Abstract
Background:
Dorsal spanning plate fixation can be used to treat comminuted distal radius fractures not amenable to volar plating. However, there is a relative paucity of outcomes data; so, the aim of this retrospective study was to investigate outcomes and complications after dorsal spanning plate fixation for distal radius fractures.
Methods:
Distal radius fractures treated with dorsal spanning plate fixation at a level-1 trauma center were retrospectively identified via Current Procedural Terminology coding and chart review from 2014 to 2019. Patient demographics, fracture pattern characteristics, fixation techniques, and clinical outcomes were all obtained via chart review using the electronic medical record.
Results:
In all, 43 dorsal plates were identified out of 369 operatively treated distal radius fractures (12%). Of these, 84% were AO type C, 28% were open fractures, and 86% resulted from falls. At the time of dorsal plating, 28% had an additional procedure. One patient had a major complication after surgery, requiring unplanned surgery for a radius nonunion. Average final follow-up occurred 9 weeks after dorsal plate removal, with mean range of motion at the wrist measuring: 36° flexion, 48° extension, 75° pronation, and 63° supination. Finger flexion was also measured, using either tip of finger to palm distance or total active motion, depending on the available data. These were measured at an average of 1.2 cm and 194°, respectively.
Conclusions:
Dorsal spanning plate fixation provides a safe and effective method for treating complex distal radius fractures. In our series, patients had good functional outcomes with few complications.
Keywords: distal radius, fracture/dislocation, diagnosis, wrist, open fractures, trauma, anatomy
Introduction
Distal radius fractures are some of the most common fractures in adults, accounting for nearly 1 out of every 6 fractures seen in the emergency department. 1 For fractures requiring operative fixation, volar locking plates were a major innovation and have now become one of the most common methods of fixation. 2 Some distal radius fractures, however, are not amenable to volar plating and require alternative means of stabilization. For severely comminuted AO type C injuries in the elderly or polytraumatized patient, there remains a role for fixation using a dorsal spanning plate. 3
Dorsal spanning plate fixation acts as an internal fixator, using ligamentotaxis to maintain length and joint integrity. Plates are commonly placed proximally on the distal radius metaphysis and distally over the second or third metacarpal shaft. This bridge plate serves as rigid fixation until fracture healing is complete or can be temporizing until more definitive fixation is achieved. It also has the added benefit of allowing patients to immediately bear weight after surgery, which in the polytraumatized patient may be of considerable advantage.3,4 Dorsal spanning plates are occasionally compared to external fixators but are advantageous as they do not have the risk of pin site complications. 5 However, as dorsal plates are typically in place for 8 to 12 weeks, postoperative stiffness is a concern.
The indications and surgical technique for dorsal spanning plates have been researched; however, there is a relative paucity of outcomes and complications related data in the literature. A few recent studies have shown dorsal spanning plates can provide acceptable results for complex fractures with relatively few major complications.6 -8 The aim of our study is to characterize both demographic data and functional outcomes in distal radius fractures fixed with dorsal spanning plate fixation. We also sought to describe any additional associated procedures at the time of surgery and complications reported postoperatively.
Methods
After obtaining approval from our institutional review board, distal radius fractures that underwent operative fixation with a dorsal spanning plate were retrospectively identified over a 5-year period from 2014 to 2019. These procedures were performed by 3 fellowship-trained hand surgeons at a major level-1 trauma center. Patients were included if they were older than 18 years, and underwent open reduction and internal fixation via dorsal spanning plate fixation. There were no specific exclusion criteria. These patients were identified by using the Current Procedural Terminology codes for distal radius open reduction and internal fixation 25607, 25608, or 25609. Chart review was then performed to review operative notes and identify imaging of patients with fractures fixed with dorsal spanning plates. Patient demographic information was reviewed from the electronic medical record. This included age at time of injury, sex, mechanism of injury, history of diabetes, body mass index, and smoking status. Injury-specific characteristics were also reviewed and evaluated for closed versus open injury, AO fracture type, mechanism of injury, and additional procedures performed at the time of dorsal plating. Postoperatively, occupational therapy notes were utilized to evaluate range of motion at the wrist in flexion, extension, pronation, supination, and finger flexion. Complications were defined as unanticipated patient complaints or outcomes. The distinction was made between a major or minor complication if the complication required a reoperation.
