Volar Fixation Research Articles

Volar versus Dorsal Plating for Fracture Distal Radius (A Systematic Review/Meta-Analysis)

Abstract Background Fractures of the distal radius are the most common of all orthopedic injuries accounting for nearly 16–20% of all fractures presenting to the emergency department. Treatment of distal radius fractures historically has been predominantly by inexpensive means as some surgeons advocate treatment by manipulation and plaster immobilization. Aim of the Work This study aims to review systematically and to meta-analyze the currently available literature regarding volar and dorsal plating for distal radial fractures regarding functional outcome and complications. Patients and Methods This study was approved by the Ethical Committee of Ain Shams University Faculty of Medicine. Written informed consent was not needed because of the study design(systematic review). Results The results of our study showed that there were significant difference between volar and dorsal groups regarding ROM (Flexion, Extension, Ulnar deviation and Radial deviation). Also we found significant difference regarding PRWE Score, DASH Score and complication rate. Also the results showed non significant difference between volar and dorsal plating groups regarding VAS Score for Pain, Grip Strength and ROM (Supination and Pronation). We also found the dorsal fixation offers a lower risk of neuropathy and carpal tunnel syndrome than the volar fixation, But a higher risk of tendon irritation and rupture in dorsal group so we recommend removal of dorsal plates after good healing and regain good range of motion. Conclusion In conclusion, Based on our outcomes of current systematic review and meta-analysis, it appears that fractures of distal radius treated previously with dorsal plating showed poor outcomes and unclear results, meanwhile more recent studies favored volar plating for fixation compared to indicated dorsal plating biased by these studies.

Is ultrasound superior to fluoroscopy in distal radius volar fixation?

ObjectivesIn volar distal radius fixation, conventional and additional fluoroscopic views could not be sufficient to assess dorsal screw penetration. Ultrasound (US) has been suggested as a technique to improve this assessment. The objective was to determine the agreement between these two explorations in a clinical study. Quantify time-consuming of intraoperative US was the secondary objective. Material and methodsA prospective descriptive study was performed. Thirty patients with a surgical distal radius fracture were treated with volar fixation by five consultant surgeons in a level I Trauma Centre. Final intraoperative fluoroscopic views: AP, lateral, 20º tilted lateral and Dorsal Tangential views (DTV) were performed assessing for dorsal screw protrusion. Then, ultrasound was performed to reassess dorsal cortex integrity. Those protruding screws were registered and changed. ResultsA total of 153 screws were examined. Four protruding screws were observed with no multiple protruding screws in the same fixation. Intraoperative ultrasound detected a dorsal screw protrusion in one fixation, assessed as correct by radiological projections. Almost perfect agreement was found between DTV and US examination k = 0.83 (p < 0.001). The mean surgical time was 63 ± 20.3 min while the addition of the ultrasound, supposed an average of 4 ± 1 min more. ConclusionUltrasound did not show a clinically significant improvement in the assessment dorsal screw penetration in distal radius fixation. A high agreement was observed between US and the described fluoroscopic views. The addition of intraoperative US was a non-significant time-consuming procedure.

Dorsally and volarly angulated extra-articular malunions of the distal radius treated with volar corrective osteotomy and volar locking plate fixation. A case series of 19 patients with a long-term follow-up.

To date, different technique of corrective osteotomy for the treatment of distal radius extra-articular malunions are described. With this study, we present a case series of corrective osteotomy using volar plate fixation to treat volar and dorsal extra-articular malunions aiming to evaluate the effectiveness of corrective osteotomies through volar plate stabilization in these two types of extra-articular malunions. Between August 2008 and May 2017 all patients diagnosed with extra-articular malunion were included in the study. An extended volar Orbay approach and two types of dedicated volar locking plate (Medartis AG, Switzerland and Acumed, Hillsboro,OR) were used. Clinical and radiological parameters were evaluated. The DASH and PRWE scores and the VAS scale questionnaires were administered. The results were analyzed through statistical evaluations. A retrospective analysis of 19 patients diagnosed with extra-articular malunion was carried out. Nine had a volar type deformity (group A), while the other 10 had a dorsal type deformity (group B). The active range of motion (aROM), radiographic parameters, grip strength and pinches in both groups were statistically improved, except for radial deviation in both groups, ulnar deviation in group A, and radial inclination in group B. The grip strength and pinches values were slightly better in group A. DASH, PRWE scores and VAS scale showed a significant improvement. Corrective osteotomy through volar fixation is an effective technique to treat both extra-articular dorsally and volarly angulated malunions. Statistically significant benefits are present in both types of deformities, with better outcomes in the group of volar deformities.

