Abstract
Background
Distal radius fractures with severely osteoporotic bone or articular comminution can provide challenges to fixation with traditional volar locked plating alone. The purpose of this study was to evaluate the clinical, radiographic, and patient reported outcomes of patients undergoing distal radius fixation with volar locked plating and adjunctive dorsal bridge plating.
Methods
We retrospectively identified 16 patients with distal radius fractures who underwent our preferred surgical technique for fixation. Patients underwent volar locked plate fixation as well as dorsal bridge fixation at time of surgery. Seven patients were indicated for severe articular comminution with volar rim fragmentation (44%), three patients were revised for nonunion after previous volar locked late fixation (19%), and six patients had severely osteoporotic bone with articular comminution (38%). Two patients (13%) sustained AO/OTA 23-A3 distal radius fracture, two patients (13%) had a 23-B3 fracture, two patients (13%) had a 23-C2 fracture and ten patients (63%) had a 23-C3 fracture.
Results
The average patient age was 51.8 years ± 20.6. Patients were followed for an average of 12.2±6.3 months. The dorsal bridge plate was removed at an average of 11.1±2.4 weeks. The average post-operative radial inclination was 18.9±2.4°, radial height 12.4 mm ± 2.6 mm, and volar tilt 7.1±1.9°. There were no cases of deep or superficial infection. After dorsal bridge plate removal, patients demonstrated an average wrist extension of 55.3±9.5°, flexion 54.4±12.8°, radial deviation 15.7±3.2°, 25.2±3.9 degrees of ulnar deviation.
Conclusion
Distal radius fractures in the setting of severely osteoporotic bone, salvage procedures, articular comminution, volar rim fractures, and revision surgery present uniquely difficult surgical challenges. Volar locked plating with adjunctive dorsal bridge plating can be used with good short- and long-term results.
Keywords: Distal radius, Colles fracture, Bridge plate, Volar plate, Dual plate fixation
1. Introduction
Distal radius fractures (DRF) are the most common upper extremity fracture, with incidence, recently reported as 2% increase per annum in men and 3.4% in women aged 50–59 over the period 1999–2010.1,2 Osteoporosis and prior fragility fractures may predispose older patients to DRF.3 These injuries typically occur due to falls onto an outstretched pronated forearm, with axial compressive and volar to dorsal deforming forces resulting in the commonly seen apex volar fracture pattern. Significant articular comminution and fragmentation of the distal volar rim can occur either due to higher energy mechanism of injury or poor bone quality.
Multiple treatment options exist, including nonoperative immobilization in splint or cast, Kirschner wires with closed reduction, external fixator, fragment-specific fixation, dorsal spanning plates, and volar locked plates.4,5 Current guidelines suggest operative intervention for radial shortening greater than 3 mm, dorsal tilt greater than 10°, or intraarticular displacement greater than 2 mm, though additional patient and fracture characteristics should be carefully considered as well.6 No gold standard fixation method has been identified. Volar locked plating remains popular for patients with adequate bone stock, owing in part to the simple surgical approach and rapid return of ROM and grip strength. Dorsal spanning plates facilitate reduction and immobilization but lack fracture specific fixation. Despite advances in surgical options, these injuries remain challenging to treat and controversy exists over optimal fixation strategies for severely comminuted intraarticular fractures of osteoporotic bone and fracture patterns with uniquely distal volar fragmentation.7
Here we describe an augmented technique, combining volar locked plating with dorsal wrist spanning plating to treat comminuted, intraarticular fractures with poor bone stock, volar rim fractures, and revision fixation. Our fixation method facilitates fragment specific fixation and protection of distal volar rim fragments while protecting against failure by supplementing with a dorsal plate. This combination confers the additional benefit of permitting meticulous articular surface restoration followed by joint distraction to offload the cartilage injuries commonly seen in these fractures. A detailed description of this technical pearl may provide surgeons an additional strategy for treating these challenging fractures. Illustrative case series demonstrates the authors recommended indications, including for both primary fracture fixation and as a salvage revision option.
2. Methods
After institutional review board approval, patients with complex distal radius fractures treated with volar locked plating and adjunctive dorsal bridge plating by a single surgeon were retrospectively reviewed. Patients over the age of 18 who underwent augmented fixation were included in the study. Patient demographics, physical exam findings, as well as radiographic and clinical outcomes were collected.
