Open Reduction and Internal Fixation of Distal Radius Fractures with Complete Intra-articular Involvement and Diaphyseal Extension

Abstract

Backgroud

Distal radius fractures with complete intra-articular involvement and diaphyseal extension pose significant challenges for stable fixation. Treatment options vary, with no single method demonstrating superiority. This study analyzed the outcomes of fixing these type of fractures with volar locking plates, which are widely used worldwide, and the fracture length according to plate type to determine when an extra-long plate should be used.

Methods

This retrospective review analyzed 89 consecutive patients surgically treated for Association of Osteosynthesis (AO) classification type C distal radius fractures with diaphyseal extension, excluding open fractures. The plate length was determined to be long enough accordingly to avoid placing screws in the fracture site. Radiographic evaluation and clinical outcomes were analyzed.

Results

According to the AO system, C3 type fractures comprised 50%, C1 type 28%, and C2 type 22%. The average distance from the radiocarpal joint to the most proximal fracture line was 41.1 mm, with articular step off and gap of 1.7 mm and 3.7 mm, respectively. Concomitant distal ulna fractures were present in 81%. At final follow-up, the mean radial height was 10.9 mm, radial inclination was 22.8°, volar tilt was 5.7°, and ulnar variance was 0.6 mm. Fracture union occurred on average at 2.6 months. The average Disabilities of the Arm, Shoulder, and Hand score was 12.0 and the average Modified Mayo Wrist Score was 83.6. Regarding the average wrist range of motion, extension was 63.8°, flexion was 53.7°, ulnar deviation was 25.1°, and radial deviation was 16.7°. Complications included delayed wound healing in 3% and delayed union in 1 patient, who eventually achieved union at 10 months after surgery. APTUS Wrist Distal Radius Plates XL 2.5 and 2.4-mm Variable Angle LCP Two-Column Volar Distal Radius Plates showed a statistically significant difference in fracture length, with the former being longer than the latter (62 mm vs. 35 mm, p < 0.001).

Conclusions

If the fracture length from the articular surface to the diaphysis exceeds 60 mm, we recommend preparing an extra-long distal radius plate. Volar plate fixation with appropriate length selection has yielded favorable functional outcomes and few minor complications in distal radius fractures with complete intra-articular involvement and diaphyseal extension.

Distal radius fractures (DRFs) are a common type of fracture. Specifically, DRFs occurring at the junction of the metaphysis and diaphysis in the distal radius often stem from high-energy trauma, presenting a considerable challenge for orthopedic surgeons.¹⁾ There is limited research on these injuries, and ongoing discussion regarding the most effective treatment method exists. The treatment choices have historically comprised external fixation, distraction plate fixation with a dorsal approach, standard 3.5-mm locking compression plates (LCP), and fixed-angle volar plates. Volar plate fixation has been recognized to be an effective and safe treatment in unstable DRFs.²⁾ However, when the fracture line extends to a significant part of the diaphysis with intra-articular DRF, it is not easy to obtain a reduction of the intra-articular part and proper alignment at the diaphysis part. Achieving a gap or step-off of less than 2 mm would be reasonable, given the consistent association between joint incongruity and the subsequent development of degenerative changes.³⁾ Incorrect reduction of the radius diaphysis may result in malunion, potentially causing instability in the distal radioulnar joint, even with an intact triangular fibrocartilage complex, and may require corrective osteotomy.⁴⁾ Due to the aforementioned factors, achieving satisfactory outcomes in this type of fracture is a challenging task.

Past literature has introduced various fixation methods for DRF involving both articular and diaphyseal components. However, there is still no consensus on the choice of instrument for treating this type of fracture. This study aimed to propose internal fixation using a volar locking plate, which is widely used and familiar around the world, as the standard treatment for DRF and suggest when an extra-long plate should be used based on the fracture length. The first hypothesis of this study was that successful bone union and functional recovery could be achieved in DRF with complete intra-articular involvement and diaphyseal extension through internal fixation using a volar locking plate. The second hypothesis was that a retrospective examination of the plates used would reveal a significant difference in fracture length between the standard volar locking plate, commonly used for articular and metaphyseal fractures, and the extra-long plate. Specifically, the second hypothesis was tested to determine when it is necessary to prepare an extra-long plate set instrument in advance during preoperative planning. If the fracture length exceeds a certain threshold, a standard volar locking plate may not provide sufficient stability due to its inadequate length.