Corrective Osteotomy with Volar and Dorsal Fixation for Malunion of Intra-Articular Fracture of the Distal Radius: A Retrospective Study.

ObjectivesAlthough corrective osteotomy with volar or dorsal plate fixation can treat malunion of distal radius fractures, each has its own disadvantages. Little is currently known on whether dorsal fixation combined with volar fixation may further improve recovery. This study aimed to evaluate the clinical value of corrective osteotomy combined with volar and dorsal plate fixation in patients with malunion of intra‐articular fractures of the distal radius.MethodsSeventeen patients with malunion of intra‐articular fractures of the distal radius treated with corrective osteotomy with volar and dorsal plate fixation from 1 January 2016 to 31 November 2018 were retrospectively analyzed. The enrolled patients included seven males and 10 females with an average age of 54.9 years (range: 36–70 years). The radiographic parameters, including the radial length, the radial inclination angle, the ulnar variance, and the volar tilt, as well as clinical outcomes, including wrist and forearm range of motion (ROM), grip strength, the Mayo Modified Wrist Score (MMWS), and the disabilities of the Arm, Shoulder, and Hand (DASH) score, were examined at 3 months and 18 months after operation and compared with the preoperative state. The paired t‐test was used for statistical analysis.ResultsAfter corrective osteotomy combined with volar and dorsal plate fixation, all included patients were followed up for 18 months, and there was no surgical site infection. Patients reported postoperative pain due to the irritation of extensor tendon (two cases) and wrist arthritis (two cases). The radial length increased from 1.34 ± 2.34 mm to 9.25 ± 2.65 mm and 9.03 ± 2.47 mm at 3 months and 18 months postoperatively (t = 8.257, 7.954, all p < 0.05). The radial inclination angle increased from 6.45° ± 0.76° to 19.35° ± 3.43° and 19.03° ± 3.63° at 3 and 18 months (t = 12.517, 12.122, all p < 0.05). The ulnar variance decreased from 5.11 ± 0.23 mm to 1.32 ± 0.31 mm and 1.54 ± 0.62 mm at 3 and 18 months (t = 4.214, 4.895, all p < 0.05). The volar tilt was corrected from 4.47° ± 3.46° to 15.51° ± 2.72° and 14.12° ± 2.41°, respectively (t = 11.247, 10.432, all p < 0.05). Moreover, wrist ROM increased from 42.53° ± 8.99° to 98.70° ± 7.61° and 101.24° ± 7.66° (t = 41.433, 46.627, all p < 0.05), while forearm ROM was increased from 94.82° ± 6.54° to 134.47° ± 5.06° and 137.24° ± 5.52°, respectively (t = 31.507, 32.584, all p < 0.05). Similarly, grip strength, MMWS, and DASH were also remarkably improved. There were no significant differences in the wrist and forearm ROM, grip strength, MMWS, and DASH scores between follow‐up at 3 and 18 months (all p > 0.05).ConclusionsCorrective osteotomy with volar and dorsal fixation can improve recovery of volar tilt, relieve wrist pain, restore wrist and forearm function, and increase grip strength of patients with malunion of intra‐articular fractures of the distal radius.