Patients were indicated for adjunctive fixation in the setting of severely osteoporotic bone (Fig. 1), articular comminution (Fig. 2), volar rim fractures (Fig. 3), and revision surgery (Fig. 4). Fractures were classified in accordance with the AO/OTA distal radius fracture classification system.
Fig. 1.
Pre-operative (left) and post-operative (right) PA and lateral radiographs of a comminuted osteoporotic distal radius fracture treated with volar locked fixation and dorsal bridge plating.
Fig. 2.
Pre-operative (left) and post-operative (right) PA and lateral radiographs of a distal radius fracture with severe articular comminution treated with volar locked fixation and dorsal bridge plating.
Fig. 3.
Pre-operative (left) and post-operative (right) PA and lateral radiographs of a dorsal, comminuted distal radius fracture with distal volar rim component treated with volar locked fixation and dorsal bridge plating.
Fig. 4.
Pre-operative (left) and post-operative (right) PA and lateral radiographs of a revision distal radius fracture treated with volar locked fixation and dorsal bridge plating.
3. Description of surgical technique
All patients remain supine on hospital stretcher with operative upper extremity extended over a hand table. Following induction on anesthesia, the operative arm is exsanguinated and pneumatic tourniquet inflated on the upper arm. All included patients were treated by one of two fellowship trained trauma surgeons. Standard FCR approach or extended FCR approach was used to expose the volar distal radius. Existing hardware is removed in standard fashion if this technique is used for salvage or revision. Fracture fragments are mobilized and hematoma is removed with curettes and irrigation to facilitate reduction. Further irrigation and removal of devitalized or contaminated tissues may be performed at this stage for open fractures.
A volar locking plate of appropriate size and length based on patient anatomy is then selected, appropriately placed with fluoroscopic guidance, and provisionally fixed to the radial shaft with a screw in oblong hole and multiple K wires. Under direct visualization articular congruency is restored and fragments reduced to the plate with K wires. Reduction and length are confirmed with fluoroscopy after which the plate is fixed proximally with locking screws. We then place locking fixed angle elements in the distal segment of the plate, sequentially removing K-wires to mitigate loss of reduction. Reduction and hardware placement is again confirmed with fluoroscopy prior to beginning with supplemental fixation.
An incision over the second metacarpal shaft is carried down to bone, protecting sensory nerves and extensor tendons. Using a combination of sharp and blunt dissection, we create a tunnel under the second extensor compartment and introduce a dorsal spanning plate through this pocket. We select a plate of sufficient length to extend the length of our volar plate proximal to our volar fixation so as to minimize stress risers and sufficiently protect the volar reconstruction. We localize the plate with fluoroscopy and incise directly over the plate. Once appropriately aligned on and provisionally held to the radius with clamps, the plate it is fixed to the metacarpal and radial shaft with a combination of cortical and locking screws.
Wounds are irrigated and multi-layered closure of both wounds is undertaken in standard fashion. Soft dressings are applied and anesthesia is reversed. All patients are instructed to be non-weightbearing on the operative extremity. Early finger motion is encouraged and removal of the spanning plate is performed once there are signs of radiographic healing. This tends to be earlier than in situations where dorsal spanning plate fixation is used in isolation.
4. Results
We retrospectively identified 16 patients with distal radius fractures who underwent our preferred surgical technique for fixation. Patients underwent volar locked plate fixation as well as dorsal bridge fixation through the second metacarpal at time of surgery.
Seven patients were indicated for severe articular comminution with volar rim fragmentation (44%), three patients were revised for nonunion after previous volar locked late fixation (19%), and six patients had severely osteoporotic bone with articular comminution (38%). Two patients (13%) sustained AO/OTA 23-A3 distal radius fracture, two patients (13%) had a 23-B3 fracture, two patients (13%) had a 23-C2 fracture and ten patients (63%) had a 23-C3 fracture.
The average patient age was 51.8 years ± 20.6. Patients were followed for an average of 12.2±6.3 months. The dorsal bridge plate was removed at an average of 11.1±2.4 weeks (Table 1). The average post-operative radial inclination was 18.9±2.4°, radial height 12.4 mm ± 2.6 mm, and volar tilt 7.1±1.9°. There were no cases of deep or superficial infection. After dorsal bridge plate removal, patients demonstrated an average wrist extension of 55.3±9.5°, flexion 54.4±12.8°, radial deviation 15.7±3.2°, 25.2±3.9 degrees of ulnar deviation (see Table 2).