METHODS

The study design was approved by the Institutional Review Board of CHA Bundang Medical Center (IRB No. CHAMC 2023-08-043). Patient consent requirement was waived by the Board due to the retrospective design of this study. Clinical photographs containing exposed patient body parts were captured without including facial features to prevent individual identification.

Patient Selection and Demographics

From 2002 to 2022, all patients underwent operations by a single surgeon (SHH) in a single hospital. Among 2,511 patients who underwent surgery, 89 patients who underwent open reduction and internal fixation for DRF with diaphyseal extension and complete intra-articular involvement, corresponding to AO type 2R3C, were involved in this study (Fig. 1). Patients included 63 women (71%) and 26 men (29%). The mean age at surgery was 63 years (range, 21–86 years). The injury side was left in 59 cases (66%) and right in 30 cases (34%). Among the 89 patients, slip down was the most common cause of injury, affecting 65 patients (73%). As for the second most common cause of injury, DRFs were caused by a fall from height and a motor vehicle accident in 12 patients (13%) each. Among the patients, the most frequent fracture type was 2R3C3 (44 patients, 49%), followed by 2R3C1 (25 patients, 28%) and 2R3C2 (20 patients, 22%). Distal radius articular gap and step-off were measured using computed tomography (CT) coronal view images.⁵⁾ The average length of the distal radius articular gap and step-off were 3.7 mm and 1.7 mm, respectively. A total of 72 fractures (81%) involved fractures of the ulna bone. Regarding the ulna fractures, the most frequent fracture type was 2U3A1 (65 patients, 90% of ulna fractures), followed by 2U3A1 (7 patients, 10% of ulna fractures). The length of the fracture from the radiocarpal joint to the diaphysis was measured by checking the posterior-anterior view of x-ray (Fig. 2). The average length of the fracture was 41.1 mm. The average duration of the operation was 30.5 minutes (Table 1).

Fig. 1. Flow diagram of results after inclusion and exclusion criteria applied in this study. A total of 89 patients were included.

Fig. 2. Fracture length measurement. The length of the fracture from the radiocarpal joint to the diaphysis was measured by checking the posterior-anterior view of x-ray.

Table 1. Patient Clinical and Demographic Data.

Variable			Value
Age (yr)			63 ± 20
Sex (male : female)			26 : 63 (29 : 71)
Fracture site dominant (right : left)			30 : 59 (34 : 66)
Mechanism of injury
	Fall down		12 (13)
	Motor vehicle accident		12 (13)
	Slip down		65 (74)
Type of fracture
	AO fracture classification (distal radius)
		2R3C1	25 (28)
		2R3C2	20 (22)
		2R3C3	44 (50)
	Distal radius articular fracture gap (mm)		3.7 ± 1.3
	Distal radius articular step off (mm)		1.7 ± 1.3
	Associated ulnar fracture		72 (81)
	AO fracture classification (distal ulna)
		2U3A1	65 (90)
		2U3A2	7 (10)
Length of fracture (mm)*			41.1 ± 15.8
Operation time (min)			30.5 ± 14.7

Values are presented as mean ± standard deviation or number (%).

^*The length of the fracture from the radio-carpal joint to the diaphysis was measured by checking the posterior-anterior view of x-ray.

Surgical Technique

We performed the procedure under general anesthesia. Then we made a longitudinal incision on the radio-volar aspect of the distal forearm by modified volar Henry approach. The length of the incision was determined based on the distance of the fracture from the radiocarpal joint to the diaphysis. To ensure stability, a minimum of 4 screws were inserted into the intact diaphysis, allowing for the fixation of 8 cortices. The plate length was determined to be long enough accordingly to avoid placing screws in the fracture site. This ensured that the screws could be inserted into more stable areas, providing adequate fixation for the fracture, and incisions were made to accommodate the insertion of the plate. The fracture site was exposed and reduced under direct visualization and fluoroscopic guidance with traction. If needed, diaphyseal fragments were fixed to the bone shaft using interfragmentary screws. To prevent injury of the flexor pollicis longus tendon, the plate was bent to make it flatter before use if excessive protrusion of the distal part of the plate was expected. The position of the plate was adjusted during the insertion of the cortical screw using the oblong hole, and the distal part of the plate did not cross the watershed line. After inserting an adequate number of screws into the shaft hole of the plate, a locking screw was inserted into the distal part of the plate. This locking screw serves as a buttress to provide support for articular fractures. One case each for the plates has been summarized in Figs. 3 and 4.