Radius distraction during volar plating of distal radius fractures may improve distal radioulnar joint stability at minimum 3-year follow-up: a retrospective case series study

BackgroundThe surgical technique of radius distraction for stabilization of distal radioulnar joint (DRUJ) if intraoperative DRUJ instability was found after the fixation of distal radius fracture has been previously described, but this surgical technique lacks clinical and radiographic effect in minimal 3 years follow-up. We therefore evaluated the clinical outcome and radiographic results of radius distraction in minimal 3 years follow-up as long-term evaluation.MethodsWe reviewed the case series of distal radius fracture with concomitant DRUJ instability receiving radius distraction from the senior author over a 5-year period (January 1st, 2013, to June 30th, 2017) retrospectively. Radius distraction during volar plating was performed by moving the volar plate distally via compression screw loosening/fastening to achieve firm endpoint on the dorsopalmar stress test. The evaluations of radiographic, including bone union time and ulnar variance, and clinical outcomes, including grading of DRUJ instability, NRS of wrist pain, DASH score, MMWS score, and range of motion of operated wrist at final follow-up, were performed at clinic as minimum 3-year follow-up; a total 34 patients had been evaluated.ResultsAt minimal post-operative 36 months follow-up, all cases demonstrated acceptable wrist range of motion with stable DRUJs, low NRS of wrist pain (0.6, SD 0.7), and satisfactory DASH score (mean 9.1, SD 6.2) and MMWS score (mean 87, SD 10). There were no cases suffering from nonunion of distal radius. The mean ulnar variance of injured wrist and uninjured wrist were -1.2 mm and 0.2 mm, respectively (SD 1.0 and 0.6) with significant statistical difference.ConclusionsRadius distraction during volar fixation of distal radius fracture should be considered if DRUJ instability was found by the dorsopalmar stress test intraoperatively, and the long-term DRUJ stability could be achieved by maintenance of normal-to-negative ulnar variance, with decreased wrist pain and satisfactory function outcome.Level of EvidenceTherapeutic Level IV

Dorsal Plating for Specific Fracture Pattern of the Distal Radius.

Background: Volar locking plates have provided the capability to repair both simple and complex fractures. However, complications related to the inability to fix or to maintain the fixation of some fracture patterns have been reported with volar locking plates. The purpose of this study was to evaluate the results of dorsal plating treatment for specific pattern of fractures. Methods: Patients with distal radius fractures were retrospectively evaluated. Inclusion criteria for this study were those related to the patient and treatment (adult patients, internal fixation with dorsal plating, a minimum follow-up of 12 months), and those related to the fracture pattern (displaced central articular fragment, volar distal fracture line not enough to allow volar fixation, displaced dorsal-ulnar fragment, dorsal partial fractures, combination of these patterns). Clinical outcome information including active range of motion, radiographs, PRWE and DASH questionnaires were collected. Complications were recorded. Results: During a 6-year period, 679 distal radius fractures were treated with open reduction and internal fixation. Of these, 27 patients fulfilled the inclusion criteria. Patients were examined at a median of 34 months' follow-up. All but pronation, supination, and radial deviation had a statistically significant difference compared to the opposite side. The median score on the DASH was 4.5 and 3.2 on the PRWE. No patient suffered loss of reduction during the follow-up nor were tendon ruptures recorded. Conclusions: Although most of the distal radius fractures can be treated with volar locking plates, almost 5% of them present specific patterns that are amenable to treatment with dorsal fixation, without postoperative loss of reduction. These specific patterns are: (1) displaced central articular fragment, (2) volar distal fracture with less of 1cm distance from the distal volar edge of the radius, (3) displaced dorso-ulnar fragment, (4) Barton's fracture, (5) combination of these patterns.

