Volar locking plate: Age related outcomes and complications

Abstract

Background

There is no unanimity for the treatment of distal radius fractures in older people. The purpose of our study is to assess the efficacy of volar locking plate for the treatment of unstable distal radius fractures in older independent individuals.

Methods

A retrospective comparative study of 105 patients. 58 patients were below the age of 55 years and 47 above the age of 55 years. Mean follow-up was 18.4 months in patients below the age of 55 years and 18.1 months above the age of 55 years. Wrist movements, complications, reoperations, grip strength, Visual Analogue Score (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (DASH) score, and Mayo wrist score were analysed.

Results

There was no statistical difference in the wrist movements, grip strength, complications, reoperations, VAS, QuickDASH and Mayo scores. Mean grip strength under 55 was 84.1 and above 55 was 84.5 (p = 0.87). The complication rate was 19.1% above 55 years of age and 17.2% below the age of 55years (p = 0.79). The reoperation rate above 55 years was 8.5% and below 55 years was 8.6% (p = 0.50). Mean VAS under 55 years of age was 1.6 and above 55 years was 1.7 (p = 0.58). Mean Mayo score in under 55 was 80.7 and 80.1 in above 55 (p = 0.78). Mean Quick DASH score under 55 was 20.9 and above 55 was 21.0 (p = 0.97).

Conclusion

Our results indicate that outcomes in older independent patients are satisfactory with a comparable complication and reoperation rate with younger individuals. We conclude that a volar locking plate is a favourable modality for the treatment of unstable distal radius fractures in older patients.

1. Introduction

It is estimated that about 71,000 people will sustain a distal radius fracture each year in the UK and 58,000 of these will occur in women.¹ Distal radius fractures are the most common upper limb fractures and the incidence is rising in older population.² The majority of the undisplaced and minimally displaced fractures are managed non-operatively with good results.³ The unstable distal radius fractures in older independent individuals can have significant impact on their life. The aim is to maintain their function, independence with a shorter rehabilitation and minimise disability.

There is a general agreement that better outcomes are achieved by restoration of anatomy in younger patients but the evidence in older independent patients is limited. There is no consensus on the best method of managing unstable distal radius fractures in older individuals. Volar locking plate has gained popularity over the last decade. It is biomechanically superior and forces transmitted through the distal radius following volar pate are close to those in a normal intact radius.⁴ One of the benefits of the volar locking plate is an early functional recovery which can be a distant advantage in independent elderly patients.⁵ An increasing trend of treating unstable distal radius fractures with a volar locking plate in older patients over the past few years has been seen. There are a few studies assessing the role of the volar plate in elderly distal radius fracture reporting a better grip and pinch strength in younger individuals but no other difference.^6,7

The purpose of our study was to evaluate the role of a volar locking plate for the treatment of unstable distal radius fractures in independent older individuals, compare outcomes and complications with younger individuals. Our hypothesis was that the treatment of unstable distal radius fracture with volar locking pates in older patients is associated with a higher complication and an inferior outcome.

2. Material and methods

Between April 2009 to December 2014, 112 patients were treated with a volar locking plate for a dorsally displaced unstable distal radius fracture. All of these patients were active and independent. Exclusion criteria were less than twelve months follow up, open fractures, multiple injuries, fractures extending into radial shafts, and those who had plaster immobilisation more than two weeks. Two patients were lost to follow up within the first six months of surgery, one was an open injury, and four patients had plaster cast for more than two weeks hence not included in the study. A total of 105 patients were included in this retrospective comparative study. The outcome measures were range of wrist movements, complications, reoperations, grip strength, VAS score, Quick DASH score, and Mayo wrist score. Patients were seen at 2 weeks, six weeks, three, six and twelve months. Statistical analysis was with Fishers exact test for removal of metalwork and reoperation. The unequal variance t-test was used for range of motion, VAS, grip strength, Mayo, and QuickDASH scores. The level for statistical significance was 0.05.

The procedures were performed by a consultant surgeon or a trainee under supervision. Surgery was performed through a volar approach with an above elbow tourniquet. Prophylactic antibiotics were given. The median nerve and flexor tendons were protected. Pronator quadratus was divided at its radial border and elevated. The fracture was reduced and temporarily held with K wires. A volar locking plate was applied and a final check was done under Image intensifier to ensure satisfactory reduction, plate placement, screw positioning and screw size. Drains were not used. Wound was closed in layers and a below elbow slab was applied for two weeks thereafter a removable splint and range of motion exercises were commenced at two weeks under the supervision of a physiotherapist.