Fig. 3. A 77-year-old female patient presented to the hospital after slipping and sustaining a left distal radius fracture. (A, B) X-ray images taken immediately after the injury revealed the distal radius fracture extending into the diaphysis. (C, D) A computed tomography scan showed complete intra-articular fracture with the fracture line extending into the diaphysis. (E, F) Internal fixation was performed using a 2.4-mm Variable Angle LCP Two-Column Volar Distal Radius Plate. (G, H) X-ray images at the final examination showed complete bone union. (I) At the final follow-up, the patient exhibited good functional recovery.

Fig. 4. A 57-year-old female patient presented to the hospital after slipping in house and sustaining a left distal radius fracture. (A, B) X-ray images taken immediately after the injury revealed the distal radius fracture extending into the diaphysis. (C, D) A computed tomography scan showed complete intra-articular fracture with the fracture line extending into the diaphysis. (E, F) As other plates were too short to provide sufficient stability, internal fixation was performed using a APTUS Wrist Distal Radius Plates XL 2.5. (G, H) Although there was no discomfort, plate removal was performed at the request of the patient due to resistance to the plate. X-ray images at the final examination showed complete bone union. (I) At the final follow-up, the patient exhibited good functional recovery.

Postoperatively, the wrist was immobilized in a short arm splint for 1 week. Finger range of motion was immediately permitted after surgery, while wrist immobilization was maintained. From the second week after surgery, it was replaced with a removable thermoplastic short arm splint. X-ray imaging was performed at 1, 2, and 4 weeks. At the fourth to fifth week after surgery, a full range of motion of the wrist was permitted without any immobilization.

Outcome Measurement

The reduction alignment outcomes were assessed based on several measurements, including volar tilt (in degrees), radial height (in millimeters), radial tilt (in degrees), and ulnar variance (in millimeters). These measurements were taken at 3 points: preoperatively, postoperatively, and at the final outpatient follow-up. The radiologic outcome was analyzed using x-ray: the fracture distance was measured from the radiocarpal joint to the diaphysis in lateral x-ray, and the bony union period was determined. The functional outcomes were assessed during the final follow-up period. Various measurements were taken to evaluate the wrist range of motion (including ulnar deviation, radial deviation, flexion, and extension), as well as the Disabilities of the Arm, Shoulder, and Hand (DASH) score and Modified Mayo Wrist Score (MMWS). Additionally, complications such as soft-tissue problems, wound infection, hardware failure, nonunion, malunion, and delayed union were investigated.

Indication of Plate Selection According to Fracture Length

According to the AO principle for internal fixation of forearm bone shaft fractures, screws are typically inserted to fix at least 6 cortical bones.⁶⁾ If the fracture line was too long and the Variable Angle LCP Two-Column Volar Distal Radius Plate (VA-DRP; Depuy-Synthes) could not sufficiently insert screws to secure 6 or more cortices to the diaphysis without fracture, an extra-long plate was selected. In this study, 2 types of plates were used in surgery. The 2.4-mm VA-DRP, which is commonly used in DRF where fracture lines are limited to the articular side and metaphysis, has up to 5 shaft holes and is 77 mm in length. If the fracture line was not long enough, stable fixation was possible with the above plate. When the fracture line was too long and VA-DRP was too short to provide sufficient stability, we used a longer plate, which has 12 shaft holes and is 102 mm in length (APTUS Wrist Distal Radius Plates XL 2.5 [DRP-XL]; Medartis). We finally examined the plate used and the average fracture length to provide indication of the appropriate plate according to fracture length.

Statistical Analysis

We performed repeated measures paired t-test to determine the differences in reduction alignment outcome between the postoperative and final follow-up values. We also performed Student t-test to determine the differences between the types of plates. The data were analyzed using SPSS version 27.0 statistical software package (IBM Corp.). A p-value < 0.05 was considered statistically significant.