Results
Our study identified 43 distal radius fractures fixed with dorsal spanning plates out of 369 total distal radius fractures fixed with open reduction and internal fixation (12%). There were a total of 42 patients in this study as 1 patient had bilateral distal radius fractures fixed with dorsal spanning plates. The average age of the cohort was 58 years. The majority of patients, 27 (63%), were female. With respect to sex, there was a bimodal distribution with 77% (10/13) of the patients under 55 being male and 80% (24/30) of patients greater than or equal to 55 being female. At the time of injury, 12 patients (29%) in the cohort were active smokers. The average body mass index was 30, and 5 (11%) of the patients had diabetes. Additionally, 36 patients (84%) sustained AO type C fractures. Open fractures were seen in 12 patients (28%). The most common mechanism of injury was a fall seen in 37 patients (86%) (Table 1). Of these falls, 18 (49%) were a fall from standing height, 10 (27%) were from a fall greater than 5 feet, 7 (19%) resulted from a fall down more than 2 stairs, and 2 (5.4%) were from falls off of a bicycle. In 32 patients (74%), the dorsal spanning plates were fixed to the third metacarpal with the remainder being fixed to the second. Acumed plates were used in 38 patients (88%), with Synthes 3.5 mm Locking Compression Plates being used in the remainder of the patients. There were 6 patients who sustained bilateral distal radius fractures, 1 of whom was treated with bilateral dorsal spanning plates.
Table 1.
Patient Demographics.
| Characteristics | All fractures, n = 43 |
|---|---|
| Age, mean (SD) | 58 (17) |
| Female sex, n (%) | 16 (63) |
| BMI, mean (SD) | 30 (6.3) |
| Diabetes, n (%) | 6.0 (1.1) |
| Smoker, n (%) | 12 (29) |
| AO fracture type, n (%) | |
| A | 1 (2.3) |
| B | 6 (14) |
| C | 36 (84) |
| Open fractures, n (%) | 12 (28) |
| Mechanism of injury, n (%) | |
| Fall | 37 (86) |
| MVA/MCC | 4 (9.3) |
| Other | 2 (4.7) |
Note. SD = standard deviation; BMI = body mass index; AO = Arbeitsgemeinschaft für Osteosynthesefragen; MVA = motor vehical accident; MCC = motorcycle crash.
At the time of dorsal plating, 12 of the 43 wrists (28%) had an additional procedure to the operative extremity. These included Kirschner wire (K-wire) fixation, carpal tunnel release, bone grafting, distal ulna resection, mini suture anchors, open reduction and internal fixation of the first metacarpal and trapezium, and tendon/nerve repair. Kirschner wire adjunct fixation was primarily used in a fragment-specific fashion providing additional fixation to the radial styloid (Table 2). The mini suture anchors were used in 1 patient as a reduction tool for the distal volar fragment by obtaining purchase in the distal radius and tightening the suture to the volar capsule. Another patient had significant injury to their tendons and nerves, requiring repair of the median nerve at the forearm, extensor carpi ulnaris, 4 extensor digitorum commua tendons, extensor pollicis longus/extensor pollicis brevis, zone 5 long and index finger flexor digitorum superficialis, and finally zone 5 flexor digitorum profundus of the index and ring finger. This patient also underwent open reduction and internal fixation of the first metacarpal and trapezium on the ipsilateral side. The average time to surgery was 10 days with the average time to removal of the dorsal spanning plate being 11 weeks. One patient initially had a temporizing external fixator placed 3 days prior to dorsal spanning plate fixation. Another patient initially had a volar locking plate that failed and was revised to a dorsal spanning plate.
Table 2.