873 The Keystone Challenge- Volar Displaced Intra-Articular Distal Radius Fractures with Lunate Fossa Fragment

Abstract Aim Volar displaced fractures of the distal radius are unstable and warrant operative management. A subset of patients with volar displaced fractures also has a separate lunate fossa fragment, a specific injury with greater instability that may precipitate carpal subluxation. We aim to review our long-term experience in the management of this complex injury, exploring surgical technique which may improve treatment. Method We retrospectively reviewed all volar displaced distal radius fixations between 2015 and 2020. Inclusion criteria: any displaced intra-articular volar distal radius fracture with lunate fragment involvement undergoing volar fixation and over 16 years of age. Exclusion criteria: shaft fractures, extra-articular fractures, open fractures, fractures fixed using k-wires or external fixation, revision surgery and patients without follow-up. We adapted our surgical approach in order to address this more complex fracture pattern, and all operations were performed by specialist hand surgeons. Results 468 distal radius fractures were assessed, of which 29 (6%) cases included a lunate fossa fragment. 20 (69%) of patients were female, mean age was 59 years (SD 12.4). Mean length of stay was 5 hours and mean operative time was 96 mins (range 79-95). No patients had carpal subluxation, fracture fixation failure or return to theatre for any reason. Conclusions From our experience as a specialist orthopaedic institution, we recommend the extended FCR approach and intra-focal exposure to manage this complex injury. In particular, the lunate fossa fragment is the keystone which requires dedicated reduction prior to tackling the remaining fracture configuration.

CT Based Characterization of Volar Surface of Distal Radius: Can an Ideal Volar Plate for Fixation of Distal Radial Fractures be Designed?

Background: Literature has limited evidence concerning the morphology of volar surface of distal radius. A mismatch between the plate-contour and contour of the actual volar bony surface can result in malreduction. The purpose of this study is to analyze the normal curvature morphology of volar surface of distal radius and related parameters that can help in designing of the volar plates for fixation of distal radial fractures. Methods: We retrospectively analyzed CT scans of uninjured healthy distal radii performed during a one year period (2018-2019). The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, the mediolateral surface angle between intermediate column and radial column of distal radius, the curvatures and locations of their vertices for radial and intermediate columns were measured. Results: A total of 84 CT-based studies were analyzed. The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, and the mediolateral surface angle between intermediate column and radial column of the distal radius were 24.27 mm, 144.8 degrees and 163.1 degrees, respectively. The mean volar curvatures of the radial and intermediate columns were 156.5 and 151.4 degrees, respectively and distances of their vertices from the pronator-quadratus line were 10.96 mm and 14.13 mm, respectively. Conclusions: Considerable variations occur in curvature morphology of distal radial volar surface. A best fit rather than an anatomical fit can be considered during implant selection owing to these variations. Besides volar curvature of radial and ulnar columns, location of their vertices, mediolateral angulation and surface curvature between these columns at the level of watershed line should also be considered in plate selection. A combination of a few serial increments of the described parameters in the designs of volar fixation plates would be helpful for surgeons in the best implant selection.

Biomechanical Comparison of Different Volar Screw Placements for Horizontal Oblique Scaphoid Fractures

Recently, some surgeons reported that most scaphoid waist fractures were horizontal oblique and not transverse in orientation. Therefore, this cadaveric study aimed to biomechanically compare fixation strength between central and eccentric screw placements for the volar fixation of this most common scaphoid waist fracture. Eight matched pairs of fresh-frozen forearm cadaver specimens were prepared for testing and randomly assigned to two groups: group I specimens were fixed by screws in a central placement, and group II specimens were fixed by screws in an eccentric placement. Horizontal oblique osteotomy was performed along the scaphoid waist. Then, each specimen was placed under the increasing load of a pneumatically driven plunger. We recorded stiffness, load to failure, and failure mechanisms between the central and eccentric screw placement groups. Stiffness was higher in central screw placement (74.1 N/mm) than in eccentric screw placement (29.39 N/mm). The median loads to failure in groups I and II were 54.14 and 26.22 N, respectively. In this biomechanical model, we demonstrated that central screw placement is superior to eccentric placement in terms of fixation strength. However, further clinical investigation is warranted to evaluate whether the different screw placements for volar approach of horizontal oblique scaphoid fractures affect the clinical outcomes.