RESULTS

Postoperative radiographic parameters showed a statistically significant recovery to the normal range, and the same trend was maintained at the final follow-up. At the final follow-up, the mean volar tilt, radial height, radial inclination, and ulnar variance were 5.7°, 10.9 mm, 22.8°, and 0.6 mm, respectively. There was a statistically significant difference in ulnar variance (0.0 mm vs. 0.6 mm, p = 0.001). However, the average difference in values was merely 0.6 mm, which is not considered clinically significant (Table 2). Bone union was confirmed at an average of 2.6 months after surgery. At the last follow-up, satisfactory functional outcomes were achieved, as evidenced by the measurements of range of motion, DASH, and MMWS (Table 3). Postoperative wound infection was observed in 3 patients (3.4%) The infection was successfully treated with oral antibiotics, eliminating the need for further surgical intervention. Delayed union occurred in 1 patient, who finally achieved union at 10 months after surgery (Table 3). Consistent with the study’s initial assumption, satisfactory bone union and functional results were achieved using only a volar locking plate. When comparing the 2 types of plates, there were 71 cases (80%) with VA-DRP and 18 cases (20%) with DRP-XL. The mean fracture length for VA-DRP was 35 mm, while for DRP-XL, it was 62 mm. Similarly, the mean number of plate shaft holes for VA-DRP was 4.7, whereas for DRP-XL, it was 10.3. As initially assumed in the study, there was a significant difference in fracture length between the 2 plates (p < 0.001) (Table 4).

Table 2. Reduction Alignment Outcome.

	Postoperative	Final follow-up	p-value
Volar tilt (°)	4.9 ± 5.5	5.7 ± 5.3	0.069
Radial height (mm)	11.0 ± 2.7	10.9 ± 2.7	0.485
Radial inclination (°)	23.1 ± 5.1	22.8 ± 4.8	0.832
Ulnar variance (mm)	0.0 ± 2.9	0.6 ± 2.8	0.001

Values are presented as mean ± standard deviation.

Table 3. Functional Outcome and Complication at Final Follow-up.

		Value
Range of motion (°)
	Ulnar deviation	25.1 ± 9.3
	Radial deviation	16.7 ± 8.5
	Flexion	53.7 ± 20.3
	Extension	63.8 ± 16.3
Score
	DASH	12.0 ± 15.0
	MMWS	83.6 ± 14.4
Case
	Wound infection	3
	Delayed union	1

Values are presented as mean ± standard deviation. Bone union was confirmed at an average of 2.6 ± 5.9 months after surgery.

DASH: Disabilities of the Arm, Shoulder, and Hand, MMWS: Modified Mayo Wrist Score.

Table 4. Indication of Plate Selection According to Fracture Length.

	VA-DRP (n = 71, 80%)	DRP-XL (n = 18, 20%)	p-value
Mean fracture length (mm)	35 ± 11	62 ± 14	< 0.001
Mean plate shaft hole number	4.7 ± 0.7	12 ± 0	< 0.001
Min fracture length (mm)	13	41
Max fracture length (mm)	63	89
Min plate shaft hole number	4	12
Max plate shaft hole number	5	12

Values are presented as mean ± standard deviation.

VA-DRP: Variable Angle LCP Two-Column Volar Distal Radius Plate, DRP-XL: Distal Radius Plates XL.

DISCUSSION

DRF with complete articular fracture and extension into the diaphysis are relatively rare and present challenges due to their long length and frequently accompanying comminution. The main goal of treatment is to achieve stability for both the joint and the diaphysis. By successfully reducing the fracture and ensuring satisfactory stability, favorable outcomes can be obtained. To achieve favorable outcomes, the selection of an appropriately sized plate is crucial. In the literature, the optimal fixation method for radial shaft fractures has been described as using a 3.5-mm plate and screws that engage 5 or 6 cortices proximal and distal to the fracture ends.⁷,⁸⁾ However, in this study, it was necessary to simultaneously fix both the articular and diaphyseal sides using a single plate. The screws used were 2.4 to 2.5 mm in size, smaller than the recommendations in previous literature. Despite the smaller size, sufficient stability was achieved as a sufficient number of screws were inserted into the diaphyseal side, and the smaller screws allowed for precise fixation of the small fragments on the articular side. DRF with diaphyseal extension is still a challenging injury, and the standard treatment for fixation has not yet been established. Managing this fracture pattern presents challenges due to differing mechanical considerations. In contrast, articular fractures may require thin, low-profile plates, and diaphyseal fractures benefit from long rigid plates, allowing compression across cortical interferences and maintaining axial length that permits range of motion. Using a thin plate in the distal radius area so that the plate does not protrude beyond the volar rim is important in preventing flexor tendon rupture as a postoperative complication.⁹⁾ However, the rigid plate suitable for diaphyseal fracture has the problem of being too thick in the distal area, making it difficult to contour, and not being suitable for fixing the small articular fragment.¹⁰⁾ Periarticular plates may not be effective for managing proximal comminution.¹¹⁾ So far, little research has been conducted on this fracture pattern, the types of implants chosen are diverse, and the number of cases analyzed is only around 20 at most.¹⁰,¹¹,¹²⁾

