Injury, Int. J. Care Injured 45 (2014) 528–533

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Complications after volar locking plate fixation of distal radius fractures N.A. Johnson *, L. Cutler, J.J. Dias, A.S. Ullah, C.J. Wildin, B. Bhowal Leicester Royal Infirmary, Leicester, UK

A R T I C L E I N F O

S U M M A R Y

Article history: Accepted 4 October 2013

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate fixation in a busy teaching hospital. The purpose of the study was to assess whether complication rates after volar locking plate use in general, routine trauma practice were higher than published literature from expert users. A retrospective review was carried out of patients treated with a volar locking plate between January 2009 and December 2010. The series included 206 procedures in 204 patients (77 males and 127 females) with mean age of 55 years (range 16–94). Surgery was performed by 18 different consultant surgeons and 11 registrars. A total of 22 complications were observed in 20 patients with an overall complication rate of 9.7%. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Four (1.9%) patients required re-operation for metalwork problems; four patients developed complex regional pain syndrome (CRPS). Three fracture reduction problems were noted. A total of 16 further operations were carried out for complications. The overall complication rate was low even when surgery was done by many surgeons, suggesting that this is a safe and reproducible technique. This study provides information which can be used to counsel patients about risks, including those of tendon and metalwork problems. This allows patients to make an informed decision. Surgeons must have specific strategies to avoid these complications and remain vigilant so that these can be identified and managed early. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Distal radius Volar locking plates Internal fixation Complications

Wrist fractures are a common injury and with an ageing population the incidence is rising [1]. Six percent of women in the Western world will have suffered a distal radius fracture by the time they are 80 [2]. Volar locking plates were devised to allow direct reduction, solid fixation and early mobilisation of wrist fractures. The fixed angle construct provide a strong fixation in osteoporotic bone and comminutedfractures [3]. They exploit the anatomy of the volar distal radius and aim to avoid the soft tissue complications observed with dorsal plates. Early reports described few complications [4]. Subsequent studies have noted significant tendon and metalwork problems [5–7]. The purpose of this study was to carry out a review of complications observed after volar locking plate use in a typical general unit. In our centre, surgery is performed by a large number of surgeons of various grade and subspeciality. Much of the literature is from expert users in specialist centres [3,4].

* Corresponding author at: Leicester Royal Infirmary, Orthopaedic Department, Infirmary Place, Leicester LE1 5WW, UK. Tel.: +44 0116 258 5657. E-mail address: [email protected] (N.A. Johnson). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.003

Complication rates were compared to assess whether they were higher in this general trauma setting. This information can also be used to accurately discuss risks with patients prior to surgery and aid consenting. Materials and methods A retrospective review was carried out of patients with a distal radius fracture treated with a volar locking plate in our institution between January 2009 and December 2010 inclusive. All patients of skeletal maturity managed this way were included. Theatre books were reviewed to identify all suitable patients. As many as 208 procedures in 206 consecutive patients were identified. Two patients died after discharge from orthopaedic follow-up but were still included. Two patients did not attend follow-up and hence they were excluded from the study. The series included 206 procedures in 204 patients. Surgery was carried out under general or regional anaesthesia with use of an arm tourniquet. Antibiotics were given according to local policy. A volar approach through the bed of the flexor carpi radialis was performed. The pronator quadratus was elevated to

N.A. Johnson et al. / Injury, Int. J. Care Injured 45 (2014) 528–533

expose the volar distal radius. The fracture was reduced and held temporarily with k-wires according to the surgeon’s preference. The plate was placed directly on to the radius and the position confirmed radiographically. Supplementary metalwork was used if considered appropriate for the specific fracture. Wound closure was according to the individual surgeon’s preference. A plaster of Paris backslab was applied for pain relief. Mobilisation was started at 2 weeks unless there was an additional injury or concern regarding stability that prevented this. Patients were followed up with serial radiographs and clinical assessment in the outpatients’ clinic. Case notes were retrospectively reviewed for each follow-up attendance. The mean followup period was 36 months (range 24–48 months). All complications reported by patient or surgeon were recorded. All investigations or further interventions for complications were reviewed. Fractures were grouped according to pre-operative radiographs as intra-articular or extra-articular. Volar tilt, radial inclination, radial height along with any intra-articular gap or step was measured on pre- and postoperative digital lateral and posteroanterior radiographs. Radiographic measurement was retrospectively carried out by a single observer. Comparison between groups was performed with a t-test for parametric data and the Mann–Whitney U test for non-parametric data. The Chi-squared test was used for comparing nominal data.

