Injury, Int. J. Care Injured 45S (2014) S21–S26
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Is it really necessary to restore radial anatomic parameters after distal radius fractures? Perugia Dario *, Guzzini Matteo, Civitenga Carolina, Guidi Marco, Dominedo` Cristina, Fontana Daniele, Ferretti Andrea Hand Surgery Unit, Orthopaedic and Traumatology Department, Sant’Andrea Hospital, II Faculty of Medicine and Psychology, University ‘‘La Sapienza’’ of Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Keywords: Distal radius fractures Volar plating Anatomic radiographic parameters
Small variations within normal range of radiographic parameters, except ulnar variance and volar tilt, do not influence the final functional outcome in distal radius fractures. Introduction: There are many reports in the literature on the relationship between radiographic variables and their influence on the final outcome of distal radius fractures. Most authors report that a good functional result depends on anatomical restoration of the articular surface and extra-articular alignment. The aim of this study was to verify if it is really necessary to restore anatomic radiographic parameters to obtain satisfactory functional outcome in distal radius fractures treated with volar plate. Materials and methods: We retrospectively evaluated 51 patients treated with volar locked plate for articular unstable distal radius fractures from December 2006 to March 2009. Each fracture was evaluated according to the AO classification. The average follow-up was 40.5 months. Radiological measurements were performed considering radial height, radial inclination, volar tilt and ulnar variance, both preoperatively and postoperatively, to estimate the correction value. We examined range of motion (ROM), grip strength with a Jamar1 dynamometer and Disabilities of the Arm, Shoulder and Hand (DASH) score. The t Student test was performed for statistical analysis. Results: The persistence of articular step-off was assessed in 35.3% of patients. Normal radial inclination (21–258) was restored in 74.5% of patients (range 15–27.58). Normal radial height (10–13 mm) was restored in 66.6% of patients (range 6.8–17.3 mm). Normal volar tilt (7–158) was achieved in 90.2% of patients (range 3–178). Normal ulnar variance (0.7–1.5 mm) was restored in 86.3% of patients (range 0.7–4.1 mm). There was a statistically significant difference between the preoperative and postoperative radiographic values (p < 0.01). The majority of patients showed complete recovery of ROM, with no statistically significant difference (p > 0.05) in extension, flexion, supination and pronation compared with the contralateral hand. Eight patients who had postoperative volar tilt and/or ulnar variance out of range had a statistically significant difference (p < 0.05) in ROM compared with the non-operated side. At final follow-up, all patients had a statistically significant difference (p < 0.05) in grip strength compared with the contralateral side, even with good strength values. The mean DASH score was 12.2 (range 0–61). Discussion and conclusion: Our experience suggests that ulnar variance and volar tilt are the most important radiographic parameters to be restored to obtain good functional outcome in distal radius fracture. Small variations of other radiographic parameters seem to not affect the final outcome at minimum 3 years’ follow-up. ß 2014 Elsevier Ltd. All rights reserved.
Introduction * Corresponding author at: Hand Surgery Unit, Orthopaedic and Traumatology Department, Sant’Andrea Hospital, II Faculty of Medicine and Psychology, University ‘‘La Sapienza’’ of Rome, Via Grottarossa 1035-1039, 00189 Rome, Italy. Tel.: +39 0633771. E-mail address: [email protected] (P. Dario). http://dx.doi.org/10.1016/j.injury.2014.10.018 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Distal radius fractures are the most common fractures in the upper limb and represent 17% of all fractures [1,2] and 75% of forearm fractures [3]. Nowadays a higher incidence of these events in young adult males and older women has been assessed [4,5]. ORIF
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P. Dario et al. / Injury, Int. J. Care Injured 45S (2014) S21–S26
Fig. 1. Extra-articular fracture with displacement >1 cm.
