Radial Plate Fixation of Distal Radius Fracture

Abstract

Background: A radial incision with radial plate fixation for distal radius fracture has historically been avoided due to its risk to the superficial branch of the radial nerve (SBRN). With careful technique, it is possible to avoid injury to the SBRN, thereby minimizing the soft tissue injury associated with other approaches. We compare subjective and objective functional outcomes of radial plate fixation surgeries that we performed with those of dorsal and volar plate fixation in current literature. Methods: Patients at a single center who underwent radial plate fixation for an AO type A or AO type B distal radius fracture between December 2006 and December 2014 were enrolled in the study. Postoperative grip strength and 3-digit pinch strength were measured systematically in the injured and uninjured wrists. Patients also completed a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire to assess subjective outcomes. Results: Thirty-six patients met our inclusion criteria and had available medical records. Postoperative grip strength in the injured wrist was significantly lowered—68% compared with the uninjured wrist. After subgroup analysis of dominant and nondominant wrist injuries, there was no significant difference in grip strength between injured and uninjured wrists. There was no significant decrease in postoperative 3-digit pinch strength in the injured wrist—89% compared with the uninjured wrist. The mean QuickDASH score for our study participants was 20.9. Conclusions: Radial plate fixation is an effective approach for distal radius fractures. Objective and subjective outcomes are noninferior to those of a dorsal or volar approach.

Introduction

Distal radius fracture accounts for approximately one-sixth of all fractures presenting to the emergency department, is the most common fracture in patients in the below 18 years old and above 50 years old age groups in the United States, and is usually the result of a fall on an outstretched hand.^10,12,18 Several complications can arise with distal radial fracture, including malunion, neurovascular injury, infection, tendon complications, and growth arrest.¹⁹ Prompt treatment is necessary to prevent long-term morbidity affecting the function of the hand and wrist.^{7,9,15,17,21,30} Open reduction with internal fixation has been shown to be successful in treating displaced distal radius fractures, especially in cases where complete reduction may not be achieved by external fixation.^13,17 While operative intervention is sometimes necessary to correct the fracture, surgical manipulation of the surrounding soft tissue may cause additional trauma.^10,14

There are several incisional approaches to internal plate fixation. The distal radius can be accessed from the volar surface by an incision over the flexor carpi radialis.^10,13,14 A dorsal incision and dissection between the third and fourth extensor compartments can be used to access the distal radius with good intra-articular visualization.¹³ A radial incision requires less soft tissue dissection, decreasing the risk of operative injury to neurovascular supply and connective tissues.¹³ The radial approach does include an increased risk of injury to the superficial branch of the radial nerve (SBRN), with subsequent complications including symptomatic neuroma, complex regional pain syndrome, and tendon irritation.^3,8,27

With specific and meticulous surgical technique for approaching with a radial incision, it is possible to identify morphological variations of the SBRN and carefully isolate it from injury. In addition, a radial approach is beneficial because of its ease of surgical dissection, good visualization of 3 sides of the distal radius, and avoidance of direct contact with the flexor tendons of the fingers during surgery.²³

This study examined radial plating using the radial incision approach described by one fellowship-trained hand surgeon (M.P.-C.) as the sole intervention for distal radial fracture in an attempt to achieve similar or better outcomes than dorsal or volar incisions.²⁰

Materials and Methods

This was a single-center, institutional review board–approved, retrospective cohort study. All patients treated by the TTUHSC El Paso Orthopedics Department between December 2006 and December 2014 for distal radial fractures were considered for this study. Physician notes and radiographic imaging of these patients were reviewed to distinguish subjects based on type of fracture and location/plane of plating (dorsal, volar, or radial). Patients with an AO type A (extra-articular) or AO type B (partially articular) fracture who underwent radial plate fixation were included (Figure 1). Patients with an AO type C (completely articular) fracture were excluded (Figure 2), as radial fixation by itself would not have been an appropriate treatment modality. Patients were excluded if they had open fractures requiring additional hardware, including radial plating used in conjunction with external fixation. It is important to note that patients who had the procedure performed using radial hook-plates were included. These were necessary when the extreme distal site of the fractures does not have sufficient surface area for straight screw fixation.

Figure 1.

Anteroposterior and lateral view radiographs.

Figure 2.

AO classification of distal radius fracture.

