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. 2019;39(2):55–61.

Variable-Angle Locking Compression Plate Fixation of Distal Radius Volar Rim Fractures

Mengcun Chen 1, Daniel J Gittings 2, Shuhua Yang 1, Guohui Liu 1, Tian Xia 1
PMCID: PMC7047294  PMID: 32577108

Abstract

Background:

To compare functional and radiographic outcomes of radius fractures distal to the watershed line treated with variable-angle volar rim locking compression plates (VA-LCP) with traditional fixed-angle volar rim locking compression plates (FA-LCP).

Methods:

A retrospective review of patients who underwent open reduction and internal fixation (ORIF) using either VA-LCP (19 wrists) or traditional fixation with FA-LCP (28 wrists). The average follow-up period was 14.5 months (range 11-16 months) for the VA-LCP group and 15.8 months (range 12-18 months) for the FA-LCP group. Clinical outcomes were evaluated using the Modified Mayo wrist score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, wrist range of motion (ROM) and grip strength relative to the uninjured side, and signs of flexor tendon irritation. Radiographic evaluation included radial height, radial inclination, volar tilt, and volar tear drop angle. All outcomes were assessed at 3, 6, and 12 months postoperatively.

Results:

MMWS and DASH scores improved with time postoperatively in both groups. Relative ROM was improved in VA-LCP compared to the FA-LCP at 12 months. VA-LCP was associated with a decreased incidence of flexor tendon irritation compared to FA-LCP. VA-LCP also better held the volar tilt reduction compared the FA-LCP.

Conclusion:

VA-LCP shows improved clinical and radiographic outcomes throughout the follow up period when compared to traditional fixation. VA-LCP may be an effective alternative to traditional fixation methods to treat radius fractures distal to the watershed line.

Keywords: distal radius fracture, volar rim plate, wrist surgery, treatment outcomes

Introduction

The application of a volar buttress plate in open reduction and internal fixation (ORIF) for distal radius fractures provides both construct stability and recovery of wrist function.1 A subset of distal radius fractures may propagate distal to the watershed line and involve the volar rim. These fractures have challenged current indications for fixed-angle plates.2 The most distal end of the radius is relatively flat with a volarly sloped lip that forms the lunate facet. The geometry of the lunate facet causes it to be inadequately supported by conventional fixation techniques, which may result in a loss of reduction. Sufficient stabilization by buttressing this fragment requires placement of conventional volar locked plates distal to the watershed region. This far distal fixation strategy leads to plate prominence that may cause flexor tendon irritation. Furthermore, positioning these fixed angle devices far distally may also lead to inadvertent wrist joint penetration by distally directed screws.3

Various methods and techniques have been applied to stabilize these fractures such as tension band wires, distal buttress plates, and external fixators.4-6 However, there is no consensus on the optimal fixation strategy.7,8 A variable-angle volar rim locking compression plate system (VA-LCP; Depuy-Synthes, West Chester, PA) was designed to be placed distal to the watershed line with a low profile contour to prevent flexor tendon irritation. The VA-LCP system also has 15° off axis variable angle screws that may assist in avoiding penetrating the wrist joint. Furthermore, VA-LCP has distal radial and ulnar “teardrop” holes that may be used to augment fixation of the radial styloid, lunate facet, and distal radial-ulnar joint (Figure 1). However, there is a paucity of literature examining the outcomes using VA-LCP fixation for distal radius fractures involving the volar rim. The purpose of this study is to compare functional and radiographic outcomes of VA-LCP to traditional fixation strategies with fixed angle volar locking compression plates (FA-LCP).

Figure 1.

Figure 1

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Variable angle locking compression plate for fragment-specific fracture fixation of fractures distal to the watershed line of the radius. (a) The pre-contoured variable angle volar rim plate (VA-LCP); (b) A 2.4 mm cortex screw and two 2.4 mm variable angle screws; (c) Low profile of the plate with holes allow up to 15° off-axis screw angulation in all directions.

Methods

We conducted a retrospective review of a consecutive series of patients with an intra-articular distal radius fracture that extended distal to the volar rim who underwent ORIF with a VA-LCP or FA-LCP system at a single institution between January and October 2015. Institutional review board approval was obtained for this study. All patients during this period had preoperative radiographs and computed tomography (CT) imaging of the wrist joint. Patients were included if their fracture pattern was an Orthopaedic Trauma Association (OTA) Type-B3 or Type-C fracture, which were distal radius fractures that extended distal to the watershed region. Patients were excluded from the study if they were less than eighteen years old, had an open fracture, or had all fracture fragments smaller than three millimeters (mm) in size. Forty-seven patients were identified who met these criteria including 19 patients (19 wrists) who underwent ORIF with VA-LCP and 28 patients (28 wrists) with FA-LCP.