procedure with plating is a reliable choice of treatment for displaced intra-articular distal radius fractures [6–8] defined as unstable according to stability criteria described in the literature [9]. Since the last decade, dorsal plating is no longer considered the best management of unstable dorsal displaced fractures [6,10]. This is because of complications such as extensor tenosynovitis and tendon ruptures [11,12]. The use of volar plates has seldom been associated with flexor tendon problems because the anatomy of the volar aspect of the wrist offers more cross-sectional area and the implant is separated from the tendons by the pronator quadratus [13]. There is a wide consensus among surgeons [14–16] regarding the importance of restoring preoperative radiographic parameters. On standard antero-posterior and lateral radiographs, five measurements can be easily used to evaluate the distal radius profile: volar tilt, radial inclination, ulnar variance, radial height, and articular step-off. Abnormalities in the anatomy of the wrist joint can be deleterious. Malunited displaced distal radius fractures (Figs. 1 and 2) can lead to radiocarpal and radioulnar pain, radiocarpal and distal radioulnar joint instability (carpal–ulnar deviation, triangular fibrocartilage overload), loss of strength and range of motion (ROM), and osteoarthritis. The aim of this study was to verify if it is really necessary to achieve anatomic radiographic parameters in distal radius fractures treated with volar plate and which of these parameters are important to obtain satisfactory functional outcome at shortterm follow-up. The study hypothesis is that it is not crucial to restore all radiographic measurements to the normal ranges to obtain good functional results at short-term follow-up, and that small variation of radiographic parameters can still be associated with good functional results. Materials and methods Study group We retrospectively reviewed the records on all distal radius fractures treated with volar plating that were performed
from December 2006 to March 2009 in our Hand Surgery Unit. The study protocol was approved by the Hospital Ethics Committee before the beginning of the evaluation. Inclusion criteria were unstable fracture according to Jupiter [17] (i.e. dorsal tilt > 208, initial displacement > 1 cm, intra-articular disruption) also after close reduction and secondary displacement in plaster cast. Exclusion criteria were AO/ASIF B2 fractures (Barton fracture), open fractures, bilateral wrist fractures, concurrent major traumas, association with percutaneous techniques, growth plates opening and previous wrist fractures. Patients were not excluded on the basis of age or bone quality. Sixty-one wrists in sixty patients met the criteria and were included in the study. For this retrospective review, all patients were contacted and were offered a free consultation and radiographic examination. Fifty-one patients returned for a clinical evaluation and radiographic examination. Four patients had died. There were 27 men and 24 women in the study. The mean age at the time of injury was 52.8 years. Six patients refused to return for a follow-up visit. The mean age of the patients was 52.8 years (range 35–64 years) at time of surgery. Thirty-nine patients (76.5%) had involvement of the non-dominant arm. Each patient was classified on the basis of preoperative X-rays according to the AO/ASIF system [18]. There were four type A3 fractures, one type B1, four type B3, twelve type C1, eight type C2 and twenty-two type C3. The fractures were treated with ORIF with volar plate (Acu-loc by Acumed1) by the same surgeon. Clinical assessment Patients were evaluated by the same observer for the determination of active and passive wrist ROM and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Grip strength was measured with a Jamar1 dynamometer. In addition, the patients were asked to grade the subjective result as very satisfied, satisfied, uncertain, or disappointed.
P. Dario et al. / Injury, Int. J. Care Injured 45S (2014) S21–S26
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Fig. 2. Postoperative X-rays show incorrect restoration of anatomical parameters.
Radiographic evaluation Our retrospective study was based on a dorso-palmar and lateral X-ray at time of injury and postoperatively. A standardised radiological assessment was performed postoperatively at 1 month, 3 months, 6 months, 1 year, and annually thereafter. The evaluation was made by one senior resident and the same
medical consultant for every wrist. We performed measurements for radial height, radial inclination, volar tilt and ulnar variance both preoperatively and postoperatively to estimate correction value (Figs. 3 and 4). We also considered postoperative articular step-off persistence. We measured volar tilt on a LL radiograph by determining the angle between the line along the distal radial articular
Fig. 3. Preoperative X-rays and radiographic measurements. Intra-articular fracture with displacement >1 cm.
P. Dario et al. / Injury, Int. J. Care Injured 45S (2014) S21–S26
S24
Fig. 4. Postoperative X-rays and radiographic measurements.
surface and the line perpendicular to the longitudinal axis of the radius at the joint margin. Normal volar tilt was considered to be 11 58. We measured radial inclination on a PA radiograph by determining the angle formed between the long axis of the radius and a line drawn from the distal tip of the radial styloid to the ulnar corner of the lunate fossa. Normal radial inclination was considered to be 22 38. We measured ulnar variance on a PA radiograph using the method of perpendiculars. We identified the long axis of the radius and drew a line perpendicular to this, extending through the ulnar-most corner of the lunate fossa. We recorded the distance between this line and the distal-most point of the ulnar dome as the ulnar variance, where a positive number denoted ulnar positive and a negative number denoted ulnar negative. Normal ulnar variance was considered to be 0.7 1.5 mm. We determined radial height by finding the long axis of the radius and then extending a line perpendicular to it at the tip of the radial styloid on a PA radiograph. We recorded the distance between this line and the distal-most point of the ulnar dome. Normal radial height was considered to be 14 1 mm. We defined the accepted functional range for each measurement, excluding radial height, based on functional outcomes from the literature (>208 dorsal angulation, >108 radial inclination, >5 mm ulnar variance, and >2 mm step-off). We evaluated articular congruency by looking at the articular surface of the distal radius on either a PA or lateral film. We measured any noted step-off and recorded it as either less than 2 mm or 2 mm or greater. Postoperative rehabilitation Immediately after surgery, the patient was encouraged to elevate the hand and begin early finger motion. A short arm plaster splinting was maintained for 2 weeks until the first follow-up visit. At that visit, the dressings and sutures were removed, radiographs were taken, and therapy was started under the supervision of a certified physiotherapist. A prefabricated orthosis was also applied for comfort and protection for a further 2 weeks. During weeks 2–6, an anti-oedema protocol was started along with tendon gliding and ROM exercises. Statistical analysis The Student t test was used for statistical analysis.