Patient outcomes were evaluated at follow-up intervals using subjective and objective scoring methods. Postoperative grip and 3-finger pinch strength were evaluated systematically in the injured and noninjured wrists in the outpatient clinic. Patients were also asked to subjectively assess their postoperative function by filling out the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey. A component of the QuickDASH questionnaire asked patients to describe any postoperative pain as well as quantify how often the pain occurred and how severely the pain has affected their quality of life. Descriptors used to characterize the pain included numbness, burning, tingling, aching, dull, sharp, stabbing, cold, pressure, cramping, and so forth.² An unpaired t test was used to compare postoperative grip and pinch strengths in the injured and uninjured hands.

Surgical Technique

A radial midline incision is made beginning at the tip of the radial styloid process and continuing approximately 12 cm proximally. Continuation of the incision distally beyond the styloid process places the radial artery at risk of injury. Blunt dissection is then carried out to identify the SBRN in the subcutaneous tissue above the first dorsal extensor compartment. Occasionally, one may also identify the terminal branches of the lateral antebrachial cutaneous nerve in this region. The SBRN can present with one of 2 different patterns—Type I with 1 main nerve and Type II with 2 distinct nerves. The identification of these 2 patterns for the SBRN is observational data based on the primary surgeon’s experience with this radial approach; we have not found these patterns described within the literature.

The first dorsal extensor compartment is then opened dorsally, exposing the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). These tendons are then released from their compartment and retracted dorsally or palmarly, as necessary. Frequently, there is a separate compartment for the EPB, which needs to be released. Following retraction of the APL and EPB tendons, the terminal insertion of the brachioradialis (BR) tendon is exposed. At this level, the terminal 3 to 4 cm strip of the BR tendon can be excised or detached from the radius and later reattached prior to closure. By removing the terminal strip of this tendon, it facilitates a better exposure of the fracture and allows the implant to sit anatomically against the radius. In addition, as the BR is a deforming force in some displaced distal radius fractures, the excision of the terminal insertion may aid in fracture reduction. Volarly, the pronator quadratus (PQ) is released from its radial attachment exposing the distal volar surface of the radius. Release of the PQ allows the fracture reduction to be easily checked by evaluating the volar aspect of the distal radius.

Next is subperiosteal dissection of the radius to fully expose the fracture site. The radial shaft is commonly displaced in an ulnar direction; a bone clamp may be used to mobilize the shaft radially to the plate and thereby reducing the fracture and reestablishing the normal interosseous distance between the radius and ulna. One or two 0.045 Kirschner wires can be placed through the radial styloid to maintain the reduction while the plate is applied. It is important to avoid placing the wires where they may interfere with the position of the radial plate.

The plate should be positioned approximately 1.0 cm proximal to the tip of the radial styloid process and directly along the midline axis of the radial styloid process. In some cases, an intracompartmental septum has to be removed to place the plate in the correct position. In addition, the metaphyseal flare of the radius can be used to match the corresponding bend on the plate and help with plate positioning. Another Kirschner wire is now inserted in the most distal hole of the plate to check the proposed position of the most distal screw. The plate and distal screw positions are checked radiographically in the anteroposterior, lateral, and oblique positions. If their positions are satisfactory, the distal Kirschner wire can be replaced with the first screw, and the remaining screws can be inserted.

Final radiographs may be obtained at this point to check the reduction and fixation. Repair of the PQ muscle can usually be carried out by anchoring the muscle to one of the empty screw holes on the plate. The BR can be reattached using empty screw holes on the radial plate as with the pronator muscle. The skin is then closed with care not to cause injury to the SBRN. We typically close the skin without a subcutaneous stitch to reduce the risk of developing a symptomatic neuroma.

A sterile dressing with a volarly based plaster splint is applied to allow for early metacarpophalangeal joint motion. Finger range of motion exercises are encouraged immediately, aiding in reducing postoperative swelling and decreasing the risk of postoperative finger stiffness.²³

Results

Study Population

In total, 401 patients with distal radial fractures were identified. Sixty-three patients received at least a radial plate for treatment. Thirty-six patients were enrolled who met our inclusion criteria and had available records. The average age in our patient group was 53.86 years old, with a range from 19 to 78 years old. There were 12 males (33.3%) and 24 females (66.7%) in our study. Identification of the dominant wrist was documented in 23 cases; of these, 13 (56.5%) of our patients suffered injury to their dominant wrist. Follow-up varied widely, ranging from 24 days to 1351 days. Patient demographic information is shown in Table 1.