All patients underwent an extended volar approach of the distal radius to enable adequate visualization of the cortical rim of the distal radius.9 Distal fracture fragments were reconstructed using the volar cortical bone of the middle column of the distal radius as a point of reference. Kirschner wires (K-wires) were utilized for provisional fixation to hold the reduction. In the FA-LCP group, a conventional volar locking plate was positioned as far distally to stabilize the VMF. Auxiliary K-wires were added to augment fixation if stability was inadequate. In the VA-LCP group, a 2.4 mm VA-LCP low profile plating system was positioned straddling the watershed line, and held preliminarily in place with a K-wire in the distal end of the plate. The distal variable angle screws were placed as a “row of nails” to raft and support the articular surface. Additional variable angle locking screws were placed in the radial and ulnar distal “teardrop” holes to augment fixation (Figure 2). After fixation in both groups, the reduction and hardware position were checked with fluoroscopy. Stability was assessed with passive wrist range of motion (ROM) and stress examination by loading the lunate facet. Patients in the FA-LCP group were immobilized with a plaster splint for six weeks before initiating rehabilitation. Patients in VA-LCP group wore a wrist brace for one week and then started gradual rehabilitation thereafter.

Figure 2.

Figure 2

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Radiograph obtained pre-operatively and two days postoperatively in a 49-year-old woman who had undergone ORIF using a VA-LCP. (a) Pre-operative images demonstrate an intra-articular distal volar marginal rim fracture with extension into the dorsal surface; (b) Postoperative images after ORIF with VA-LCP.

All the patients were routinely evaluated during the first month after surgery. Patients were also assessed at three, six, and twelve months postoperatively with functional outcome measures and radiographic imaging. Patient reported functional outcomes were assessed using the modified Mayo wrist score (MMWS) and the disabilities of the arm, shoulder and hand (DASH) score.10,11 Wrist ROM and grip strength were recorded as a percentage of the contralateral extremity’s function.12 Postoperative complications including numbness, pain, and discomfort during ROM or grip strength evaluation were also noted. Tendon irritation was defined as swelling or palpable crepitus during thumb and finger flexion and extension. Anterior-posterior and lateral wrist radiographs were used to assess interval healing and maintenance of reduction. Postoperative CTs were obtained when necessary based upon surgeon preference. Radiographs were reviewed by independent radiologists to measure radial inclination and height, volar tilt angle, and volar teardrop angle using previously described methods.13,14 Statistical analysis was performed using SPSS version 18.1. Student t-test and chi-square test were used for data analysis. Statistical significance was set at p=0.05.

Results

In the VA-LCP group, there were 19 patients (4 male, 15 female) with an average age of 52.9 years (range 42-65 years). The patients’ dominant wrists were involved in 47.4% (9/19) of the injuries. Average time between injury and surgery was 2.8 days (range 2-5 days). The average postoperative follow-up period was 14.5 months (range 11–16 months). In the FA-LCP group, there were 28 patients (6 male, 22 female) with an average age of 53.5 years (range 39-66 years). 42.9% (12/28) of the injuries involved the patient’s dominant wrist. Average time between injury and surgery was 2.9 days (range 2-5 days). The average postoperative follow-up period was 15.8 months (range 12–18 months) (Table 1).

Table 1.

Comparison of Patient Demographics Between Both Groups

Number of Patients Gender(Male/Female) Age(year) Dominant injured hand Time and between surgery(injury day)
VA-LCP 19 4M / 15F 52.9 (42-65) 9 2.8 (2-5)
FA-LCP 28 6M / 22F 53.5 (39-66) 12 2.9 (2-5)
p value - 0.77 0.74 0.73 0.89
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The results of MMWS and DASH scores throughout follow up are summarized in Table 2. The mean MMWS and DASH improved in both groups throughout follow up. All patients obtained a satisfactory outcome. The VA-LCP group had significantly improved MMWS and DASH scores throughout follow up compared to the FA-LCP group. At three months follow up, the VA-LCP MMWS and DASH were 76.3±5.7 and 24.4±2.1 respectively. The FA-LCP group had an MMWS of 67.4±5.3 and DASH of 31.7±2.9. The differences between these two groups at early follow up were significant (p = 0.02 for MMWS and p = 0.04 for DASH). Furthermore, the VA-LCP group continued to have significantly improved MMWS and DASH outcomes a latest follow up evaluation at 12 months with MMWS 93.8±4.8 and DASH 9.2±1.0 compared to FA-LCP with MMWS 83.5±3.8 and DASH 12.8±1.6 (p < 0.01 for MMWS and p = 0.02 for DASH).

Table 2.