Results All cases were assessed at an average follow-up time of 40.5 months (range 31–64 months). Articular step-off persistence was assessed in 35.3% of patients. Normal radial inclination (21–258) was restored in 74.5% of patients (range 15–27.58). Normal radial height (10–13 mm) was restored in 66.6% of patients (range 6.8– 17.3 mm). Normal volar tilt (7–158) was achieved in 90.2% of patients (range 3–1878). Normal ulnar variance (0.7–1.5 mm) was restored in 86.3% of patients (range 0.7–4.1 mm) (Table 1). The statistical analysis showed a significant difference between the preoperative and postoperative radiographic values (p < 0.01). Wrist ROM assessed with a goniometer showed an average 628 wrist extension (range 40–758), 738 wrist flexion (range 45–858), 148 radial deviation (range 10–158), 378 ulnar deviation (range 28–458), 828 supination (range 74–858) and 838 pronation (range 80–858) (Table 1). Forty-three patients (84%) had a complete recovery of ROM, without a statistically significant difference (p > 0.05) with regard to extension, flexion, supination and pronation compared with the contralateral hand. The other patients who had a statistically significant difference (p < 0.05) in ROM compared with the non-operated side had postoperative volar tilt and/or ulnar variance out of range. These patients also had a worse outcome in terms of DASH score. At
Table 1 Percentage of radiographic parameters evaluated and wrist ROM values. Radiographic parameters
% of patients with restored parameters
Radial inclination (21–258) Radial height (10-13 mm) Volar tilt (7–158) Ulnar variance (0.7–1.5 mm)
74.5% 66.6% 90.2% 86.3%
Wrist ROM Extension Flexion Radial deviation Ulnar deviation Pronation Supination
628 738 148 378 838 828
(40–758) (45–858) (10–158) (28–458) (80–858) (74–858)
P. Dario et al. / Injury, Int. J. Care Injured 45S (2014) S21–S26
final follow-up, all patients had a statistically significant difference (p < 0.05) in grip strength compared with the contralateral side, even though they had good strength values. On average, the grip strength was 87% of the grip strength of the contralateral extremity. (The mean grip strength was 27.19 kg.) The mean DASH score was 12.2 (range 0–61) out of a possible 100 points: the score was 0–10 for 68.6% of patients, 10–30 for 15.6%, 30–50 for 7.8% and >50 for 7.8%; the latter score indicates minimal impairment in daily activities. There was one complication in the study. One patient had a flexor tendon rupture, which was treated with plate removal and tendon suture. Discussion Our review of the literature found several different data regarding the clinical outcome of displaced fractures of the distal radius. Rubinovich and Rennie [19] reported that failure to restore the normal radius volar tilt has a deleterious effect on the functional outcome, particularly grip strength. Altissimi et al. [20], showed that radiological deformities are associated with significantly bad results only in case of greatly altered values. Although good functional results can be obtained despite a poor anatomical surgical reduction, an excellent function is more likely when anatomy has been properly restored. McQueen and Caspers [14] showed that the shortening of the radius and an increased volar tilt results in a weak, stiff and painful wrist with a high likelihood of difficulty in performing the normal activities of daily living. Mann et al. [15] reported that the importance of ulnar variance lies in its statistical association with several diseases of the wrist, including lunatomalacia, acute scapholunate instability, ulnocarpal impaction, and radioulnar impingement. The thin triangular fibrocartilage seen with ulnar positive variance is predisposed to early degenerative change. Furthermore, patients who have a radial tilt of less than 58 have poorer results than those with normal or near normal inclination. Several reports have associated radial shortening with pain, instability and restricted forearm pronation and supination, stating that radial length was the most important factor affecting functional outcome [6,16,17,21–26]. Some authors [27–29] demonstrated that radial shortening causes an increased pressure in the distal radioulnar joint (DRUJ) and a shift in the centre of pressure within the sigmoid notch. This is manifested by a decrease in grip strength as well as in motion of the DRUJ, which, in a patient who has a volar displaced fracture, decreases the extension of the wrist [30]. Tsukazaki et al. [31] showed a weak correlation between radiographic findings and functional endresults. They demonstrated that dorsal angulation was the only radiographic feature correlated with loss of flexion. Many reports support that an increase of the volar tilt causes a decrease in grip strength, a decrease in extension and ulnar deviation of the hand and wrist. Furthermore the restoration of anatomical alignment and articular congruity after a displaced fracture is essential for satisfactory functional results [16,32–38]. Other authors [39,40] showed that there is a difference in patients younger or older than 60 years with extra-articular distal radius fractures: in the younger patients there was a very strong link between poor outcomes and the presence of a malalignment of the distal radius. Fractures with a loss of radial length correlated more often with pain and disability, and there were trends towards higher pain and disability with unacceptable degrees of radial tilt and dorsal tilt. It was demonstrated that patients over 65 years showed no statistically significant relationship between radial length, radial tilt or dorsal tilt and pain and disability [40]. Kasapinova showed that there is no significant statistical correlation between the radiographic parameters and the patient-rated outcome [41]. The trend towards open reduction and internal fixation of distal radius fractures reflects the negative impact that disruption of anatomical
