EVIDENCE-BASED MEDICINE

Complications After Volar Plating of Distal Radius Fractures Justin W. Griffin, MD, A. Bobby Chhabra, MD THE PATIENT A 52-year-old, right handedominant female teacher presents 4 weeks after volar plate fixation of a distal radius fracture. Her wound is healed. She has full finger and forearm motion and 30 each of wrist flexion and extension. She is wondering whether the plate and screws can cause problems and whether they should be removed. THE QUESTION What is prevalence of and risk factors for adverse events associated with volar plate fixation of a fracture of the distal radius? CURRENT OPINION Volar plating fixation is a popular choice for operative stabilization of an unstable fracture of the distal radius.1,2 Adverse events that are either possibly or definitely related to the implant include extensor and flexor tendon rupture, intra-articular screw penetration, and carpal tunnel syndrome (CTS).3 THE EVIDENCE Bienek et al3 observed a cohort of 60 patients with nonsurgically treated fractures of the distal radius for 5 years. Twelve patients were diagnosed with CTS months to years after the fracture, with no relationship to fracture pattern.4 Other studies looking at carpal canal pressure monitoring found no benefit in prophylactic release. Fuller et al5 followed carpal tunnel pressures prospectively in 10 patients who underwent From the Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA. Received for publication January 15, 2014; accepted in revised form March 30, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: A. Bobby Chhabra, MD, Department of Orthopaedic Surgery, University of Virginia Hand Center, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.038

volar plating. They inserted slit catheters into the carpal canal for continuous pressure monitoring for 24 hours. Peak pressures in all but 1 patient remained less than 40 mm Hg; 1 patient who had fracture blisters demonstrated a pressure of 65 mm Hg. No patients had symptoms of median neuropathy. Gwathmey et al6 performed a retrospective clinical study to evaluate the safety and efficacy of a hybrid flexor carpi radialis (FCR) approach for volar plate fixation of displaced distal radius fracture with concurrent prophylactic carpal tunnel release (CTR). That study included 65 patients with displaced distal radius fractures treated with volar plate fixation through this approach. The authors found 2 cases of late median nerve dysfunction with no cases of tendon or median nerve injury using the approach. Odulama et al7 studied 69 patients with displaced distal radius fractures treated with volar plate fixation. They found 17 cases of median neuropathy with 8 of 45 patients who received prophylactic CTR demonstrating some level of dysfunction versus 9 of 24 who did not receive prophylactic release. Of note, 6 of the 9 patients with median neuropathy and no CTR resolved spontaneously, and the other 3 had CTR. Ward et al8 performed a retrospective review of 96 distal radius fractures treated with volar locked plate fixation and found that 21 of 96 experienced complications, 5 of which required surgery (3 requiring CTR). Of the 22 patients with complications, 12 had transient median nerve dysfunction.8,9 Of these, paresthesias or numbness occurred in 9 patients, 4 of whom had symptoms of CTS that were controllable with nighttime splinting, and 2 of whom had persistent thenar eminence numbness in the palmar cutaneous distribution. Three patients experienced transient superficial radial nerve distribution dysesthesias around the area of the temporary K-wire. Carpal tunnel syndrome was diagnosed in 3 patients, 2 of whom were treated with CTR. Two patients experienced transient flexor pollicus longus (FPL) dysfunction of uncertain etiology and 1 patient had a prominent radial styloid screw. The rate of complications decreased with surgeon experience.

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Arora et al10 reviewed 141 patients with distal radius fractures treated with volar plating, with an overall complication rate of 27%. Two patients had extensor pollicus longus (EPL) ruptures, 4 had extensor tenosynovitis, 2 had FPL ruptures, and 9 had flexor tendon irritation. Intraoperative intra-articular screw placement was diagnosed in 1 wrist during plate removal. Drobetz et al11 diagnosed an FPL rupture in 6 of 41 patients treated with volar plate fixation that the authors related to prominence of a screw with a sharp edge. Since the series, the authors used the same plate, but routinely remove it 4 months after surgery, with no tendon ruptures. Pronator repair has been proposed as 1 way to prevent flexor tendon irritation and rupture. A recent study examining 5 years of distal radius fractures at 1 institution compared 112 patients undergoing volar plate fixation with and without pronator quadratus repair.12 Of the 112 patients with 1-year follow-up, they looked at range of motion, strength, radiographs, and complications. They found no difference in pronation among patients not undergoing pronator quadratus repair and no difference in pain or Disabilities of the Arm, Shoulder, and Hand scores. One patient undergoing pronator repair had plate removal. Two patients had EPL rupture 6 weeks after surgery, and 1 had flexor tendon irritation treated with plate removal 3 months after the initial surgery. Soong et al13 analyzed 2 groups of patients who underwent volar locked plating of distal radius fractures over a 3-year period with a minimum 6-month follow-up. One group included 73 distal radius fractures treated using a plate design that extended over the so-called “watershed” area (the most volar part of the bone) toward the radial styloid; the other group included 95 distal radius fractures treated with a plate that was below that watershed line. Flexor pollicus longus rupture occurred in 3 of 73 patients with a prominent plate and none with the other plate.