Results Between January 2009 and December 2010, as many as 206 acute distal radius fractures in 204 patients were treated with volar locking plates. All surgery was performed by experienced orthopaedic registrars or consultant surgeons. The mean patient age was 55 years with a range from 16 to 94 years. There were 127 females and 77 males in the study group. A total of 109 fractures occurred in the left wrist with 97 on the right. The mean time to surgery was 8 days with a range from 0 to 36 days. As many as 67 fractures were extra-articular with 139 being intra-articular. Two types of plating systems were used: the VariAx plate (Stryker, Mahwah, NJ, USA) in 136 (66%) cases and the Aptus plate (Medartis, Exton, PA, USA) in 70 (34%) cases. Five patients in the series were treated with combined volar locking plate and radial styloid plate to reduce a large displaced radial styloid fragment. Distal ulna fractures were treated in three patients with tension band wiring due to a large displaced ulna styloid fragment or concerns about distal radioulnar joint (DRUJ) stability during intra-operative examination. A total of 176 cases were carried out by 18 different consultant surgeons and 30 cases by 11 orthopaedic registrars. Difficult fractures tended to be triaged towards the three hand consultants on the trauma rota who performed 115 of the procedures. Four upper-limb consultants and 11 orthopaedic consultants of other specialities carried out the other 61 consultant-led procedures. A total of 22 complications were seen in 20 patients, with an overall complication rate of 9.7% (Table 1). Four patients developed a CRPS and were referred to a pain specialist for further treatment. Table 1 Complications of volar locking plate surgery. Complication

Number of cases

Tendon Metalwork Fracture reduction CRPS Wound Nerve Other

7 4 3 4 1 1 2

529

The mean time to diagnosis was 15 weeks with a range of 3–38 weeks. One superficial wound infection was observed 2 weeks postoperatively. This was successfully treated with a course of oral antibiotics. One patient developed an acute carpal tunnel syndrome 1 day postoperatively. This was treated with emergency decompression of the carpal tunnel with evacuation of haematoma. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Extensor pollicis longus (EPL) rupture was observed in three patients and a flexor pollicis longus (FPL) rupture in one patient. Three tendon ruptures were treated with removal of metalwork and tendon transfer. An extensor indicis pollicis-to-EPL transfer was performed for the two EPL ruptures treated operatively. The FPL rupture was reconstructed using a palmaris longus graft. One elderly patient refused further surgery due to minimal loss of function and was treated conservatively. All three EPL ruptures were diagnosed within 8 weeks of fracture fixation. The single FPL rupture was identified nearly 12 months after surgery. Three patients had exploration of tendons due to loss of function. Tenosynovitis of FPL was observed in two patients and EPL tenosynovitis secondary to a prominent screw in the third patient. There was no tendon rupture. All metalwork was removed. In all three cases with FPL problems, the volar plate was observed to be prominent and distally placed intra-operatively. One of the EPL ruptures was secondary to a prominent screw tip, whilst in the other case there was residual dorsal displacement of the fracture impinging on the tendon. Problems with fracture reduction or displacement were observed in three (1.5%) cases. Two fractures had a large radial styloid fragment, which follow-up radiographs showed had displaced (Fig. 1). In both cases, revision surgery was performed with a radial styloid plate to reduce and hold this fragment. One patient with an extra-articular fracture was initially fixed with significant radial translation and hence underwent revision surgery. Four (1.9%) patients required re-operation for metalwork problems. Two patients with intra-articular fractures treated with a volar locking pate and supplementary radial styloid plates had ongoing problems with pain and limitation of movement despite extensive physiotherapy. Both underwent removal of all metalwork with subsequent improvement in their symptoms. One patient was noted to have a screw in the radiocarpal joint and one patient had a screw into the DRUJ (Fig. 2). Both patients were treated with removal of this single screw only. Two (1%) patients with large ulna styloid fragments treated with tension band wiring along with volar locking plates for a distal radius fracture (Fig. 3) developed pain and tenderness over the prominent ulna metalwork. The ulna metalwork was removed but the volar locking plate was left in situ. No significant difference in complication rates was demonstrable for age of patient, grade of surgeon, time to surgery and type of plate. The VariAx system was used in 70% of those with complications and in 74% of those with no complications (P = 0.96). The mean patient age was 49 (range 30–70) in the complication group compared to 53 (range 16–94, P = 0.29) in the non-complication group. Patients in the complication group waited for a mean of 6 days (range 2–18) to surgery compared to 8 days (range 0–36, P = 0.30) for those without complications. Hand surgeons carried out 50% of the cases in the complication group and 63% of the cases in the non-complication group (P = 0.76). Analysis of radiographs showed similar fracture characteristics. No significant difference was found between any pre-operative radiologically measured parameter (Table 2). Seventy percent of fractures in the complications group were intra-articular and 75% were dorsally angulated compared to the no complications group

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Fig. 1. (a) Initial radiographs of a 47 year old man who sustained an intra-articular distal radius fracture with large radial styloid fragment. (b) Post-operative radiographs 2 weeks after surgery showing displaced radial styloid fragment.

with 67% of fractures being intra-articular (P = 0.99) and 60% of fractures with dorsal angulation (P = 0.27). Intra-articular residual displacement was significantly higher in the complication group. This may reflect a more comminuted fracture with significant joint

Table 2 Comparison of mean radiological parameters.