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relationships and biomechanical properties of the wrist joint can have on outcomes. Volar plates were designed to minimise extensor tendon irritation while providing stable internal fixation. Furthermore, these plates permit early motion and optimise functional rehabilitation of the wrist. Our experience shows that the focal point of the treatment of wrist fractures with volar-locked plates is to reduce the fractures to restore particularly volar tilt and ulnar variance, as shown by the results of recovery of ROM and of the DASH score. We believe ulnar variance and volar tilt are the most important radiographic parameters that have to be restored to obtain good functional outcome in distal radius fracture. In our series, only patients with volar tilt and ulnar variance restored had a good functional outcome. Nevertheless, small variations (not over 178 of volar tilt, 27.58 of radial inclination, 17.3 mm of radial height and 4 mm of ulnar variance) do not influence a good functional outcome. Our results show that the patients return to the normal ROM and to the almost normal grip strength considering that in 76.4% this involved the non-dominant arm. A stable internal fixation obtained with this kind of plate enables an early kinesitherapy that improves the capacity of the wrist to perform normal activities and prevents joint stiffness. In this study, observers who made radiographic measurements of volar tilt, radial inclination, ulnar variance, radial height, and articular step-off were not blinded to results. The study outcomes may also have been influenced by the particular type of plate used or by the fact that more severe fracture types that required additional fixation (Kirschner wires, external fixators, etc.) were excluded. This study was also limited because we reviewed only plain radiographs when making our measurements. Compared with computed tomography for evaluation of gap and step-off in fractures of the distal radius, plain radiographs have been shown to underestimate the amount of articular incongruency. More studies are necessary to evaluate the functional outcome of wrist fractures at long-term follow-up to consider the likely postoperative arthritic changes involving the wrist. Conflict of Interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. References [1] Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 150000 adults: the influence of age and gender. J Bone Surg 1998;80B: 243–8. [2] Kopylov P, Johnell O, Redlund-Johnell L, Bengner U. Fractures of the distal end of the radius in young adults: a 30-year follow-up. J Hand Surg Br 1993; 18B:45–9. [3] O’Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001; 12(7):555–8. [4] Swiontkowski MF. Increasing rates of forearm fractures in children. JAMA 2003;290(24):3193. [5] Mensforth RP, Latimer BM. Hamman–Todd collection aging studies: osteoporosis fracture syndrome. Am J Phys Anthropol 1989;80(4):461–79. [6] Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205–15. [7] Rausch S, Schlonski O, Klos K, Gras F, Gueorguiev B, Hofmann GO, et al. Volar versus dorsal latest-generation variable-angle locking plates for the fixation of AO type 23C 2.1 distal radius fractures: a biomechanical study in cadavers. Injury 2013;44:523–6.
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[8] Toros T, Sugun TS, Ozaksar K. Complications of distal radius locking plates. Injury 2013;44:336–9. [9] Ru¨edi TP, Murphy WM. AO principles of fracture management. 1st ed. Stuttgart/New York: Thieme Verlag; 2001, 4.3.3:362. [10] Osada D, Kamei S, Masuzaki K, Takai M, Kameda M, Tamai K. Prospective study of distal radius fractures treated with a volar locking plate system. J Hand Surg 2008;33A:691–700. [11] Rozental TD, Beredjikian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956–60. [12] Grewal R, Perey B, Wilmink M, Stothers K. A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini-open reduction, percutaneous fixation, and external fixation. J Hand Surg Am 2005;30:764–72. [13] Matschke S, Wentzensen A, Ring D, Marent-Huber M, Audige´ L, Jupiter JB. Comparison of angle stable fixation approaches for distal radius fractures. Injury 2011;42:385–92. [14] McQueen M, Caspers J. Colles’ fractures: does anatomical result affect the final function? JBone Joint Surg Br 1988;70:649–51. [15] Mann FA, Wilson AJ, Gilula LA. Radiographic evaluation of the wrist: what does the hand surgeon want to know? Radiology 1992;184:15–24. [16] Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury 2002;33:499–502. [17] Jupiter JB, Masem M. Reconstruction of post-traumatic deformity of the distal radius and ulna. Hand Clin 1988;4:377–90. [18] Mu¨ller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990. [19] Rubinovich RM, Rennie WR. Colles’ fracture: end results in relation to radiologic parameters. Can J Surg 1983;26:361–3. [20] Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long term results of conservative treatment of fractures of distal radius. Clin Orthop 1986;206:202–10. [21] Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles’ fracture. JHand Surg 1988;13B:291–3. [22] Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius. J Bone Joint Surg 1988;70A:1538–51. [23] Pogue DJ, Viegas SF, Patterson RM, Peterson PD, Jenkins DK, Sweo TD, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg 1990;15A:721–7. [24] Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19A: 325–40. [25] Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clin Orthop 1996;327:135–46.