Additional Procedures at Time of Dorsal Plating.
| Procedure | All fractures, n = 43 |
|---|---|
| n (%) | |
| K-wires | 5 (12) |
| Carpal tunnel release | 3 (7.0) |
| Bone graft | 3 (7.0) |
| Distal ulna resection | 1 (2.3) |
| Mini suture anchors | 1 (2.3) |
| Tendon/nerve repair | 1 (2.3) |
| ORIF trapezium/thumb metacarpal | 1 (2.3) |
Note. K-wires = Kirschner wires; ORIF = open reduction and internal fixation.
In this study, there were complications seen in 10 patients. One patient had a major complication and 9 patients experienced minor complications, for a total complication rate of 23%. The major complication was a distal radius nonunion requiring revision open reduction and internal fixation with dorsal compression plating and bone grafting. This patient also underwent a Darrach distal ulna resection after revision open reduction and internal fixation, and ultimately went on to fracture union. Minor complications included hardware failure, arthritis, wound complications, and hand paresthesias. The 2 patients with hardware failure broke 1 or 2 of their metacarpal screws. One patient had posttraumatic radiocarpal arthritis, and 1 patient had ulnar-sided wrist pain with positive ulnar variance. Two patients had delayed wound healing due to a suture reaction and 1 patient had cellulitis with a superficial wound dehiscence, requiring oral antibiotics. Another patient had pain and perceived restricted extensor pollicis longus motion. Finally, 2 patients had peripheral nerve problems: 1 with persistent median nerve symptoms and another with isolated small finger paresthesias (Table 3).
Table 3.
Complications.
| Complication | All fractures, n = 43 |
|---|---|
| n (%) | |
| Total complications | 10 (23) |
| Distal radius nonunion | 1 (2.3) |
| Broken metacarpal screws | 2 (4.7) |
| Suture reaction | 2 (4.7) |
| Post traumatic arthritis | 1 (2.3) |
| Cellulitis | 1 (2.3) |
| Peripheral nerve problems | 2 (4.7) |
| Ulnar wrist pain | 1 (2.3) |
All patients were referred to hand therapy after dorsal spanning plate removal. A resting wrist orthosis was fabricated, and patients were instructed to wear this as needed for comfort. The average final follow-up with hand therapy was 74 days after dorsal plate removal. There were 3 patients lost to follow-up, and an additional 4 patients who never went to occupational therapy. There were 37 wrists available for final range of motion assessment. Flexion and extension were assessed in 32 and 33 of these wrists, respectively, with an average of 36° (standard deviation [SD] = 15) of flexion and 48° (SD = 13) of extension. With respect to pronation, 24 wrists were assessed with an average of 75° (SD = 20). There were 29 wrists available for assessment of supination with an average of 63° (SD = 22). Finger flexion was also assessed in 27 wrists. Due to heterogeneity in measurements made by the therapists, the data were separated into 2 groups. The first of which measured finger flexion via tip to palm distance in centimeters, and the second in total active range of motion. Tip to palp distance (TTP) is an established metric where the distance from the distal phalanx to the palm at full active flexion is measured. This measurement was available in 18 wrists with an average TTP distance of 1.2 cm (SD = 1.4). The second group measured finger flexion using total active motion (TAM) which was assessed by taking the summation of range of motion in degrees at each of the joints of the finger: metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints. These ranges were then averaged across the fingers to obtain the TAM. There were 9 wrists with TAM data for an average of 194° (SD = 47). Range of motion data were also dichotomized by age using 55 as the age cutoff. These data are shown in Table 4.
Table 4.
