauma from a basket ball in one. The mean follow up period was 12.45months. All fractures united within a mean of 4.36weeks. Patients were evaluated by subjective and objective criteria: the mean of pain was 0.5, quick-DASH was 10.48 and Kapandji score was 9.8. While the mean of the grip strength was 94% and the pinch strength was 99% of the contra lateral hand. There were no complications except local irritation of the k-wires in two patients that had to be removed at 4months. Tension band technique proved to be a valuable technique which is easy to apply and gives rigid fixation with early mobilization.

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures.

We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks. IV.

Minimally invasive surgical treatment for unstable fractures of the proximal phalanx: intramedullary screw

ObjectiveTo analyze the clinical-functional parameters and quality of life of patients undergoing minimally invasive surgical treatment for extra-articular fractures of the proximal phalanx, using an intramedullary screw (Acutrak®). MethodsBetween January 2011 and September 2014, a prospective study was conducted on 41 patients (48 fingers) with unstable extra-articular fractures of the proximal phalanx, who underwent minimally invasive surgical treatment using an intramedullary screw (Acutrak®). These patients were evaluated 12 months after the surgery by means of the DASH quality-of-life questionnaire, VAS pain scale, measurement of range of motion (ROM, in degrees) and radiographic assessment. ResultsAll the patients achieved adequate reduction and consolidation of their fractures. There were statistically significant improvements in quality of life on the DASH scale, pain on the VAS scale and range of motion. ConclusionThe minimally invasive technique for treating unstable extra-articular fractures of the proximal phalanx using an intramedullary screw (Acutrak®) is effective and safe, and it presents satisfactory clinical-functional results.

Comparing the effect of volar plate fixators and external fixators on outcome of patients with intra-articular distal radius fractures: A clinical trial.

Background:Distal radius fractures (DRFs) are much more prone to malunion than unstable extra-articular fractures. There is no clear consensus concerning what the proper treatment should be, and the best approach to use for displaced DRFs remains challenging.Objective:To compare the effect of two different therapeutic surgical methods, i.e., volar plate fixators and external fixators, on outcomes of patients with intra-articular distal radius fractures.Methods:From May 2010 to November 2014, 76 subjects who had experienced intra-articular fractures of the distal radius were enrolled in this double-blind, randomized, controlled trial in Imam Ali Hospital in Bojnourd, Iran. The patients were divided into two groups, i.e., 1) patients who were treated with internal fixation using the volar plate (group A) and 2) patients who were treated with external fixators (group B). The primary outcome was a composite measure of the patient’s quality of life using three different scores, i.e., 1) the MAYO score, 2) Disabilities of the Arm, Shoulder, and Hand (DASH (score, and 3) the Short Form (36) (SF-36) Health Survey score.Results:A total of 76 patients were allocated randomly to groups A and B. The mean ages for external fixator cases and volar plate cases were 51.7 and 46.3, respectively. No significant age distribution was seen between the two groups (p=0.348). Gender distribution between the two groups was not significantly different (p=0.022). Grip power was significantly different between the two groups, but no significant differences were detected in range of motion (p=0.008, p=0.367, respectively). The MAYO score was significantly higher in the open reduction and internal fixation (ORIF) group, and, according to the SF-36 test, the ORIF group also a higher level of general mental and physical health, social functioning, and personal physical functioning than the other group. However, postoperatively, the mental discomfort and physical discomfort were more prevalent in the external fixator group. The DASH score was not significantly different between the two groups (p=0.124).Conclusions:ORIF and its subtitle, volar plate fixation, is a more preferred surgical procedure than the external fixator for the treatment of intra-articular distal radius fractures. This conclusion is important when one considers cost-effectiveness and an earlier return to work.Trial registration:The trial is registered at the Thai Clinical Trial Registry (clinicaltrials.in.th) with the TCR identification number TCTR20150609002Funding:The authors received no financial support for the research, authorship, and/or publication of this article.

Percutaneous Distal Radius–Ulna Pinning of Distal Radius Fractures to Prevent Settling

To evaluate the clinical and radiological outcomes of distal radius fractures treated by percutaneous fixation using distal radius-ulna pinning and to assess its effectiveness especially for preventing fracture settling. We retrospectively reviewed 18 distal radius fractures (15 AO type A2 and 3 AO type C1). Range of motion and Disabilities of the Arm, Shoulder, and Hand scores were evaluated. We measured radiographic parameters at the final follow-up and compared them with those on immediate postoperative x-rays. All fractures united and average time to initial healing was 6.9 weeks (range, 6-7 wk). Average follow-up was 29 months (range, 26-43 mo). Average wrist flexion and extension were 70° and 65°, respectively. Average forearm supination and pronation were 82° and 83°, respectively. Average pain score was 1.2 and average Disabilities of the Arm, Shoulder, and Hand score was 13. Mean difference of ulnar variance, volar tilt, and radial inclination between immediate and final follow-up x-rays was 0.7 mm, 1°, and less than 1°, respectively. Percutaneous fixation of distal radius fractures using distal radius-ulna pinning had favorable radiologic and functional outcomes and was effective in preventing fracture settling during initial healing in unstable extra-articular fractures and some simple sagittal split intra-articular fractures. Therapeutic III.