[26] Sato K, Nakamura T, Iwamoto T, Toyama Y, Ikegami H, Takayama S. Corrective osteotomy for volarly malunited distal radius fracture. J Hand Surg 2009;34A:27–33. [27] Werner FW, Murphy DJ, Palmer AK. Pressures in the distal radioulnar joint: effect of surgical procedures used for Kienbock’s disease. J Orthop Res 1989;7:445–50. [28] Werner FW, Palmer AK, Fortino MD, Short WH. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg 1992;17A:423–8. [29] Crisco JJ, Moore DC, Marai GE, Laidlaw DH, Akelman E, Weiss APC, et al. Effects of distal radius malunion on distal radioulnar joint mechanics – an in vivo study. J Orthop Res 2007;25:547–55. [30] Kazuki K, Kusunoki MA, Shimazu A. Pressure distribution in the radiocarpal joint measured with a densitometer designed for pressure-sensitive film. J Hand Surg 1991;16A:401–8. [31] Tsukazaki T, Takagi K, Iwasaki K. Poor correlation between functional results and radiographic findings in Colles’ fracture. J Hand Surg 1993;18B:588–91. [32] Howard PW, Stewart HD, Hind RE, Burke FD. External fixation or plaster for severely displaced comminuted Colles’ fractures? A prospective study of anatomical results. J Bone Joint Surg Br 1989;71:68–73. [33] Fernandez DL, Jupiter JB. Malunion of the distal end of the radius. In: Jupiter JB, Fernandez DL, editors. Fractures of the distal radius. New York: Springer; 1996. p. 263–315. [34] Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am 1997;79A:1303–12. [35] Shea K, Fernandez DL, Jupiter JB, Martin C. Corrective osteotomy for malunited, volarly displaced fractures of the distal end of the radius. J Bone Joint Surg 1997;79A:1816–26. [36] McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study for bridging versus non-bridging external fixation. J Bone Joint Surg Br 1998;80B:665–9. [37] Arora L, Lutz M, Fritz D, Zimmermann R, Oberladsta¨tter J, Gabl M. Palmar locking plate for treatment of unstable dorsal dislocated distal radius fractures. Arch Orthop Trauma Surg 2005;125:399–404. [38] Orbay JL, Tuohami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res 2006;445:58–67. [39] Grewal R, MacDermid JC. The risk of adverse outcome in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg 2007;32A:962–70. [40] Kumar S, Penematsa S, Sadri M, Deshmukh SC. Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures? Int Orthop 2008;32:505–9. [41] Kasapinova K, Kamiloski V. Outcome evaluation in patients with distal radius fracture. Contrib Sec Biol Med Sci 2011;XXXII/2:231–46.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Is it really necessary to restore radial anatomic parameters after distal radius fractures? Perugia Dario *, Guzzini Matteo, Civitenga Carolina, Guidi Marco, Dominedo` Cristina, Fontana Daniele, Ferretti Andrea Hand Surgery Unit, Orthopaedic and Traumatology Department, Sant’Andrea Hospital, II Faculty of Medicine and Psychology, University ‘‘La Sapienza’’ of Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Keywords: Distal radius fractures Volar plating Anatomic radiographic parameters
Small variations within normal range of radiographic parameters, except ulnar variance and volar tilt, do not influence the final functional outcome in distal radius fractures. Introduction: There are many reports in the literature on the relationship between radiographic variables and their influence on the final outcome of distal radius fractures. Most authors report that a good functional result depends on anatomical restoration of the articular surface and extra-articular alignment. The aim of this study was to verify if it is really necessary to restore anatomic radiographic parameters to obtain satisfactory functional outcome in distal radius fractures treated with volar plate. Materials and methods: We retrospectively evaluated 51 patients treated with volar locked plate for articular unstable distal radius fractures from December 2006 to March 2009. Each fracture was evaluated according to the AO classification. The average follow-up was 40.5 months. Radiological measurements were performed considering radial height, radial inclination, volar tilt and ulnar variance, both preoperatively and postoperatively, to estimate the correction value. We examined range of motion (ROM), grip strength with a Jamar1 dynamometer and Disabilities of the Arm, Shoulder and Hand (DASH) score. The t Student test was performed for statistical analysis. Results: The persistence of articular step-off was assessed in 35.3% of patients. Normal radial inclination (21–258) was restored in 74.5% of patients (range 15–27.58). Normal radial height (10–13 mm) was restored in 66.6% of patients (range 6.8–17.3 mm). Normal volar tilt (7–158) was achieved in 90.2% of patients (range 3–178). Normal ulnar variance (0.7–1.5 mm) was restored in 86.3% of patients (range 0.7–4.1 mm). There was a statistically significant difference between the preoperative and postoperative radiographic values (p < 0.01). The majority of patients showed complete recovery of ROM, with no statistically significant difference (p > 0.05) in extension, flexion, supination and pronation compared with the contralateral hand. Eight patients who had postoperative volar tilt and/or ulnar variance out of range had a statistically significant difference (p < 0.05) in ROM compared with the non-operated side. At final follow-up, all patients had a statistically significant difference (p < 0.05) in grip strength compared with the contralateral side, even with good strength values. The mean DASH score was 12.2 (range 0–61). Discussion and conclusion: Our experience suggests that ulnar variance and volar tilt are the most important radiographic parameters to be restored to obtain good functional outcome in distal radius fracture. Small variations of other radiographic parameters seem to not affect the final outcome at minimum 3 years’ follow-up. ß 2014 Elsevier Ltd. All rights reserved.