Table 1.
Patient characteristics of adjunctive treatment of distal radius fractures.
| Patient Number | Age (years) | Sex | Follow-Up Time (months) | AO/OTA Classification | Indication | Time to Plate Removal (weeks) | Complication: Deep/Superficial Infection |
|---|---|---|---|---|---|---|---|
| 1 | 38 | M | 14 | 23-C2 | Distal Volar Rim Fracture | 12 | 0/0 |
| 2 | 53 | F | 16 | 23-A3 | Revision | 17 | 0/0 |
| 3 | 30 | F | 9 | 23-C3 | Articular Comminution | 10 | 0/0 |
| 4 | 55 | F | 14 | 23-C3 | Revision | 10 | 0/0 |
| 5 | 89 | F | 11 | 23-B3 | Osteoporosis | 11 | 0/0 |
| 6 | 87 | F | 16 | 23-A3 | Osteoporosis | 16 | 0/0 |
| 7 | 29 | M | 12 | 23-C3 | Distal Volar Rim Fracture | 10 | 0/0 |
| 8 | 32 | M | 9 | 23-C3 | Articular Comminution | 9 | 0/0 |
| 9 | 66 | F | 17 | 23-C3 | Distal Volar Rim Fracture | 10 | 0/0 |
| 10 | 20 | M | 25 | 23-C2 | Revision | 10 | 0/0 |
| 11 | 36 | M | 23 | 23-C3 | Distal Volar Rim Fracture | 9 | 0/0 |
| 12 | 69 | F | 8 | 23-C3 | Osteoporosis | 12 | 0/0 |
| 13 | 64 | F | 6 | 23-B3 | Osteoporosis | 10 | 0/0 |
| 14 | 44 | M | 7 | 23-C3 | Distal Volar Rim Fracture | 10 | 0/0 |
| 15 | 66 | M | 7 | 23-C3 | Distal Volar Rim Fracture | 10 | 0/0 |
| 16 | 51 | M | 1 | 23-C3 | Distal Volar Rim Fracture | – | 0/0 |
| Average (SD) | 51.8 (20.6) | 12.2 (6.3) | 11.1 (2.4) | ||||
Table 2.
Patient outcomes one-year after adjunctive treatment of distal radius fractures.
| Outcome | Mean (n = 16) | Standard Deviation |
|---|---|---|
| Radial Inclination (degrees) | 18.9 | 2.4 |
| Radial Height (mm) | 12.4 | 2.6 |
| Volar Tilt (degrees) | 7.1 | 1.9 |
| Wrist Extension (degrees) | 55.3 | 9.5 |
| Wrist Flexion (degrees) | 54.4 | 12.8 |
| Radial Deviation (degrees) | 15.7 | 3.2 |
| Ulnar Deviation (degrees) | 25.2 | 3.9 |
5. Discussion
Distal radius fractures in the setting of severely osteoporotic bone, salvage procedures, articular comminution, volar rim fractures, and revision surgery present uniquely difficult surgical challenges. Volar locked plating alone may not be sufficient in such cases and can lead to early failure and higher complication rates. We describe a case series of highly comminuted distal radius fractures treated with dorsal spanning plating, as well as volar plating. Particularly given the challenges of severely comminuted intra-articular distal radius fractures and revision fixation, we feel our radiographic and range of motion results indicate excellent outcomes with this approach.
Distal radius fractures, while a common orthopedic problem,8 can be challenging to treat, particularly in cases associated with severe osteoporosis, intra-articular comminution, and significant length instability. Previously many patients underwent external fixation of these fractures, the advent of the dorsal spanning plate with locking screw fixation has greatly diminished the use of this surgical option, as the dorsal spanning plate is better tolerated and associated with less complications.9
In primary fixation of comminuted distal radius fractures, as well as very distal fractures of the radius, such as those with comminution of the volar or dorsal rim, the maintenance of reduction can be challenging, particularly with the use of traditional volar plating alone. We have found that in these circumstances, the use volar plating to obtain anatomic reduction of the articular surface, followed by application of a dorsal spanning plate to supplement the fixation and maintain length and overall alignment, is a safe and reliable technique in preventing loss of reduction. Moreover, in cases of patients with osteoporotic bone, the engagement of the metacarpal and radial diaphysis for fixation as opposed to relatively weak bone in the distal radius metadiaphysis is likely of biomechanical advantage. Additional biomechanical studies are needed to confirm this.