Pre-op (mean) Angulation (8) Radial length (mm) Radial inclination (8) Intra-articular gap (mm) Intra-articular step (mm) Post-op (mean) Angulation (8) Fig. 2. 48 year old man with an intra-articular distal radius fracture treated with volar locking plate. CT scan shows the screw penetrating into the DRUJ eight weeks after fixation. The patient complained of pain and clicking on forearm rotation. Plain radiographs were inconclusive so a CT scan was performed. Symptoms resolved after screw removal.

Radial length (mm) Radial inclination (8) Intra-articular gap (mm) Intra-articular step (mm)

Complication group

No complication group

P value

18 Dorsal (range 54D–33V) 1 (range 17–13) 10 (range 12–24) 4 (range 1–6) 2 (range 0–4)

11 Dorsal (range 50D–54V) 4 (range 20–17) 12 (range 45–41) 4 (range 0–11) 1 (range 0–8)

0.22

2 Volar (range 12D–20V) 10 (range 4–18) 20 (range 9–27) 2 (range 0–5) 1 (range 0–3)

5 Volar (range 24D–22V) 10 (range 5–27) 21 (range 4–31) 1 (range 0–4) 0.5 (range 0–5)

0.07 0.47 0.78 0.72

0.20 0.78 0.58 0.009 0.026

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Discussion

Fig. 3. Plain radiograph demonstrating volar locking plate and tension band wire to large ulna styloid fragment in a 32 year old man. The ulna metalwork was prominent and painful so was removed five months following surgery after the fractures had united.

injury which was not obviously apparent on pre-operative radiographs. However, reduction still appeared reasonable with a mean residual articular step of 1 mm and a gap of 2 mm. Overall, 16 further operations were carried out for complications in 15 patients. Eight patients underwent plate removal.

Volar locking plates are frequently used for the treatment of distal radius fractures. Advantages include a biomechanically stable fixation [8,9] allowing rapid mobilisation and return of wrist function [10]. Placing the plate on the volar surface of the distal radius aims to avoid the soft-tissue complications observed with dorsal plating [11–14]. Early reports by Orbay suggested few complications [4]. In the present study, we carried out a large review of complications from a busy UK trauma unit to compare the data with the published literature and assess whether this is a safe and reliable technique for the general trauma surgeon. Our complication rates in general trauma practice were low. The overall complication rate of 9.7% confirms the rates recorded in some published literature (Table 3). Tendon and metalworkrelated complication rates were comparable to other series but remain a significant preventable problem. Arora et al. reported an overall complication rate of 27% in 141 patients with most complications being tendon problems [5]. This was attributed to distal placement of plates and comminuted fracture patterns causing screws to cut through and cause tendon irritation or rupture. A retrospective review by Rozental et al. described a complication rate of 22% [15]. This was a relatively small study and included four cases with comminuted fractures displaced leading to a loss of reduction in 10% of patients. More recent studies demonstrate complication rates similar to ours, which may reflect improved technology and the learning curve seen with any new implant [16,17]. Extensor tendon problems after volar locking plates are well recognised with extensor tendon rupture occurring in 4.4–8.6% of cases [18,19]. Flexor tendon irritation and rupture is less common but has been described secondary to the use of volar plates [5,20,21]. Drobetz et al. reported rupture of the FPL in 12% of cases [6]. This was attributed to the shape of the screw heads used in their locking plate system. All the three EPL ruptures seen in our study were diagnosed within 2 months of surgery, whereas the one FPL rupture took almost 12 months to identify. This may be due to the increased knowledge and awareness of surgeons and trainees regarding EPL rupture compared to flexor tendon rupture. Careful drilling, screw placement and knowledge of the anatomy of the distal radius are essential to minimise these complications. Tendon rupture rates observed in recent studies were very similar to our own [16,17]. We agree with Arora et al. that tenosynovitis in the presence of metalwork may progress to rupture [5]. Lattman et al. described no flexor tendon ruptures in 245 patients treated with Synthes LC-T locking plates (Bettlach, Switzerland) and followed up for 1 year [17]. They reported two cases of FPL tenosynovitis, both of which resolved after removal of metalwork. In this study, three patients had metalwork removed following loss of function. Tenosynovitis with impinging metalwork was confirmed intra-operatively. They did not progress to rupture. Careful clinical assessment is advised to assess for flexor or extensor tendon problems. Early investigation

Table 3 Comparison with published literature. Study

N

Complication rate

CRPS

Wound

Nerve

Tendon (rupture)