Introduction * Corresponding author at: Hand Surgery Unit, Orthopaedic and Traumatology Department, Sant’Andrea Hospital, II Faculty of Medicine and Psychology, University ‘‘La Sapienza’’ of Rome, Via Grottarossa 1035-1039, 00189 Rome, Italy. Tel.: +39 0633771. E-mail address: [email protected] (P. Dario). http://dx.doi.org/10.1016/j.injury.2014.10.018 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Distal radius fractures are the most common fractures in the upper limb and represent 17% of all fractures [1,2] and 75% of forearm fractures [3]. Nowadays a higher incidence of these events in young adult males and older women has been assessed [4,5]. ORIF
S22
P. Dario et al. / Injury, Int. J. Care Injured 45S (2014) S21–S26
Fig. 1. Extra-articular fracture with displacement >1 cm.
procedure with plating is a reliable choice of treatment for displaced intra-articular distal radius fractures [6–8] defined as unstable according to stability criteria described in the literature [9]. Since the last decade, dorsal plating is no longer considered the best management of unstable dorsal displaced fractures [6,10]. This is because of complications such as extensor tenosynovitis and tendon ruptures [11,12]. The use of volar plates has seldom been associated with flexor tendon problems because the anatomy of the volar aspect of the wrist offers more cross-sectional area and the implant is separated from the tendons by the pronator quadratus [13]. There is a wide consensus among surgeons [14–16] regarding the importance of restoring preoperative radiographic parameters. On standard antero-posterior and lateral radiographs, five measurements can be easily used to evaluate the distal radius profile: volar tilt, radial inclination, ulnar variance, radial height, and articular step-off. Abnormalities in the anatomy of the wrist joint can be deleterious. Malunited displaced distal radius fractures (Figs. 1 and 2) can lead to radiocarpal and radioulnar pain, radiocarpal and distal radioulnar joint instability (carpal–ulnar deviation, triangular fibrocartilage overload), loss of strength and range of motion (ROM), and osteoarthritis. The aim of this study was to verify if it is really necessary to achieve anatomic radiographic parameters in distal radius fractures treated with volar plate and which of these parameters are important to obtain satisfactory functional outcome at shortterm follow-up. The study hypothesis is that it is not crucial to restore all radiographic measurements to the normal ranges to obtain good functional results at short-term follow-up, and that small variation of radiographic parameters can still be associated with good functional results. Materials and methods Study group We retrospectively reviewed the records on all distal radius fractures treated with volar plating that were performed
from December 2006 to March 2009 in our Hand Surgery Unit. The study protocol was approved by the Hospital Ethics Committee before the beginning of the evaluation. Inclusion criteria were unstable fracture according to Jupiter [17] (i.e. dorsal tilt > 208, initial displacement > 1 cm, intra-articular disruption) also after close reduction and secondary displacement in plaster cast. Exclusion criteria were AO/ASIF B2 fractures (Barton fracture), open fractures, bilateral wrist fractures, concurrent major traumas, association with percutaneous techniques, growth plates opening and previous wrist fractures. Patients were not excluded on the basis of age or bone quality. Sixty-one wrists in sixty patients met the criteria and were included in the study. For this retrospective review, all patients were contacted and were offered a free consultation and radiographic examination. Fifty-one patients returned for a clinical evaluation and radiographic examination. Four patients had died. There were 27 men and 24 women in the study. The mean age at the time of injury was 52.8 years. Six patients refused to return for a follow-up visit. The mean age of the patients was 52.8 years (range 35–64 years) at time of surgery. Thirty-nine patients (76.5%) had involvement of the non-dominant arm. Each patient was classified on the basis of preoperative X-rays according to the AO/ASIF system [18]. There were four type A3 fractures, one type B1, four type B3, twelve type C1, eight type C2 and twenty-two type C3. The fractures were treated with ORIF with volar plate (Acu-loc by Acumed1) by the same surgeon. Clinical assessment Patients were evaluated by the same observer for the determination of active and passive wrist ROM and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Grip strength was measured with a Jamar1 dynamometer. In addition, the patients were asked to grade the subjective result as very satisfied, satisfied, uncertain, or disappointed.
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Fig. 2. Postoperative X-rays show incorrect restoration of anatomical parameters.
Radiographic evaluation Our retrospective study was based on a dorso-palmar and lateral X-ray at time of injury and postoperatively. A standardised radiological assessment was performed postoperatively at 1 month, 3 months, 6 months, 1 year, and annually thereafter. The evaluation was made by one senior resident and the same
medical consultant for every wrist. We performed measurements for radial height, radial inclination, volar tilt and ulnar variance both preoperatively and postoperatively to estimate correction value (Figs. 3 and 4). We also considered postoperative articular step-off persistence. We measured volar tilt on a LL radiograph by determining the angle between the line along the distal radial articular
Fig. 3. Preoperative X-rays and radiographic measurements. Intra-articular fracture with displacement >1 cm.