Range of Motion.
| Motion | All patients | Patients <55 years | Patients ≥55 years |
|---|---|---|---|
| Flexion in degrees, mean (SD) | 36 ± 15 (32) | 34 ± 17 (9) | 36 ± 14 (23) |
| Extension in degrees, mean (SD) | 48 ± 13 (33) | 50 ± 15 (10) | 47 ± 12 (23) |
| Pronation in degrees, mean (SD) | 75 ± 20 (24) | 64 ± 28 (8) | 80 ± 11 (16) |
| Supination in degrees, mean (SD) | 63 ± 22 (29) | 60 ± 20 (10) | 63 ± 23 (19) |
| Finger flexion tip to palm distance in cm, mean (SD) | 1.2 ± 1.4 (18) | 0.5 ± 1.2 (6) | 1.5 ± 1.4 (12) |
| Finger flexion total active motion in degrees, mean (SD) | 194 ± 46 (9) | 179 ± 85 (2) | 198 ± 40 (7) |
Note. Data are mean ± standard deviation. Number in parentheses is sample size.
Discussion
Distal radius fractures remain one of the most common fractures seen in adults. Highly comminuted intra-articular fractures not amenable to volar plating have been shown to be effectively treated with dorsal spanning plate fixation. 3 Our study focused on characterizing patients who underwent dorsal spanning plate fixation and describing their outcomes with respect to range of motion and complications. Demographic data in our study are consistent with other published literature on dorsal spanning plate fixation. Falls were the most common mechanism of injury, seen in 86% of our patients. We chose to further describe falls to characterize the level of energy associated, with most of the patients falling from standing height. In studies by both Hanel et al 6 and Richard et al 8 nearly 70% of the patients sustained injuries from falls. In our study, 84% of the patients had AO type C fractures; an expected result, given these are the fracture patterns most indicated for dorsal spanning plate fixation. Lauder et al 7 noted that 100% of their 18-patient cohort were AO type C fractures.
Our overall complication rate was 23.2%, with the overwhelming majority (9/10) being minor complications. The most common complications were reactions to suture material or hardware failure where the metacarpal screws fractured and were left in place. There was only one patient with a major complication, a nonunion requiring revision surgery. This patient fell off a ladder and sustained a severely comminuted open distal radius and ulna fracture. He subsequently went on to nonunion requiring revision open reduction and internal fixation with a dorsal compression plate. The fracture healed with positive ulnar variance, and a distal ulna resection was performed for persistent wrist pain. Hanel et al 6 reported a 12% complication rate in their cohort of 144 dorsal spanning plates with 7 minor and 9 major complications. As with our series, the major complications were mainly nonunion or malunions. Hanel also reported on the percentage of patients requiring adjunct fixation at the time of dorsal spanning plating. In their cohort, 57% of the patients underwent additional fixation, the majority of which were K-wires. Approximately 1 in 4 of our patients underwent additional procedures at the time of dorsal spanning plate placement; half of these were K-wire placement for adjunct fixation.
Lauder also reported on functional outcomes after dorsal spanning plate fixation. In their 18 wrists, at an average follow-up of 2.9 years, the mean flexion was 43°, extension of 46°, pronation of 66°, and supination of 71°. 7 Compared to our cohort, this was substantially longer average follow-up but similar end range of motion. Richard et al 8 also reported range of motion data in their cohort of 33 wrists. These were patients over 70 years of age and followed for an average of 47 weeks. These patients had surprisingly good range of motion with mean of 46° of flexion, 50° of extension, 79° of pronation, and 77° of supination. Our cohort also assessed wrist flexion, extension, pronation, and supination data at an average of 63 days after removal of hardware. Flexion and extension data were available for 34 patients and were 36° and 48°, respectively. With respect to pronation and supination, fewer patients had these data available. Pronation range of motion was recorded in 22 patients with an average of 75°. Supination data were available for 27 patients with an average of 63°.