MMWS and DASH Functional Outcome Scores Over the 12 Month Follow Up Visit

3 Months 6 Months 12 Months
MMWS DASH MMWS DASH MMWS DASH
VA-LCP 76.3(70-85) 24.4(20-28) 93.3(80-100) 10.5(2-14) 93.8(85-100) 9.2(2-12)
FA-LCP 67.4(60-75) 31.7(25-34) 80.6(70-90) 14.1(8-20) 83.5(75-90) 12.8(6-18)
p value 0.02 0.04 <0.01 0.03 <0.01 0.02
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ROM showed recovery of 94.8% of flexion-extension and 93.8% of supination-pronation movements as compared to the contralateral side in the VA-LCP group at 12 months follow up (Figure 3). In contrast, the FA-LCP group recovered 82.8% of flexion-extension and of 84.5% supination-pronation movements compared to the contralateral side at 12 months follow up. This difference in ROM was significantly different (p<0.01). Grip strength as relative to the contralateral side at 3 months follow up was 78.8% for the VA-LCP group and 75.7% for the FA-LCP group (p =0.03). At 12 months follow up percent grip strength was not different between groups (91.3% VA-LCP, 92.3% FA-LCP) (Figure 4). There was no soft tissue necrosis, infection, nerve palsy, vascular occlusion, or compartment syndrome observed in all patients. Two patients (2/19, 10.5%) in the VA-LCP group displayed flexor tendon irritation, but one of the two patients had their symptoms resolve within five days after their operation. Another patient complained of mild irritation while forcefully gripping, but their symptoms were not severe enough for the patient to elect to undergo removal of hardware. In the FA-LCP group, six patients (6/28, 21.4%) suffered from intermittent or persistent flexor tendon irritation. Two of these patients elected to undergo removal of hardware secondary to their symptoms. The incidence of flexor tendon irritation between the two groups was statistically significant (p=0.02).

Figure 3.

Figure 3

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Clinical photographs demonstrating ROM of the 49-year-old female patient (Figure 2) at thirteen months postoperatively. Relative wrist flexion-extension (a) and supination-pronation (b) motion were near 100% compared with the contralateral side. (c) Incision demonstrating the successful treatment of her right-sided injury.

Figure 4.

Figure 4

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Relative range of motion and grip strength throughout the 12 month follow up period. (a) Relative flexion-extension ROM (b) Relative supination-pronation ROM (c) Relative grip strength. *p<0.05 when comparing between the two groups.

Radiographic results showed a loss of reduction over the follow up period with decreases in radial inclination, radial height, and volar tilt in both groups between initial postoperative radiographs and 12 month follow up. There was a significant difference in volar tilt lost between the VA-LCP and FA-LCP groups at 3(p=0.01), 6(p=0.03) and 12 month(p=0.02) follow up visits. The initial volar tilt measured postoperatively was 10.05 degrees and 9.86 degrees in the VA-LCP and FA-LCP groups respectively. The latest follow up volar tilt was 8.37 degrees and 7.11 degrees in the VA-LCP and FA-LCP groups respectively (p=0.02). There was no difference in radial height, radial inclination, and volar tear drop angles detected between groups at all time points (Figure 5).

Figure 5.

Figure 5

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Postoperative radiographic measurements of radial height, radial inclination, volar tilt, and volar tear drop angle throughout the 12 month follow up period; *p<0.05 when comparing between the two groups.

Discussion

Intra-articular distal radius fractures that involve the volar rim are challenging to manage. In these cases, it is paramount to restore the lunate facet as it is indispensable to maintain length, alignment, and stability of the wrist joint. Failure to stabilize the lunate facet may lead to carpal subluxation or dislocation.7,15 A volar marginal fragment (VMF) may be either too small or too distal to the watershed line to be adequately supported with traditional fixation strategies.2 Although conventional volar locked plates may provide a stable reduction,16,17 the geometry of the lunate facet poses exceptional challenges. In order to support the entire volar surface effectively using conventional locked plates, the plate must be placed distal to the watershed line, which may lead to tendon irritation and intra-articular screw penetration.18-20 Furthermore, loss of fixation of the lunate facet may still occur. Harness et al. reported loss of fixation of a volar lunate facet fragment with carpal dislocation in a series of seven patients with an average of 24-months of follow-up.15 The VA-LCP low profile plating system was designed to be placed distal to the watershed line with an anatomically pre-contoured geometry that allows supplemental fixation into the lunate facet. Thus, the purpose of this study is to compare outcomes of VA-LCP to traditional fixation strategies with FA-LCP.