3. Results

58 patients were below the age of 55 years and 47 patients above the age of 55 years. Mean age in patients below 55 years was 40 years (Range 17-54 years) and above 55 years was 59 years (Range 55-80 years). All patients were active and independent. Table 1 shows patient demographics. 64 fractures were as a result of a simple fall; 16 in falls from bicycles, 13 in motorbike accidents, and 12 in roller skating. All fractures were unstable as per Lafontaine.5 Mean operating time was 92 min (54–118 Minutes). Mean time to surgery was 5.4 days (Range 2–21 days) in patients below the age of 55 years and above 55 years of age was 5.5 days (Range 1–14 days). All fractures united between ten to seventeen weeks of surgery (Mean 12 weeks). Table 2 shows range of the wrist movements with p-value. There was no significant difference in grip strength, Mayo score; VAS and QuickDash score (Table 3). Mean VAS under 55 years of age was 1.6 (Range 0–7) and above 55 years was 1.7 (Range 0–4) (p-value = 0.58). Mean Mayo score in under 55 was 80.7(Range 44–98) and 80.1(Range 42–96) in above 55 (p-value = 0.78). Mean QuickDASH score under 55 was 20.9 (Range 0–78) and 21.0 (Range 3–72) above 55 (p-value = 0.97). Mean grip strength under 55 was 84 (Range 32–100) and 84.5 (Range 55–98) above 55 years of age (p-value = 0.87).

Table 1.

Patient demographics.

	Under 55	55 and Over
Number of patients	58	47
Male	20	7
Female	34	40
Right Hand Dominant	50	38
Left Hand Dominant	8	9
Mean Time to Surgery	5.4 Days	5.5 Days
Follow-up Duration	18.4 Months	18.1 Months

Table 2.

Range of Movements in degrees.

	Flexion		Extension		Pronation		Supination		Ulnar Deviation		Radial Deviation
	Range	Mean	Range	Mean	Range	Mean	Range	Mean	Range	Mean	Range	Mean
Over 55	25–65	54.6	15–60	46.9	45–90	79.2	45–90	74.5	10–30	23.3	10–20	17.5
Under 55	20–70	52.7	15–60	45.78	45–90	78.5	45–90	73.3	5–30	22.4	5–20	17.3
p-value		0.35		0.59		0.76		0.61		0.40		0.76

Table 3.

QuickDASH, VAS, Grip strength and Mayo score.

	Under 55 years	Over 55 years	p-value
Visual Analogue Scale
Mean	1.6	1.7	0.58
Median	1	2
Grip Strength
Mean	84.1%	84.5%	0.87
Median	88%	88%
MAYO score
Mean	80.7	80.1	0.78
Median	82	82
QuickDASH score
Mean	20.9	21.0	0.97
Median	17.3	17.1

The complication rate was 19.1% above 55 years of age and 17.2% below the age of 55 years (p-value = 0.79). The reoperation rate above 55 years was 8.5% and below 55 years was 8.6% (p-value = 0.50). Table 4 shows the complications and reasons for reoperations.

Table 4.

Complications and removal of metalwork.

	>55 years	<55 years
Carpal Tunnel syndrome	3b	1a
CRPS		3
Pain and early OA	1a	1a
Wound Infections	2	2
Flexor Tenosynovitis	1	1a
Post op Pain	1a
Post op Stiffness	1
FPL Rupture		1a
Metalwork malposition		1a
Total Complications	9	9	p-value 0.79
Metalwork Removal	4	5	p-value 0.50

^aRemoval of metalwork.

^bRemoval of metalwork required for 2 of 3 patients.

4. Discussion

The goal of treatment is to achieve a painless wrist with a good function. Malunion can result in persistent pain, reduced range of motion, decreased grip power, limitation in day-to-day activities, which can be disabling. Various surgical treatment options are available for the treatment of distal radius fractures. Each technique has advantages and disadvantages. Intramedullary nailing for distal radius fractures is not used too often due to a higher complication rate.⁸ Closed reduction and Kirschner wiring are less costly but drawbacks are prolonged immobilisation, pin tract infection, stiffness, complex regional pain syndrome, may not be sufficient in comminuted fractures, and loss of reduction after removal of K wires.⁹ Grip strength and supination is better in patients with unstable distal radius fractures treated with a volar locking than those treated with closed reduction and percutaneous Kirschner wiring.¹⁰ External fixation once popular is not used widely now due to a variety of reasons that include post-operative stiffness, patient inconvenience, pin tract infection, pin loosening, loss of reduction following removal, median and superficial nerve neuropathies.¹¹ External fixation when compared with plating for unstable distal radius fractures has higher complications including infection and malunion.¹² The clinical and radiological results of a volar locking plate are superior to a non-bridging and bridging external fixator in treatment of intra articular comminuted distal radius fractures.¹³