Wrist function recovery course in patients with scaphoid nonunion treated with combined volar bone grafting and a dorsal antegrade headless screw

BackgroundSurgical treatment is necessary for scaphoid nonunion. Open surgery with a combined volar and dorsal approach is thought to have poor functional outcomes and a prolonged recovery course. However, the detailed recovery course for this approach is rarely reported. The aim of this study was to investigate the recovery course and radiographic outcome for patients with scaphoid nonunion who underwent a combined volar bone grafting and dorsal antegrade headless screw approach.Material and methodsEighteen patients with scaphoid nonunion who underwent combined volar bone grafting and dorsal antegrade headless screw fixation were enrolled in this retrospective study. Preoperative and serial postoperative wrist functional and radiographic outcomes were collected and analysed.ResultsAll 18 patients achieved bone union at a mean time of 14.3 weeks. Compared to the preoperative status, the grip strength, wrist motion arc, and Mayo Wrist score were improved significantly 6 months after surgery, whilst the Disabilities of the Arm, Shoulder, and Hand (DASH) score did not recover until 12 months after surgery. Significant improvements were found in all scaphoid radiographic parameters.ConclusionThe surgical outcomes for scaphoid nonunion treated with a combined volar bone grafting and dorsal antegrade headless screw achieved a high union rate, with great wrist functional and radiographic outcomes. The earliest recovered wrist functional parameters were grip strength, motion arc, Mayo Wrist score and finally the DASH score at postoperative 6 months and 12 months, respectively.

Flexor Tendon Rupture After Distal Radius Malunion Associated With Electromyographic Abnormalities

A 63-year-old woman with a history of a malunited distal radius fracture presented with left hand pain and inability to flex her thumb, index, and middle fingers. Anterior interosseous neuropathy was suggested because of abnormal electromyography findings. However, magnetic resonance imaging later revealed flexor tendon ruptures. A distal radius corrective osteotomy with autograft and volar fixation was performed with tendon transfers and carpal tunnel release. Attritional flexor tendon rupture after a nonoperatively managed distal radius fracture is rare but remains an important differential diagnosis in patients with signs and symptoms of anterior interosseous nerve paralysis.

Minimally Invasive Fixation With a Volar Approach Using a Cannulated Compression Screw for Acute Hook of Hamate Fractures

Optimal treatment of acute hook of hamate fractures (HHF) remains controversial. Isolated acute HHF can be treated nonsurgically or surgically (with excision of the hook or open reduction internal fixation). The authors present the functional outcomes of a case series of patients who were treated with minimally invasive volar fixation for acute HHF. This retrospective study reviewed 6 patients with nondisplaced acute HHF treated with a minimally invasive volar approach and cannulated mini-screw fixation. The development of postoperative complications (tendon and ulnar nerve lesions), pain evaluated using a visual analog scale, and radiological union evaluated on computed tomography scan is reported. Wrist range of motion and grip strength were measured bilaterally. Mayo Wrist Score and Quick-Disabilities of the Arm, Shoulder, and Hand were assessed. All outcomes were measured at 1, 2, 3, and 6 months after surgery. Fixation of HHF through the volar approach was achieved in all cases with no complications. The clinical and radiological union rate was 100%. All patients were able to return to their work or hobbies after an average of 7 weeks. This study suggests that acute HHF can be treated successfully by open reduction internal fixation using a volar approach with minimal morbidity and complications, a good union rate, and a fast return to daily activities. Therapeutic V.

Incidence of Flexor Pollicis Longus Complications Following Volar Locking Plate Fixation of Distal Radius Fractures.