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Fig. 4. Postoperative X-rays and radiographic measurements.
surface and the line perpendicular to the longitudinal axis of the radius at the joint margin. Normal volar tilt was considered to be 11 58. We measured radial inclination on a PA radiograph by determining the angle formed between the long axis of the radius and a line drawn from the distal tip of the radial styloid to the ulnar corner of the lunate fossa. Normal radial inclination was considered to be 22 38. We measured ulnar variance on a PA radiograph using the method of perpendiculars. We identified the long axis of the radius and drew a line perpendicular to this, extending through the ulnar-most corner of the lunate fossa. We recorded the distance between this line and the distal-most point of the ulnar dome as the ulnar variance, where a positive number denoted ulnar positive and a negative number denoted ulnar negative. Normal ulnar variance was considered to be 0.7 1.5 mm. We determined radial height by finding the long axis of the radius and then extending a line perpendicular to it at the tip of the radial styloid on a PA radiograph. We recorded the distance between this line and the distal-most point of the ulnar dome. Normal radial height was considered to be 14 1 mm. We defined the accepted functional range for each measurement, excluding radial height, based on functional outcomes from the literature (>208 dorsal angulation, >108 radial inclination, >5 mm ulnar variance, and >2 mm step-off). We evaluated articular congruency by looking at the articular surface of the distal radius on either a PA or lateral film. We measured any noted step-off and recorded it as either less than 2 mm or 2 mm or greater. Postoperative rehabilitation Immediately after surgery, the patient was encouraged to elevate the hand and begin early finger motion. A short arm plaster splinting was maintained for 2 weeks until the first follow-up visit. At that visit, the dressings and sutures were removed, radiographs were taken, and therapy was started under the supervision of a certified physiotherapist. A prefabricated orthosis was also applied for comfort and protection for a further 2 weeks. During weeks 2–6, an anti-oedema protocol was started along with tendon gliding and ROM exercises. Statistical analysis The Student t test was used for statistical analysis.
Results All cases were assessed at an average follow-up time of 40.5 months (range 31–64 months). Articular step-off persistence was assessed in 35.3% of patients. Normal radial inclination (21–258) was restored in 74.5% of patients (range 15–27.58). Normal radial height (10–13 mm) was restored in 66.6% of patients (range 6.8– 17.3 mm). Normal volar tilt (7–158) was achieved in 90.2% of patients (range 3–1878). Normal ulnar variance (0.7–1.5 mm) was restored in 86.3% of patients (range 0.7–4.1 mm) (Table 1). The statistical analysis showed a significant difference between the preoperative and postoperative radiographic values (p < 0.01). Wrist ROM assessed with a goniometer showed an average 628 wrist extension (range 40–758), 738 wrist flexion (range 45–858), 148 radial deviation (range 10–158), 378 ulnar deviation (range 28–458), 828 supination (range 74–858) and 838 pronation (range 80–858) (Table 1). Forty-three patients (84%) had a complete recovery of ROM, without a statistically significant difference (p > 0.05) with regard to extension, flexion, supination and pronation compared with the contralateral hand. The other patients who had a statistically significant difference (p < 0.05) in ROM compared with the non-operated side had postoperative volar tilt and/or ulnar variance out of range. These patients also had a worse outcome in terms of DASH score. At
Table 1 Percentage of radiographic parameters evaluated and wrist ROM values. Radiographic parameters
% of patients with restored parameters
Radial inclination (21–258) Radial height (10-13 mm) Volar tilt (7–158) Ulnar variance (0.7–1.5 mm)
74.5% 66.6% 90.2% 86.3%
Wrist ROM Extension Flexion Radial deviation Ulnar deviation Pronation Supination
628 738 148 378 838 828
(40–758) (45–858) (10–158) (28–458) (80–858) (74–858)
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final follow-up, all patients had a statistically significant difference (p < 0.05) in grip strength compared with the contralateral side, even though they had good strength values. On average, the grip strength was 87% of the grip strength of the contralateral extremity. (The mean grip strength was 27.19 kg.) The mean DASH score was 12.2 (range 0–61) out of a possible 100 points: the score was 0–10 for 68.6% of patients, 10–30 for 15.6%, 30–50 for 7.8% and >50 for 7.8%; the latter score indicates minimal impairment in daily activities. There was one complication in the study. One patient had a flexor tendon rupture, which was treated with plate removal and tendon suture. Discussion Our review of the literature found several different data regarding the clinical outcome of displaced fractures of the distal radius. Rubinovich and Rennie [19] reported that failure to restore the normal radius volar tilt has a deleterious effect on the functional outcome, particularly grip strength. Altissimi et al. [20], showed that radiological deformities are associated with significantly bad results only in case of greatly altered values. Although good functional results can be obtained despite a poor anatomical surgical reduction, an excellent function is more likely when anatomy has been properly restored. McQueen and Caspers [14] showed that the shortening of the radius and an increased volar tilt results in a weak, stiff and painful wrist with a high likelihood of difficulty in performing the normal activities of daily living. Mann et al. [15] reported that the importance of ulnar