Our study is limited by multiple factors. We describe a limited case series of patients treated with dual dorsal and volar plate fixation for severe distal radius fractures or revision fixation. While our criteria for utilization of dual plate fixation was osteoporotic bone, comminuted intra-articular fractures, and revision fixation, we did not utilize standardized criteria to indicate patients for dual plate fixation. Furthermore, only 16 patients were identified for inclusion in this case series and given the retrospective nature limited outcome measures were available for inclusion.
We feel this is a valuable addition to available techniques for distal radius fracture fixation techniques, particularly in the setting of poor bone quality, severe comminution or revision as we have shown no cases of loss of reduction and reasonable clinical outcomes with this novel technique. Additional biomechanical and clinical studies are needed to better understand what patients may benefit from this approach.
Funding statement
No funding was received for this study.
Guardian/parent consent
Due to the retrospective nature of this project, consent was not obtained.
Ethical statement
This project was performed in a retrospective fashion in accordance with all ethical principles. All data was deidentified.
CRediT authorship contribution statement
Clarke Cady-McCrea: Writing – original draft, Writing – review & editing. James D. Brodell: Writing – original draft, Writing – review & editing. Thomas J. Carroll: Writing – original draft, idea, Conceptualization, data acquisition. Urvi Patel: Writing – original draft, Writing – review & editing. Akhil Dondapati: Writing – original draft, Writing – review & editing. Sandeep Soin: Idea, Conceptualization, data acquisition, Writing – review & editing. John Ketz: Data acquisition, Writing – review & editing.
Acknowledgements
None.
Contributor Information
Thomas J. Carroll, Email: thomasj_carroll@urmc.rochester.edu.
Akhil Dondapati, Email: akhil_dondapati@urmc.rochester.edu.
References
- 1.Corsino C.B., Reeves R.A., Sieg R.N. StatPearls Publishing; Treasure Island (FL): 2022. Distal Radius Fractures. [Updated 2021 Aug 11]. In: StatPearls [Internet] [PubMed] [Google Scholar]
- 2.Jerrhag D., Englund M., Karlsson M.K., Rosengren B.E. Epidemiology and time trends of distal forearm fractures in adults - a study of 11.2 million person-years in Sweden. BMC Muscoskel Disord. 2017 Jun 02;18(1):24. doi: 10.1186/s12891-017-1596-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mauck B.M., Swigler C.W. Evidence-based review of distal radius fractures. Orthop Clin N Am. 2018 Apr;49(2):211–222. doi: 10.1016/j.ocl.2017.12.001. [DOI] [PubMed] [Google Scholar]
- 4.Meaike Joshua J. MD1; Kakar, Sanjeev MD1,a Management of comminuted distal radius fractures. JBJS Reviews. August 2020;8(8) doi: 10.2106/JBJS.RVW.20.00010. [DOI] [PubMed] [Google Scholar]
- 5.Brogan D.M., Richard M.J., Ruch D., Kakar S. Management of severely comminuted distal radius fractures. J Hand Surg Am. 2015 Sep;40(9):1905–1914. doi: 10.1016/j.jhsa.2015.03.014. Epub 2015 Aug 1. [DOI] [PubMed] [Google Scholar]
- 6.Lichtman D.M., Bindra R.R., Boyer M.I., et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010 Mar;18(3):180–189. doi: 10.5435/00124635-201003000-00007. [DOI] [PubMed] [Google Scholar]
- 7.Richard M.J., Katolik L.I., Hanel D.P., Wartinbee D.A., Ruch D.S. Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients. J Hand Surg Am. 2012 May;37(5):948–956. doi: 10.1016/j.jhsa.2012.02.034. Epub 2012 Apr 4. [DOI] [PubMed] [Google Scholar]
- 8.Court-Brown C.M., Caesar B. Epiemiology of adult fractures: a Review. Injury. 2006 Apr;37(8):691–697. doi: 10.1016/j.injury.2006.04.130. [DOI] [PubMed] [Google Scholar]
- 9.Golden A.S., Kapilow J.M. Distal radius fractures and the dorsal spanning plate in the management of the polytraumatized patient. J Orthop Trauma. 2021 Sep 1;35(Suppl 3):s6–s10. doi: 10.1097/BOT.0000000000002204. [DOI] [PubMed] [Google Scholar]