Background: Distal radius fractures are among the most common orthopedic injuries presenting to emergency departments. The complications of distal radius open reduction and internal fixation (ORIF) range from paresthesia to tendon ruptures. The Soong grading system was designed to evaluate volar plate position to predict postoperative flexor pollicis longus (FPL) ruptures. This study evaluates post-distal radius volar fixation FPL ruptures and other postoperative complication rates relative to Soong grade, surgical training, and plate design. Methods: A retrospective chart review was conducted to assess recorded complications after distal radius ORIF. Soong grade was determined on postoperative radiographs. Other demographic features, along with the surgeon fellowship training and plate design, were noted. Analysis was performed via t test, χ2 test, rank sum test, and Fisher exact test. Results: A total of 522 patients met inclusion criteria. Flexor tenosynovitis was the most commonly recorded complication (21% of total complications). No FPL ruptures were recorded. Soong grades between patients with and without complications were not significantly different. Soong grades between patients with flexor tenosynovitis and other complications were not significantly different. Flexor tenosynovitis had higher odds of occurring compared with other complications when the surgeon was hand-trained or when the plate type was designed by Acumed. These higher odds were not maintained under multivariate regression analysis. Conclusion: Lack of FPL ruptures in this large series may reflect improved plate technology and increased awareness. The association between flexor tenosynovitis and hand fellowship-trained surgeons may be associated with more complex cases being referred to specialists.

Fixation du scaphoïde carpien par vissage palmaire ou dorsal : étude en éléments finis

PurposeScaphoid waist fractures may be fixed through volar or dorsal screw fixation. However, there is no consensus on which surgical fixation method should be performed. The purpose of this study was to compare volar versus dorsal screw fixation of scaphoid waist fractures under physiological loading conditions utilizing finite element analysis. MethodsA transverse scaphoid waist fracture (Herbert type B2) model was fixed with a headless cannulated compression screw using either a volar or dorsal approach. Displacement and rotation of the fragments and stress analysis on the scaphoid bone and screw were analyzed in the models using 3D finite element analysis in three different wrist positions; total extension (TE), neutral (N) and total flexion (TF). ResultsDisplacement of the fracture gap in volar fixation in all planes (x, y, z) was less than in dorsal fixation in the TF and N positions. Furthermore, rotational stability was stronger in volar fixation in all planes and wrist positions. Von Mises stress values were concentrated on the proximal fragment in all wrist positions. ConclusionsAlthough both volar and dorsal fixation techniques can be preferred in Herbert type B2 fractures, results of this finite element analysis suggest that centrally placed volar compression screw fixation may be biomechanically advantageous over dorsal screw fixation. Level of evidenceI.

Comparison of volar versus dorsal screw fixation for scaphoid waist fractures: A finite element analysis

PurposeScaphoid waist fractures may be fixed through volar or dorsal screw fixation. However, there is no consensus on which surgical fixation method should be performed. The purpose of this study was to compare volar versus dorsal screw fixation of scaphoid waist fractures under physiological loading conditions utilizing finite element analysis. MethodsA transverse scaphoid waist fracture (Herbert type B2) model was fixed with a headless cannulated compression screw using either a volar or dorsal approach. Displacement and rotation of the fragments and stress analysis on the scaphoid bone and screw were analyzed in the models using 3-D finite element analysis in three different wrist positions; total extension (TE), neutral (N) and total flexion (TF). ResultsDisplacement of the fracture gap in volar fixation in all planes (x, y, z) was less than in dorsal fixation in the TF and N positions. Furthermore, rotational stability was stronger in volar fixation in all planes and wrist positions. von Mises stress values were concentrated on the proximal fragment in all wrist positions. ConclusionsAlthough both volar and dorsal fixation techniques can be preferred in Herbert type B2 fractures, results of this finite element analysis suggest that centrally placed volar compression screw fixation may be biomechanically advantageous over dorsal screw fixation. Level of evidenceI.

Functional Outcomes in Early Rehabilitation of 202 Distal Radius Fractures After Volar Fixation