Metalwork

Fracture

Other

Johnson Phadnis (2012) Lattmann (2011) Sahu (2011) Arora (2007) Chung (2006) Rozental (2006) Al-Rashid (2006) Drobetz (2003)

206 180 245 114 141 161 41 35 50

9.7% 15% 15% 10.5% 27% 4.9% 22% 8.6% 32%

1.9% 9.0% 3.7% – 3.5% – 0 – 6%

0.5% 1.1% 0.4% – 0 3.1% 2.4% – 4%

0.5% 2.2% 3.7% – 2.1% 0.6% – – 2%

3.4% (1.9%) 1.7% (1.7%) 3.7% (1.6%) 1.8% (0.9%) 12% (2.8%) – 7.3% 8.6% (8.6%) 16% (14%)

1.9% – – 10.5% 2.1% – – – 2%

1.5% – 0.8% – 2.1% – 9.8% – 2%

1% – Ulna metal removal 0.5% – Deep infection

1.9% – Blisters/haematoma/aspiration 2.4% – Stiffness

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Fig. 4. 27 year old woman with a comminuted intra-articular fracture treated with volar locking plate and radial styloid plate. The patient was unable to regain a satisfactory range of motion until all metalwork was removed 6 months after fracture fixation.

with an ultrasound scan or magnetic resonance imaging (MRI) should be performed if there is any clinical suspicion of tendon irritation or rupture. We would recommend metalwork removal if tenosynovitis is confirmed. In the presence of rupture, functional loss should be assessed and tendon transfer performed if appropriate. Metalwork problems are increasingly recognised as a complication of volar plating resulting in further surgery in up to 10% of cases [7]. Intra-articular screw penetration is a serious problem as the articular cartilage is irreversibly damaged and this is likely to be due to incorrect placement not detected intra-operatively or secondary to later fracture collapse. Every attempt must be made to confirm that the screw tip is not in the joint at the time of surgery, using fluoroscopy and/or arthroscopy. If the surgeon is still uncertain, the screw should be re-sited. Computed tomography (CT) scanning is useful for diagnosis and inclined lateral radiographs are advocated by some [22,23]. Two patients in our study with comminuted fractures treated with a volar plate and a radial styloid plate struggled to regain full range of motion. Radiographs demonstrated the plate to be slightly proud and distal (Fig. 4). Movement subsequently improved after metalwork removal. We advise meticulous intra-operative screening with accurate assessment of the joint surface to avoid intra-articular screw placement. Follow-up radiographs should be performed early for comminuted fractures with potential for collapse or displacement. If plain radiographs are unhelpful, CT scanning is recommended. Carpal tunnel syndrome is a well-known complication after wrist fracture, which may occur early or late independent of the treatment method [24,25]. Other studies have reported an incidence of carpal tunnel syndrome following volar plating of up to 14% [26,27]. Only one (0.5%) case of carpal tunnel syndrome was observed in this series. Prophylactic carpal tunnel decompression was not routinely carried out during fracture fixation. Our rates of infection (0.5%) and CRPS (2%) were similar to other large case series [5,17]. To our knowledge, this is the largest study in the literature specifically investigating complications following volar locking plates for distal radius fractures. Of 206 patients, 204 had clinical notes and radiographs available for review until discharge. This provides valuable information for patients and surgeons. In our institution, we explain to patients that one in 10 patients suffers a

complication and one in 30 sustains a tendon problem. One in 15 requires further surgery for problems with metalwork or malreduction. This helps the patients to make an informed choice regarding surgery. We acknowledge the limitations in our study, particularly the retrospective collection of data. The procedures were performed by a large number of surgeons. The choice of implant was not controlled, with two types of plates used depending on the surgeon’s choice. Injuries requiring supplementary metalwork were also included. However, we believed that this pragmatic approach allowed the study to more accurately reflect the usual practice in a busy trauma unit. Further areas for study should aim to reduce the rate of preventable complications. New technology may enable plates to be of lower profile and be less irritant to soft tissues. Radiological techniques can help identify erroneously placed metalwork intraoperatively [23]. Further understanding of the anatomy of the distal radius and relationship with surrounding structures will help the surgeon position the metalwork safely [28]. A large, multicentre, prospective study would provide more data regarding complication rates and may allow possible risk factors for complications to be identified. This study provides a review of a large number of volar locking plates and complications occurring in a typical trauma unit. Surgery was carried out by a variety of different grade and speciality of surgeon. Complication rates in general practice were low. This suggests that volar locking plate use is a reproducible and safe technique in a general orthopaedic trauma service. Conflicts of interest There are no conflicts of interest to declare. Funding No funding was received for this work from any source. References [1] McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg 2001;26A:916–22.

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Complications after volar locking plate fixation of distal radius fractures.

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate f...
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