variance lies in its statistical association with several diseases of the wrist, including lunatomalacia, acute scapholunate instability, ulnocarpal impaction, and radioulnar impingement. The thin triangular fibrocartilage seen with ulnar positive variance is predisposed to early degenerative change. Furthermore, patients who have a radial tilt of less than 58 have poorer results than those with normal or near normal inclination. Several reports have associated radial shortening with pain, instability and restricted forearm pronation and supination, stating that radial length was the most important factor affecting functional outcome [6,16,17,21–26]. Some authors [27–29] demonstrated that radial shortening causes an increased pressure in the distal radioulnar joint (DRUJ) and a shift in the centre of pressure within the sigmoid notch. This is manifested by a decrease in grip strength as well as in motion of the DRUJ, which, in a patient who has a volar displaced fracture, decreases the extension of the wrist [30]. Tsukazaki et al. [31] showed a weak correlation between radiographic findings and functional endresults. They demonstrated that dorsal angulation was the only radiographic feature correlated with loss of flexion. Many reports support that an increase of the volar tilt causes a decrease in grip strength, a decrease in extension and ulnar deviation of the hand and wrist. Furthermore the restoration of anatomical alignment and articular congruity after a displaced fracture is essential for satisfactory functional results [16,32–38]. Other authors [39,40] showed that there is a difference in patients younger or older than 60 years with extra-articular distal radius fractures: in the younger patients there was a very strong link between poor outcomes and the presence of a malalignment of the distal radius. Fractures with a loss of radial length correlated more often with pain and disability, and there were trends towards higher pain and disability with unacceptable degrees of radial tilt and dorsal tilt. It was demonstrated that patients over 65 years showed no statistically significant relationship between radial length, radial tilt or dorsal tilt and pain and disability [40]. Kasapinova showed that there is no significant statistical correlation between the radiographic parameters and the patient-rated outcome [41]. The trend towards open reduction and internal fixation of distal radius fractures reflects the negative impact that disruption of anatomical
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relationships and biomechanical properties of the wrist joint can have on outcomes. Volar plates were designed to minimise extensor tendon irritation while providing stable internal fixation. Furthermore, these plates permit early motion and optimise functional rehabilitation of the wrist. Our experience shows that the focal point of the treatment of wrist fractures with volar-locked plates is to reduce the fractures to restore particularly volar tilt and ulnar variance, as shown by the results of recovery of ROM and of the DASH score. We believe ulnar variance and volar tilt are the most important radiographic parameters that have to be restored to obtain good functional outcome in distal radius fracture. In our series, only patients with volar tilt and ulnar variance restored had a good functional outcome. Nevertheless, small variations (not over 178 of volar tilt, 27.58 of radial inclination, 17.3 mm of radial height and 4 mm of ulnar variance) do not influence a good functional outcome. Our results show that the patients return to the normal ROM and to the almost normal grip strength considering that in 76.4% this involved the non-dominant arm. A stable internal fixation obtained with this kind of plate enables an early kinesitherapy that improves the capacity of the wrist to perform normal activities and prevents joint stiffness. In this study, observers who made radiographic measurements of volar tilt, radial inclination, ulnar variance, radial height, and articular step-off were not blinded to results. The study outcomes may also have been influenced by the particular type of plate used or by the fact that more severe fracture types that required additional fixation (Kirschner wires, external fixators, etc.) were excluded. This study was also limited because we reviewed only plain radiographs when making our measurements. Compared with computed tomography for evaluation of gap and step-off in fractures of the distal radius, plain radiographs have been shown to underestimate the amount of articular incongruency. More studies are necessary to evaluate the functional outcome of wrist fractures at long-term follow-up to consider the likely postoperative arthritic changes involving the wrist. Conflict of Interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. References [1] Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 150000 adults: the influence of age and gender. J Bone Surg 1998;80B: 243–8. [2] Kopylov P, Johnell O, Redlund-Johnell L, Bengner U. Fractures of the distal end of the radius in young adults: a 30-year follow-up. J Hand Surg Br 1993; 18B:45–9. [3] O’Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001; 12(7):555–8. [4] Swiontkowski MF. Increasing rates of forearm fractures in children. JAMA 2003;290(24):3193. [5] Mensforth RP, Latimer BM. Hamman–Todd collection aging studies: osteoporosis fracture syndrome. Am J Phys Anthropol 1989;80(4):461–79. [6] Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205–15. [7] Rausch S, Schlonski O, Klos K, Gras F, Gueorguiev B, Hofmann GO, et al. Volar versus dorsal latest-generation variable-angle locking plates for the fixation of AO type 23C 2.1 distal radius fractures: a biomechanical study in cadavers. Injury 2013;44:523–6.
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