Introduction: The incorporation of stable fixation techniques over the past 10 years has allowed the early mobilization of distal radius fractures (DRFs), maximizing the chances of achieving optimal functional outcomes in rehabilitation. Purpose: The purpose of this study was to describe the functional outcomes after early rehabilitation for DRFs treated with volar plate fixation. Materials and Methods: A descriptive cross-sectional study was carried out on 202 patients with a DRF based on the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification system. They were treated with open reduction over the 2006-2015 period. Baseline and final therapy evaluations were carried out to collect demographic data—gender, age, and occupation (Swanson)—and functional information—pain using the visual analogue scale (VAS), range of movement (ROM) with a goniometer, grip strength tested with a standard Jamar hydraulic hand dynamometer, and self-report outcomes with the Patient-Rated Wrist Evaluation (PREW). Results: Sample mean age was 56.2 years (SD, ±16.4); 73% of the group were women, 43% of whom performed manual labor. Fifteen percent of the group had associated injuries. On average, therapy started 4 weeks after surgery. Mean treatment period was 68 days and 93 days in the case of those with associated lesions. The median VAS score at the onset was 4 (minimum: 0, maximum: 10) and at the end of treatment was 0 (minimum: 0, maximum: 9) ( P &lt; .0001). Mean ROM was 52.7° for flexion, 57.9° for extension, 78.4° for pronation, and 67° for supination. Mean grip strength was 19.85 kg. Mean PREW score was 13.4. Conclusion: The study results indicate that early therapy after DRF surgery optimizes ROM and grip strength with good functional recovery and a quick return to daily activities and work.

Diagnostic Test Study of the Skyline View for Dorsal Screw Protrusion After Fixation of Distal Radius Fractures

Background: Distal radius fractures are one of the most common orthopedic injuries, and around 50% of them are intra-articular which leads to requiring open reduction and fixation. One of the most common complications involving the distal radius volar locking plate, when used as a method for fixation, is the possibility of leaving the distal screws to long and crossing the dorsal cortex leading to rupture of the extensor tendons of the wrist and hand. The skyline view of the wrist allows the evaluation of different aspects of the fixation in distal radius fractures, including the screw that crosses the dorsal cortex; however, no studies report the accuracy of this view to predict this and eventually prevent tendon ruptures. Objectives: Describe the accuracy of the skyline view (specificity, sensibility) to predict protrusion of the screws in the dorsal cortex compared with a postoperative computed tomographic (CT) scan in patients who underwent volar fixation of distal radius fractures. Methods: A retrospective analysis was undertaken on patients with fixation of distal radius fractures using distal radius volar locking plates between January 2013 and January 2016 that had the skyline view of the wrist taken immediately after the end of the surgery and had a CT scan in the follow-up. Patients that had any other type of fixation were excluded from the study. The sample size predicted a total of 36 x-rays. Only patients operated by orthopedic hand surgeons were included. Two experienced orthopedic hand surgeons evaluated both the skyline view and the CT scan (used as gold standard) and evaluated in each image whether any screw crossed the dorsal cortex of the distal radius. Results: A total of 44 patients with distal radius volar locking plate fixation were identified, including 27 females and 21 males with a mean age of 52 (range, 25-87 years), and the leading cause of the fractures was low-energy trauma. The skyline view and the CT scans were randomized for each observer, meaning that each observer analyzed 44 x-rays and 44 CT scans. The prevalence of protruded screws in the dorsal cortex of the distal radius was 25% confirmed with the gold standard study the CT scan. The sensibility of the skyline view to predicting protruded screw in the dorsal cortex was 81% and the specificity 94%. The positive predictive value was 81% and a negative predictive value 94%, all values with P values less than .05. Conclusions: The skyline view is an accurate tool to evaluate protrusion of the screws in the dorsal cortex of the distal radius when using distal radius volar locking plates as a method for fixation of distal radius fractures. With a high specificity and sensibility allowing orthopedic hand surgeons an easy and accessible tool to assess the appropriate length of the distal screws for the distal radius volar locking plate in radius fractures to prevent possible tendon ruptures.

Comparison of volar and dorsal percutaneous screw fixation in acute scaphoid waist fracture