We were also able to assess finger flexion in 27 of our cohort’s wrists. This was assessed using 2 separate methods, TAM or TTP distance. The discrepancy in this metric was based on hand therapist preference. Attempts were made to synthesize these 2 different metrics, but no reliable literature or formula was found to support this. Instead, literature was found that recommended against correlating these 2 measurements, as Macdermid et al 9 noted that the correlation between TTP and TAM was only moderate and were not interchangeable. A total of 18 wrists had TTP measurements available with an average of 1.2 cm. Nine wrists had TAM data available with an average of 194°. To our knowledge, there is no other literature reporting on finger range of motion related to dorsal spanning plate outcomes. Additionally, when range of motion data were dichotomized by age, there did not seem to be a major difference between groups. An exception was seen when looking at finger flexion TTP distance. In our study, patients under 55 had nearly 1 cm greater TTP distance compared to patients who were 55 or greater (0.5 cm vs 1.5 cm). However, these data points ranged widely as seen by a standard deviation of 1.2 cm in the 18 patients evaluated for TTP under 55. The small sample size available for finger range of motion, when dichotomizing by age, also makes these results less convincing.
Range of motion in our patients was restricted compared to the Hanel cohort but similar to the Lauder cohort. This could be explained by the younger average age of the Hanel cohort and their potential to work more rigorously with therapy and regain their deficits. Conversely, younger patients typically experience higher energy injuries, and one might expect them to have worse outcomes. When we separated out our data by age, there did not seem to be notable difference in range of motion outcomes. Previous studies have shown the functional range of motion at the wrist is 40° of flexion, 30° of extension, and 100° of prono-supination arc.10 -12 The patients in our study in general had injuries that were not amenable to volar locking plate fixation. These were overwhelmingly AO type C injuries, which are comminuted intra-articular fractures by definition. For these patients to obtain a near functional wrist arc of motion on average is an important finding, and it provides further evidence that dorsal spanning plate fixation is a viable option for fixing comminuted distal radius fractures. Another option for providing stability to these fractures is external fixation. A recent meta-analysis comparing dorsal spanning plate fixation and external fixation did not look at range of motion but did comment on some other important outcomes. This paper found that there were no significant differences in Disabilities of the Arm, Shoulder and Hand (DASH) scores, radiographic parameters, or re-operation rates between the 2 fixation methods. It did show that dorsal bridge planning had a lower infection rate at the cost of having a higher rate of hardware failure. 5
Our study should be interpreted in light of its strengths and limitations. The retrospective nature of this review is the most apparent limitation. Demographic information found in patient charts is only as reliable as the documentation by authors in the chart, and it is susceptible to reporting bias. Similarly, range of motion data relies on the accounts of multiple hand therapists and other clinicians documenting their clinical encounters, making it susceptible to recall bias. Another potential weakness could be the perceived limited sample size in our cohort; this, however, was somewhat expected given the relatively rare indications for dorsal spanning plate fixation. Even at our level-1 trauma center, only 43 wrists were able to be identified over a 5-year period, representing less than 12% of operatively treated distal radius fractures during this time. These patients also had widely variable follow-up time with hand therapy, and 4 patients were lost to follow-up entirely. Due to a lack of uniformity in reporting, finger flexion data were assessed on using 2 separate metrics, tip to palm distance and total active motion. This unfortunately further reduced the available reported sample size, especially when dichotomizing by age. Additionally, validated outcomes scoring systems such as the DASH questionnaire were not asked of these patients. These scores would be able to give a better idea of the patients’ overall outcomes. Despite these limitations, this study is one of the larger case series reporting on outcomes after dorsal spanning plate fixation for distal radius fractures. In this cohort, we were able to describe complications after surgery and show that reoperation was rare. Furthermore, to our knowledge, this study is unique in its reporting of finger range of motion data after dorsal spanning plate fixation.
These data add to the body of literature that support dorsal spanning plate fixation as a safe and acceptable means of treating complex distal radius fractures. Future prospective studies may be helpful to further characterize the functional outcomes after dorsal spanning plate fixation, particularly in young patients who sustain high-energy injuries.
Footnotes
Authors’ Note: University of Massachusetts Medical Center Human Research Committee Study #: H00022373: Dorsal spanning plate.
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: This study was a retrospective review and does not contain identifying data.
Statement of Informed Consent: This study was a retrospective review and does not contain identifying data.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Matthew W. DeFazio 
https://orcid.org/0000-0002-9372-3501
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