This study has several limitations. First, we recognize the limitations of our retrospective review. We had a limited number of patients with a relatively short follow-up period that may not capture long term outcomes including development of post traumatic osteoarthritis and flexor tendon rupture. Second, our differences in DASH scores throughout the follow up period, although statistically significant, were relatively small (<10 points). Previous studies have determined the threshold for minimal clinically important difference in DASH scores to be greater than 10 points.21 Furthermore, although there was a significant decrease of volar tilt in the FA-LCP group than the VA-LCP group, the volar tilt in both groups were within range of acceptable alignment. However, other functional assessments, including flexor tendon irritation and need for secondary surgery to remove hardware, were significantly greater in FA-LCP. This higher incidence of re-operation in the FA-LCP group compared to the VA-LCP group is clinically significant. Orbay et al. emphasized that salvage procedures may lead to further impaired functional outcomes in this patient population.2 Thus, the results of this study in aggregate demonstrate a meaningful clinical difference between VA-LCP and FA-LCP.

This study shows differences in functional outcomes between VA-LCP and FA-LCP. MMWS and DASH were improved at all time points in the VA-LCP compared to FA-LCP group. As discussed in the limitations section, although these results were statistically significant, the clinical significance of this difference is less apparent. When assessing the relative wrist ROM, the VA-LCP had better recovery compared to FA-LCP. This difference in relative wrist ROM may contribute to the difference in MMWS.22 However, the difference in relative wrist ROM may be confounded by different postoperative immobilization protocols. The FA-LCP group was immobilized for a longer period of time (six weeks for FA-LCP versus one week for VA-LCP) because there was concern the fixation construct was less stable than that used for VA-LCP. This increased period of immobilization and delayed rehabilitation may have introduced a lag time bias. Longer follow up is needed to whether FA-LCP patients will recover more ROM to catch up to the VA-LCP group.

Relative grip strength was also improved in VA-LCP compared to FA-LCP at early follow up at three months. Again, this difference may have been related to the longer immobilization protocol and delayed rehabilitation in FA-LCP. Interestingly, the FA-LCP group recovered grip strength more rapidly after three months and we were unable to detect a difference in grip strength between both groups at 12 month follow up. However, there was an apparent difference in flexor tendon irritation between both groups. The FA-LCP group had a high incidence of flexor tendon irritation (21.4% FA-LCP versus 10.5% VA-LCP) and a re-operation rate for removal of hard ware (7.1% FA-LCP versus 0% VA-LCP). In the FA-LCP group, the conventional plate had to be positioned distal to the watershed line in order to adequately stabilize the lunate facet, which may have contributed to flexor tendon irritation. Furthermore, the supplemental K-wires used for fixation may have also injured the tendons. A cadaveric study by Chia et al, found that volar radial styloid, transverse radial, and dorso-ulnar K-wires may penetrate both tendons and nerves about the wrist.23 Although VA-LCP also straddled the watershed line, the low profile anatomically contoured design with highly polished cambered surface may have contributed to a lower incidence of flexor tendon irritation. Other studies describing various techniques using fragment-specific fixation, such as volar hook plates, found satisfactory outcomes in their series.2,8,16 However, O’Shaughnessy et al. reported 20% (5/25) of patients with an average follow up of nine months required removal of hardware secondary to flexor tendon irritation.8 This reported incidence is higher than what we observed with VA-LCP (0%, 0/19, average 15.8 months follow up). These results suggest that the design of the VA-LCP system may be successful at reducing tendon irritation at midterm follow up.

In addition to differences in clinical outcomes, we observed differences in radiographic outcomes. Radial height, radial inclination, and volar tear drop angle were not found to be different between groups at all time points. There was a larger loss of volar tilt in FA-LCP group compared to VA-LCP. The differences in stability of fixation holding the reduction can be explained by prior studies. In the FA-LCP group, although K-wire augmentation has been reported to be effective to enhance stability of the reduction in volar rim fractures, they are biomechanically inferior to a volar buttress for these fragments.6 Thus additional immobilization periods after conventional fixation may be necessary to augment stability and prevent a greater loss of reduction. In contrast, the VA-LCP system firmly buttressed the volar rim with its additional options for fixation into the radial styloid, lunate facet, and distal radial-ulnar joint with variable angle screws in the radial and ulnar “tear drops” holes. However, the application of the VA-LCP device is not without limitations. Highly comminuted intra-articular fractures and extremely distal fractures that preclude capture with screws may not be well suited for VA-LCP. In these cases, external fixation may be the only salvage operation possible. Although there was difference of 1.3 degrees of volar tilt between groups, the clinical significance of this difference is likely minimal.

In conclusion, we report favorable clinical and radiographic results using the VA-LCP system compared to the FA-LCP. These results may be in part attributed to the VA-LCP system design with its low profile, anatomic contour, and multiple options for fixation that may decrease the incidence of joint penetration and improve lunate facet stability. Further research assessing the biomechanical properties of this system may further elucidate the mechanical properties of this plate and affect is has on the overlying flexor tendons. Furthermore, a long-term prospective study is needed to assess long term clinical and radiographic implications when using this device compared to conventional plates. Surgeons may consider the VA-LCP system as an alternative to conventional plates when treating radius fractures distal to the watershed region.

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