In a report published in 2005, a bridging plate type fixation to the third metacarpal bone to diaphysis of the radius using a distraction plate was introduced.¹¹⁾ However, performing wrist range of motion with this type of fixation is challenging due to the inability to initiate an early range of motion and the necessity for plate removal surgery. Furthermore, due to the use of a dorsal approach in this fixation method, there is a risk of irritation or tenosynovitis of the extensor tendons.¹³⁾

Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique is widely used for comminuted fracture of diaphysis, and there have been studies trying the same method in 9 cases of DRF with diaphysis.¹⁴⁾ While the MIPPO technique offers biological advantages for bone healing and minimizes damage to soft tissues, it is important to note that due to the nature of MIPPO, the procedure exposes patients to a longer duration of radiation. Furthermore, the time required for fracture reduction may be prolonged with this technique. Moreover, in MIPPO, the surgeon’s experience plays a crucial role, as the failure of achieving anatomic reduction can lead to surgical failure.¹⁵⁾ In the current study, we found that using an open reduction technique for DRF offers several advantages compared to MIPPO. Firstly, the shorter average operation time of approximately 30 minutes reduces tourniquet application time, thereby minimizing adverse effects such as infection. Additionally, the open reduction technique is considered easier for fracture reduction, and it has been widely utilized by many surgeons over a long period, providing a sense of familiarity and experience. Thirdly, despite open reduction, the consistent attainment of bony union in all cases implies that the biological disadvantage is not notably significant when compared to MIPPO. These factors contribute to the advantages of the open reduction technique in managing DRF. Nevertheless, considering the factors mentioned above, MIPPO is deemed a viable option, particularly in cases of severe skin damage, when cosmetic considerations are crucial¹⁶⁾ and the surgeon possesses ample experience.

Based on our review of past literature, we could not find any research on the type and length of plates for internal fixation in cases of DRF with complete intra-articular involvement and diaphyseal Extension. When using VA-DRP commonly employed in DRFs, there may be limitations in terms of plate length, and these plates may not provide enough stability when the fracture line extends long into the diaphysis. Based on the analysis conducted in this study, it was found that the VA-DRP could achieve bone union up to a maximum fracture length of 63 mm. However, considering that when using the VA-DRP, the average fracture length was 35 mm, and with the use of DRP-XL, it was 62mm, we recommend to prepare an extra-long plate instrument set, such as the DRP-XL when the fracture length exceeds 60 mm.

The strength of this study lies in its relatively larger sample size compared to previous studies. Additionally, by providing points for selecting appropriate plate lengths based on fracture length, this study offers clear guidance to surgeons. However, there are some limitations to this study. Firstly, it lacks a comparison with other fixation methods. Additionally, being a retrospective study, it is susceptible to inherent limitations such as potential bias and incomplete data.

Treatment of fracture of the distal radius involving the intra-articular portion and extending to diaphysis is yet challenging but our study showed satisfactory radiographic and clinical outcome with the use of a volar locking plate. Stable fixation was achieved on both the articular side and diaphyseal side in DRF with complete intra-articular involvement and diaphyseal extension using a distal radius volar plate. By analyzing 89 cases, sufficient evidence was obtained compared to past literature. In conclusion, as supported by past literature, it is recommended to choose a plate that can effectively secure at least 6 cortical bones in the diaphysis. This necessitates selecting a plate based on the length of the fracture. If the fracture length is too long, it may not be feasible to insert enough screws to secure 6 cortical bones in the diaphysis with a short plate. In such cases, if the fracture length exceeds 60 mm, we recommend preparing an extra-long plate instrument set in advance before surgery. Therefore, the key consideration is not merely the length of the plate but ensuring that the plate length is adequate to accommodate the insertion of sufficient screws.