Table 1.

Patient Demographics.

Characteristic	Study cohort (n = 36)
Age, y
Average	53.8 ± 2.3
Range	19–78
Gender
Male	12 (33.3)
Female	24 (66.7)
Fracture characteristic, n (%)
AO type A	28 (78)
AO type B	8 (22)

Objective Outcomes

Table 2 shows the comparison between postoperative grip and pinch strengths in the injured and noninjured wrists. Postoperative grip strength in the injured wrist was 68% (P = .0008) of the grip strength in the noninjured wrist. Subgroup analysis showed postoperative grip strength in dominant wrist injuries was 88% (P = .3712) compared with the uninjured wrist, while postoperative grip strength in nondominant wrist injuries was 73% (P = .057) compared with the uninjured wrist. Postoperative pinch strength in the injured wrist was 89% (P = .1676) of the pinch strength in the noninjured wrist. Subgroup analysis showed postoperative pinch strength in dominant wrist injuries was 96% (P = .7575) compared with the uninjured wrist, while postoperative grip strength in nondominant wrist injuries was 91% (P = .3166) compared with the uninjured wrist. These measurements were taken at postoperative follow-up visits ranging from 24 days to 3 years and 9 months after surgery. There were 5 patients who did not have postoperative pinch strength data for either wrist in their medical records; in addition, there was 1 patient who did not have postoperative pinch strength data for the uninjured wrist in the medical record.

Table 2.

Strength (kg) Comparison Between Groups.

	Operative wrist	Uninjured wrist	Difference (%)	P value
Total
Grip	41.9 ± 4 (n = 36)	60.4 ± 3.4 (n = 36)	68	0.0008*
Pinch	13.5 ± 0.9 (n = 31)	15.1 ± 0.7 (n = 30)	89	0.1676
Dominant wrist injury (n = 13)
Grip	50.6 ± 5.9	57.2 ± 4.2	88	0.3712
Pinch	12.9 ± 1.5	13.5 ± 1.2	96	0.7575
Nondominant wrist injury (n = 10)
Grip	45.6 ± 7.0	62.2 ± 4.2	73	0.057
Pinch	15.2 ± 1.4	16.7 ± 0.4	91	0.3166

^*Statistically significant.

Subjective Outcome

Patients were asked to complete a QuickDASH questionnaire to assess the function of their injured wrist; results of the questionnaire are shown in Table 3 and Table 4. The mean QuickDASH score at the latest postoperative follow-up was 20.9. Subgroup analysis showed a mean QuickDASH score of 19.2 in patients with a dominant wrist injury and a mean QuickDASH score of 15.2 in patients with a nondominant wrist injury. These surveys were completed during postoperative follow-up visits ranging from 28 days to 3 years 9 months after surgery. There were 7 patients who did not have QuickDASH scores in their medical records.

Table 3.

QuickDASH Score.²

	Score
All subjects (n = 29)	20.9 ± 4.6	P value = .7093
Dominant wrist injury (n = 13)	19.2 ± 8.1
Nondominant wrist injury ( n = 10)	15.2 ± 6.3

Note. QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand.

Table 4.

QuickDASH Pain Assessment.²

	No impact	Minimal	Moderate	Severe
Number of patients (%)	8 (36.4)	6 (27.3)	3 (13.6)	5 (22.7)

Note. QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand.

We were able to access 22 QuickDASH questionnaires in which our patients had completed the postoperative pain assessment. Fourteen (63.7%) patients reported minimal to no impact on their quality of life, of which 4 patients reported no residual pain at all. Three (13.6%) patients reported moderate impact on their quality of life, and 5 (22.7%) patients reported a severe impact on their quality of life.