Volar Plate Fixation of Intra-Articular Distal Radius Fractures: A Retrospective Study

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

Should unstable extra-articular distal radial fractures be treated with fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial

Fractures of the distal radius are commonly treated with cast immobilisation; however, those potentially unstable injuries with dorsal comminution may need operative intervention. This intervention is usually with manipulation and Kirschner wires but advances in locking-plate technology have enabled surgeons to achieve anatomical reconstruction of complex fracture patterns, even in poor-quality osteoporotic bone. To ascertain if fixed-angle volar-locked plates confer a significant benefit over manipulation and Kirschner-wire stabilisation, we prospectively randomised 56 adult patients with isolated, closed, unilateral, unstable extra-articular fractures into two treatment groups, one fixed with K-wires and the other fixed with a volar locking plate. Functional outcomes were assessed using Gartland and Werley and Disabilities of the Arm, Shoulder and Hand (DASH) scores. These were statistically better in the plate group at 3 and 6 months. Radiological assessment showed statistically better results at 6 weeks, 3 months and 6 months, post-operatively. In the plate group, there was no significant loss of fracture reduction.

Die Versorgung distaler Radiusfrakturen mit der „Nagel-Platte“

Stable fixation of unstable distal radius fractures by means of a "nail-plate" with the distal plate section lying on the dorsal surface of the distal radius fragment, and the proximal nail section inside the diaphysis of the radius. Unstable extraarticular fractures of the distal radius AO types A2 and A3, which can be managed by closed or indirect reduction. Intraarticular fractures of the distal radius showing a nondisplaced articular component. Also indicated in patients with osteoporosis. Extraarticular distal radius fractures with a distal fragment too small for placement of the distal locking pegs and/or a comminution extending into the diaphyseal portion of the radius. Displaced intraarticular fractures of the distal radius. Nascent malunions of the distal radius. Closed reduction of the fracture, straight dorsal incision of 3-4 cm length centered over Lister's tubercle. The extensor pollicis longus tendon is released and retracted toward the radial side. Lister's tubercle is exposed subperiosteally and removed with a rongeur. This creates a flat surface for seating the head of the implant. Proximal dissection is carried out to expose the fracture site and the dorsal ridge on the proximal fragment. The medullary canal is opened with an awl. The radiocarpal joint line is located by inserting a needle. The silhouette of the head of the implant is drawn with a marker pen, with its distal edge resting 4-6 mm proximal to the joint line. This is done to carve a notch on the distal edge of the proximal fragment in line with the third extensor compartment with the purpose of receiving the neck of the device. The insertion jig is assembled to the implant. The implant is then introduced in a retrograde fashion, through the fracture site, into the proximal fragment and advanced with gentle rotational motion. The head of the device is seated flush on the distal fragment. Under fluoroscopic guidance, in an anatomic lateral view, the tract for the central peg is drilled and the peg is applied in the central hole. This peg fixes the palmar tilt. By use of the jig, the proximal unicortical holes are drilled, and the proximal locking screws, which fix the radial length, are applied. After removal of the insertion jig, the remaining distal pegs are applied. During drilling, the distal fragment must be pushed up against the implant to assure that the head is flush with its surface. After application, the extensor pollicis longus tendon will course proximal to the head of the implant in the subcutaneous position while the tendons of the second and fourth extensor compartments will travel on each side of the implant, thereby avoiding tendon impingement. Use of a palmar synthetic splint for 10 days. Active range of motion of the fingers is allowed immediately after surgery. On the 11th postoperative day, a custom-formed short arm splint is provided and active wrist motion is started. Radiologic control 4 weeks postoperatively. In the time between April 2005 and October 2006, 32 distal radius fractures were treated at the author's institution using the "nail-plate". Two complications were observed: loosening of a locking screw, and rupture of the extensor pollicis longus tendon 4 months postoperatively. In a study of more than 200 cases, only few complications were reported: a wound hematoma in a dialysis patient, loss of fixation of an articular fracture that was poorly indicated, and hypertrophic scar formation. In one patient complaining of persistent discomfort at the implantation site, the implant was removed.