Objective To compare volar and dorsal percutaneous screw fixation in acute scaphoid waist fracture. Methods Retrospectively collected patients received percutaneous screw fixation after acute scaphoid fracture between January 2009 and December 2014 with non-displacement/minimal displacement waist fracture, patients with open fracture or combined with perilunate dislocation or fracture which need reduce were excluded, 28 patients with intact follow-up were enrolled, 26 men and 2 women, with an average age of 31 years old. Based on Herbert classification, there were 15 A2 type, 5 B1 type, 8 B2 type. 7 cases were high energy trauma and 21 were low energy. The patients were divided into 2 groups by volar and dorsal approach. The general condition, surgery notes, radiological evidence and follow-up were collected and analyzed. Results 28 cases with full follow-up were enrolled, 18 cases received surgery via volar approach, and 10 cases via dorsal approach, the mean follow-up period is 33 months. Peri-operative data showed that operation time in dorsal approach group was longer (75 min vs. 54 min). We evaluated screw position by measuring the angulation between screw and fracture line as well as screw and long axis of scaphoid based on AP view and lateral view of wrist X-rays. There was no significant difference in length of screws (21.4 mm vs. 21.8 mm). Patients gradually went back to work after 2 weeks and got fracture healing within 12 weeks after operation. Radiological evidence showed that angulation between screw and long axis of scaphoid was 6.11°±4.82° in AP position and 8.48°±5.77° in lateral position, angulation between screw and fracture line was 73.58°±20.75° in AP position and 70.72°±21.19° in lateral position. There were no significant differences between screw insertion positions between 2 groups. Visual analogue scale (VAS) was used to evaluate wrist pain in the follow-up, Mayo wrist score and Patient-Rated Wrist Evaluation (PRWE) were also used to assess wrist function in the follow-up. The clinical results were promising, the excellent or good rate of Mayo wrist score was 100%, there were no significant difference in VAS, Mayo wrist score and PRWE between volar and dorsal approach. No complications such as failure of screws, orthopaedic arthritis or scaphoid necrosis were observed. Conclusion Percutaneous screw fixation have a satisfied effect in the treatment of acute scaphoid waist fracture, and there are no differences in clinical efficacy between volar and dorsal approach. Key words: Scaphoid bone; Fractures, bone; Carpal joints; Fracture fixation, internal

Fractures of the Distal Radius: A Randomized Controlled Trial of 180 Patients Comparing Volar Locking Plates and Alternative Fixation Methods

For intra-articular and extra-articular distal radius fractures do volar locking plates (VLP) provide patients with functionally, clinically and radiologically superior results compared to fixation methods before their introduction; Kirschner wires, non-locking plates and external fixators? In this prospective, randomized controlled trial 180 participants with a median age of 65 (range 18-96) were followed up for 1 year. Outcome measures included Disability of Arm Shoulder and Hand (DASH) score, range of motion (ROM) and grip strength, radiological measurements (radial length, angle, tilt, ulnar variance and articular step) and complications. There was no statistical difference of DASH scores between groups at any time point. ROM differed at one and six weeks post operatively, favoring the VLP fixation. However these results were not sustained at 12 and 52 weeks. The results have confirmed VLP’s ability to maintain fracture reduction over 12 weeks compared to alternative fixation methods.

Radiographical measurements for distal intra-articular fractures of the radius using plain radiographs and cone beam computed tomography images

Operative treatment of an intra-articular distal radius fracture is one of the most common procedures in orthopedic and hand surgery. The intra- and interobserver agreement of common radiographical measurements of these fractures using cone beam computed tomography (CBCT) and plain radiographs were evaluated. Thirty-seven patients undergoing open reduction and volar fixation for a distal radius fracture were studied. Two radiologists analyzed the preoperative radiographs and CBCT images. Agreement of the measurements was subjected to intra-class correlation coefficient and the Bland-Altman analyses. Plain radiographs provided a slightly poorer level of agreement. For fracture diastasis, excellent intraobserver agreement was achieved for radiographs and good or excellent agreement for CBCT, compared to poor interobserver agreement (ICC 0.334) for radiographs and good interobserver agreement (ICC 0.621) for CBCT images. The Bland-Altman analyses indicated a small mean difference between the measurements but rather large variation using both imaging methods, especially in angular measurements. For most of the measurements, radiographs do well, and may be used in clinical practice. Two different measurements by the same reader or by two different readers can lead to different decisions, and therefore a standardization of the measurements is imperative. More detailed analysis of articular surface needs cross-sectional imaging modalities.