Discussion

Distal radius fractures are a common injury pattern affecting all age groups in the United States and abroad.¹⁸ Depending on the severity of the fracture, prompt surgical treatment may be needed to prevent long-term disability.¹⁹ Operative management strategies such as open reduction and internal fixation have been established to achieve successful functional and radiographical outcomes in patients with acute distal radius fracture.⁵ Traditionally, surgeons use either a dorsal or volar incision to access the injury and place the appropriate plate and screws to reduce and stabilize the bone fragments. While effective, these approaches do carry the risk of complications, such as tendon rupture, tendon irritation, carpal tunnel syndrome, and complex regional pain syndrome. A radial incision with radial plate fixation would allow the surgeon to avoid many of the structures commonly affected by dorsal and volar plate fixation.^23,29

We initially identified 63 patients who received radial plate fixation for treatment of distal radius fracture. Thirty-six patients were enrolled in our study. Ten of 27 patients who were not enrolled in our study were because they received additional fixation, and we were studying radial fixation as the sole treatment modality. The remaining 17 of 27 who were not enrolled were because they did not present to their follow-up appointments, or return clinic attempts to contact them. We hope that their lack of follow-up is due in part to satisfactory outcomes from the surgery.

In our patient cohort, we examined functional outcomes using subjective and objective measuring methods. We initially found a significant discrepancy in postoperative grip strength between the injured and noninjured hand. Upon subgroup analysis of dominant and nondominant wrist injuries, we found no significant discrepancy in postoperative grip strength between the injured and noninjured hand. In addition, there was no significant discrepancy in postoperative pinch strength between the injured and noninjured hand. Subjective outcomes as demonstrated by the QuickDASH were also similar between dominant and nondominant hand injuries.

Our outcomes were comparable to those published using dorsal and volar plate fixation. In studies examining grip strength, dorsal plate fixation has been able to achieve 78% to 90% strength compared with the uninjured wrist, while volar plate fixation has been able to achieve 75% to 94%.^{3,6,11,22,24-25,26,29} Fewer studies examined lateral pinch, but dorsal and volar plate fixation have been demonstrated to achieve 94% to 96% and 92% to 94% compared with the contralateral side, respectively.^6,11,26,29 Mean DASH scores at the latest postoperative follow-ups range from 6.3 to 19.3 for dorsal plate fixation and from 4 to 14 for volar plate fixation in recent literature.^{6,11,20,22,24-25,26,29} A summary of our literature review is included in Table 5. Our study results demonstrate that a radial approach to distal radius fracture can allow patients to achieve good postoperative functional outcomes similar to those seen in patients treated with a dorsal or volar approach.

Table 5.

Literature Review of Functional Outcomes and Complications Associated With Dorsal and Volar Plate Fixation.

Study	Level of evidence	Size, technique, follow-up	Functional results			Complications
			Grip strength (mean, SD)	Pinch strength (mean, SD)	DASH (mean, SD)
Disseldorp et al6	IV: retrospective review	Dorsal: 123 patients, average age 58.2 y, median 47-mo follow-up	90.30%,	96.30%	19.3	3/123 CRPS/dystrophy, 1/123 skin infection, 5/123 tendinitis, 3/123 tendon rupture, 2/123 neurologic problems, 1/123 other soft tissue problems, 4/123 hardware failure, 3/123 bone/fracture, 1/123 loss of reduction
		Volar: 91 patients, average age 57.2, median 50-mo follow-up	93.50%	92.20%	13.3	1/91 CRPS/dystrophy, 1/91 skin infection, 1/91 tendinitis, 1/91 tendon rupture, 5/91 neurologic problems, 1/91 other soft tissue problems, 1/91 hardware failure, 3/91 bone/fracture, 1/91 malunion
		Volar: 47 patients, average age 56, average follow-up 38 mo				1/47 failure of reduction, 4/47 hardware discomforts, 3/47 tendon irritation/ruptures, 4/47 neuropathy
Wei et al29	I: therapeutic trial	Volar: 12 patients, average age 61, 12-mo follow-up	75%	94%	4	2/12 transient neuropathy of median nerve
Rozental et al25	IV: retrospective review	Volar: 41 patients, average age 53, average follow-up 17 mo	94%		14	4/41 loss of reduction with fracture collapse, 3/41 tendon irritation, 1/41 wound dehiscence, 1/41 MCP joint stiffness
Kamath et al11	IV: retrospective review	Dorsal: 30 patients, average age 59, median follow-up 18 mo	78%	94%	15	1/30 loss of reduction, 1/30 tendon adhesion, 2/30 hardware loosening
Matzon et al20	IV: retrospective review	Dorsal: 110 patients, average age 54, average follow-up 28 mo			6.3	8/110 tenosynovitis, 3/110 pain, 4/110 stiffness, 1/110 supination contracture, 1/110 intra-articular malunion
Simic et al26	IV: retrospective review	Dorsal: 50 patients (51 fractures), average age 55, average follow-up 24 mo	90%	94%	11.9	1/10 pain
Chung et al4	II: prospective controlled trial	Volar: 55 patients, average age 47.6, 12-mo follow-up	78.60%			1/55 tendinitis, 1/55 cellulitis, 2/55 skin blisters, 1/55 suture abscess, 3/55 median nerve damage, 2/55 intersection syndrome, 1/55 scar adherence, 3/55 hematoma, 3/55 hardware loosening, 1/55 minimal collapse of fracture
Orbay et al22	IV: retrospective review	Volar: 23 patients (24 fractures), average age 82, average follow-up 63 wk	77%		8.28	1 transient regional pain syndrome
Rozental et al24	III: retrospective cohort study	Dorsal: 28 patients, average age 42, average follow-up 21 mo	94%		14.5	7/28 extensor tenosynovitis, 2/28 extensor tendon rupture