A prospective study of a new locking plate for proximal humeral fracture

Displaced and unstable extra-articular fractures of the proximal humerus are treated by operative reduction and fixation using various techniques such as fixed plates and intramedullary implants. This prospective study evaluates the clinical efficacy of a novel implant that is attached to the humeral head with fixed-angle locking screws. Between October 2002 and November 2005, 99 people (mean age 62.8 years) with proximal humeral fractures received treatment involving this plate in our department. The mean follow-up time was 17.8 months. Outcome was assessed with radiography, the Constant–Murley (C–M) shoulder evaluation and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The mean C–M score was 64.95% and the mean DASH score was 30.1 points. Outcome was judged excellent in 51%, good in 19%, moderate in 19% and poor in 11% of cases.

Biomechanical Evaluation of Volar Locking Plates for Distal Radius Fractures

Fixed-angle devices have been a major advancement in orthopedic fracture care and have become an attractive option for fixation of distal radius fractures. Several volar locking plates exist, but there is insufficient literature comparing the strengths of these plates. This study compares the biomechanical strength of two popular volar locking plate systems (Synthes LCP and Hand Innovations DVR-A) along with a nonlocking volar T-plate (Synthes). Twenty-three formalin-fixed cadaveric forearms were divided into three groups with similar ages and bone densities. An unstable extra-articular fracture was created using a standardized osteotomy. Each group was fixed with one of the three plates. Each specimen was loaded in axial compression for 2000 cycles at a force of 400 N. Each specimen that completed cyclic testing was loaded to failure. Stiffness, yield point, and ultimate strength were recorded for each construct. Each fixed-angle construct completed all 2000 cycles. The nonlocking plates failed at an average of 560 cycles. The mean stiffness of the DVR-A, LCP, and the volar T-plates were 277.00, 343.17, and 175.67 N/mm, respectively. There was a statistically significant difference between both fixed-angle plates and the nonlocking plate (p < 0.05). The difference between each fixed-angle construct did not reach significance. Yield point and ultimate strength could only be determined for the two fixed-angle devices. There was no statistically significant difference between the constructs for both yield point (DVR-A = 855.56 N, LCP = 894.15 N) and ultimate strength (DVR-A = 1,021.97 N, LCP = 1,114.87 N). Given our data, fixed-angle constructs withstand cyclical loading representing normal physiologic forces encountered during post-operative rehabilitation. There was no significant biomechanical difference between the two fixed-angle constructs. Our results support that volar fixed-angle locking plates are an effective treatment for unstable extra-articular distal radius fractures, allowing early postoperative rehabilitation to safely be initiated.

Fixed Angle Fixation of Distal Radius Fractures Through a Minimally Invasive Approach

Treating unstable distal radius fractures in osteoporotic patients remains a challenge for the surgeon. Fixed angle plate fixation requires ample surgical dissection but has been shown to improve stability, allow early functional use of the hand and facilitate rehabilitation. We herein describe a treatment method that provides the benefits of fixed angle fixation while utilizing a minimally invasive approach. Stability is achieved by the use of a new implant that is placed through a small dorsal incision and minimizes extensor tendon disruption. This method finds application in the unstable extra-articular fracture of the high risk patient where minimal surgical morbidity is desirable and when reduction can be obtained without the need of extensive dissection. Clinical examples are fractures in the elderly patient where confusion can follow prolonged anesthesia, fractures in the patient with a bleeding disorder where a small wound volume is desirable and fractures in the polytraumatized patient where surgical time must be kept to a minimum. This technique allows anatomic reduction and stable fixation to be achieved in a short operative time and with minimal surgical insult while providing the compromised patient with a rapid recovery.

External fixation of distal radius fractures: do benefits outweigh complications?

Fractures of the distal radius are the most common bony injuries in the upper extremity, and many treatment methods have been described in the literature. External fixation remains a highly versatile method to treat many fracture types involving the distal radius. The primary indications for external fixation include reduction of unstable extra-articular fractures and most intra-articular fractures. The use of adjuvant pinning or “mini” open procedures can be used when external fixation inadequately reduces the joint line alone, especially with central depressions and highly comminuted injuries. The ease of use of the implants and successful track record make it an extremely versatile tool for treating complex fractures of the distal radius.

CLOSED REDUCTION AND PERCUTANEOUS PINNING OF FRACTURES OF THE PROXIMAL PHALANX

This study reports the results of 12 unstable extraarticular fractures of the proximal phalanx treated with transarticular intramedullary Kirschner wires. Early proximal interphalangeal joint motion was allowed and all patients achieved uneventful union, with an average total active motion of 265°. Objective physical assessment revealed one significant flexion contracture, one flexor tendon adhesion and one significant rotational deformity. Excellent results were observed in ten of the 12 patients.