The data regarding the role of prophylactic CTR during volar plate fixation are limited by the lack of high-level, randomized, controlled trials comparing outcomes of releasing the carpal tunnel prophylactically versus release in the setting of postoperative acute CTS. Long-term outcomes and median nerve dysfunction of patients released prophylactically and those treated acutely are unavailable. Although it is clear that prominent implants place tendons at risk, it is not clear whether there is a risk to using shorter screws. Some patients with EPL rupture do not have screws that protrude dorsally. Some speculate that the tendon is injured by a drill or a wire, but it is also possible that realigning the fracture creates a situation akin to the minimally displaced fracture of the distal radius known to be associated with EPL rupture with nonsurgical treatment. In other words, EPL ruptures may or may not be related to the implant. Current literature is confounded by variables including amount of comminution and fracture pattern variability, which makes it difficult to compare techniques and implants directly in relation to outcomes and complications. DIRECTIONS FOR FUTURE RESEARCH Prospective randomized trials comparing routine (eg, FCR-hybrid approach14) and selective release of the carpal tunnel during volar plate fixation would be helpful. Prospective cohort studies using implants and techniques designed to keep the tendons safe could determine whether we are getting better at avoiding these problems. Arthroscopy as a means to exclude intraarticular screw placement might be tested, perhaps in a prospective cohort at first, to determine how frequently this is a problem, and then in a randomized trial to determine whether arthroscopy improves outcomes. OUR CURRENT CONCEPTS FOR THIS PATIENT For patients with median nerve symptoms before volar plate fixation, we release the radial aspect of the transverse carpal ligament after retracting the flexor carpi radialis during our volar exposure of the wrist (hybrid FCR approach). For postoperative acute or delayed CTS, we use a separate midpalmar incision CTR. It is important for patients to understand that constant numbness in the setting of acute CTS will slowly improve over the next year, whereas patients with constant numbness that may be related to preexisting severe idiopathic CTS may have permanent numbness. To limit the potential for tendon irritation and rupture, we drill both cortices, but size screws so that they do not penetrate the dorsal cortex. We use a

SHORTCOMINGS OF THE EVIDENCE With the exception of acute CTS, it is not clear whether fracture of the distal radius with or without residual deformity and with or without a volar plate is a risk factor for CTS. Carpal tunnel syndrome is common. It is likely that many patients who fracture their wrist have preexisting undiagnosed CTS that comes to their attention or becomes more symptomatic after injury. Although it might seem as if the fracture or plate contributed to the CTS, it would take a careful scientific experiment to establish causation rather than just association. J Hand Surg Am.

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tangential image intensifier view as described by Ozer and Toker15 to help monitor screw length.

8. Ward CM, Kuhl TL, Adams BD. Early complications of volar plating of distal radius fractures and their relationship to surgeon experience. Hand (N Y). 2011;6(2):185e189. 9. Hattori Y, Doi K, Sakamoto S, Yukata K. Delayed rupture of extensor digitorum communis tendon following volar plating of distal radius fracture. Hand Surg. 2008;13(3):183e185. 10. Arora 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(5): 316e322. 11. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop. 2003;27(1):1e6. 12. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma. 2013;27(3): 130e133. 13. Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011;93(4):328e335. 14. Gwathmey FW Jr, Brunton LM, Pensy RA, Chhabra AB. Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach. J Hand Surg Am. 2010;35(7):1082e1088.e4. 15. Ozer K, Toker S. Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixedangle plating. Hand (N Y). 2011;6(2):190e193.

REFERENCES 1. Rhee PC, Dennison DG, Kakar S. Avoiding and treating perioperative complications of distal radius fractures. Hand Clin. 2012;28(2): 185e198. 2. Ilyas AM. Surgical approaches to the distal radius. Hand (N Y). 2011;6(1):8e17. 3. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. J Am Acad Orthop Surg. 2009;17(6):369e377. 4. Bienek T, Kusz D, Cielinski L. Peripheral nerve compression neuropathy after fractures of the distal radius. J Hand Surg Br. 2006;31(3):256e260. 5. Fuller DA, Barrett M, Marburger RK, Hirsch R. Carpal canal pressures after volar plating of distal radius fractures. J Hand Surg Br. 2006;31(2):236e239. 6. Gwathmey FW Jr, Brunton LM, Pensy RA, Chhabra AB. Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach. J Hand Surg Am. 2010;35(7):1082e1088.e4. 7. Odumala O, Ayekoloye C, Packer G. Prophylactic carpal tunnel decompression during buttress plating of the distal radius—is it justified? Injury. 2001;32(7):577e579.

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Complications after volar plating of distal radius fractures.

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