Note. DASH = Disabilities of the Arm, Shoulder and Hand; CRPS = complex regional pain syndrome; MCP = metacarpophalangeal.

Several patients reported persistent pain months after surgery in their QuickDASH surveys. Retrospective chart review did not find any official diagnosis of neuropathic pain, tendinitis, hardware-related pain, or infection. While our data on postoperative pain were limited to only a subset of our study population, we are optimistic that the majority of these patients experienced minimal to no impact on their quality of life from this procedure. It is unclear if this subset of patients accurately represents all 36 of our study population; however, we did not have any patients with major complications requiring reoperation or hardware removal. Based on our literature review, the most common complications associated with dorsal or volar plate fixation include tenosynovitis/tendinitis, tendon rupture, nerve lesion, and complex regional pain syndrome.^{6,16,20,30-32} Tendon injury is more likely due to dorsal plate fixation while neurovascular injury is more likely caused by volar plate fixation, but both types of injuries can occur with either surgical approach.^1,30 With the incidence of complications as high as 32% in dorsal plate fixation and 22% in volar plate fixation, a radial approach may be better in some cases to reduce soft tissue trauma and hardware-related problems.^11,24 While the QuickDASH scores from our subset of patients with available data do show a 22.7% of patients with severely impacting postoperative pain, our record review does not make clear if the pain is due to hardware issues, nerve or soft tissue injury, rehabilitation barriers, or the simply the impact from recovering from a wrist fracture independent of the type of hardware used. Future arms of this study will look to establish clear established diagnoses of postoperative complications and analyze complication rates of radial plate fixation compared with dorsal and volar plate fixation.

Our study focused on patients with AO types A and B fractures, while most published studies on dorsal or volar plating include AO type C fractures. We acknowledge that type C fractures are more complicated, and a radial approach may not sufficiently stabilize bone fragments without compromising the first carpometacarpal joint. Therefore, variations in outcomes may be attributed to variations in fracture type. In addition, different methods have been used across the literature to measure functional outcomes objectively and subjectively. With these limitations in mind, we compare our findings to current literature with caution and suggest future studies to verify our results.

Another limitation of our study was the amount of data missing from the medical record. This could be due to a combination of paper and electronic records, various personnel recording data, and patient loss to follow-up. It is very possible that paper records were not properly scanned in to the electronic record, and we are now unable to obtain them. As this study relies on previously collected data, any inconsistencies in data collection between health care personnel could have resulted in missing information. In addition, the population we serve at our hospital consists of patients from El Paso County, West Texas, New Mexico, and Ciudad Juarez, Mexico. Many of our patients are lost to follow-up, and it is possible that any postoperative complications were diagnosed and treated at other facilities.

The radial approach to distal radial fractures is a viable treatment option that could potentially decrease the complication rates associated with traditional dorsal or volar plate fixation. A radial incision with careful surgical technique would avoid extensive manipulation of soft tissues, decreasing the risk of serious complications requiring secondary surgery.^13,29 Level 1 and 2 studies are needed to compare functional outcomes, and complication rates between dorsal, volar, and radial plate fixation would be valuable in comparing these techniques for AO types A and B fractures.