Dorsal plating was once popular but not used widely due to late complications and volar collapse when compared with volar locking plate and no difference in outcomes ¹⁴ The use of a volar locking plate in the treatment of distal radius fractures has increased over the last many years with good outcomes.¹⁵ The advantages are restoration of the anatomy, stability, shorter duration of immobilisation, early range of motion exercises and early return to function¹⁶ but there are reports of a high complication rate.¹⁷

The frequently used treatment methods for unstable distal radius fractures in older individuals are closed reduction and plaster immobilisation, closed reduction and Kirschner wiring, external fixators and volar plating but a gold standard procedure yet to be identified. There is a general belief that older patients with unstable distal radius fractures have a satisfactory outcome with non-operative treatment as a few studies did not show a relationship between the radiological and functional outcome in elderly.^18,19 These studies consisted of elderly, low demand, dependent and demented patients with significant comorbidities hence results of these studies do not apply to older independent individuals. A significant debate on the efficacy of volar locking plate in older individuals for a displaced distal radius fracture is on-going. There has been no malunion, non-union or metalwork failure in displaced and comminuted distal radius fractures in older patients treated with a volar locking plate.²⁰ Patients above the age of 60 years with unstable distal radius fracture treated with a volar locking plate have a better grip strength, range of flexion and radiological outcome when compared with Krischner wiring.²¹ The grip strength, DASH score and Patient-related wrist evaluations (PRWE) score were better in elderly patients treated with volar locking plate than those treated non operatively at three months and one year after the injury²² however some authors do not favour a volar locking plate in the treatment of unstable distal radius fracture in elderly patients as there was no improvement of range of motion and ability to perform daily living activities in their study.²³

A systematic review looking at older patients treated with cast immobilisation, non-bridging external fixator, bridging external fixator, volar locking plate and closed reduction and Kirschner wire fixation reported a worst radiological outcomes in cast immobilisation but no difference in functional outcomes than the surgically treated patients with a low complication rate in cast immobilisation group, highest in bridging external fixator group but complications requiring surgery was highest in volar locking plates.²⁴ A multicentre randomized controlled trial concluded as no difference in wrist pain, wrist function or quality of life for patients treated with Kirschner wires or locking plates.²⁵ This study included extra articular distal radius fractures only hence the results are not applicable universally. A comparable DASH score, Short Form 36 and EuroQol scores had been reported at one year follow up following volar plate fixation and closed reduction and casting in treatment of distal radius fractures in elderly hence role of volar plate has been questioned.²⁶

A similar early complication rate and functional outcome has been reported between young and elderly patients in a study of 116 patients with intraarticular fractures of the distal radius treated with volar locking plate.²⁷ Some authors believe that age is not an independent predictor for 30-day post-operative complications in patients undergoing volar plate fixation for distal radius fractures hence favour volar locking plate in older patients with no significant comorbidities.²⁸ A high complication and reoperation rate have been reported following volar plating in distal radius fractures hence caution is advised. The complication rate following volar plating can be as high as 22%²⁹ and reoperation rate of 10.4%.³⁰ In our study, the complication rate was 19.1% in above 55 years of age and 17.2% below the age of 55years. The reoperation rate in above 55 years was 8.5% and below 55 years was 8.6%. The most frequent complications observed in our study were carpal tunnel syndrome, flexor tenosynovitis and complex regional pain syndrome. The younger patients had higher plate removal but not significant. There was one case of an overhang of the plate over distal radioulnar joint that needed plate removal in our series (Fig. 1). Intra operative dynamic screening through the range of motion of wrist and forearm including 45° protonation and supination views can help to minimise the risk of mal positioning of plate and screws.³¹ One patient who had a rupture of flexor pollicis longus tendon was referred to hand surgeons and was treated with removal of plate and tendon reconstruction with palmaris longus graft.

Fig. 1.

Plate overlying the distal radio ulnar joint.

We observed no statistical difference in the range of motion, grip strength, VAS, QuickDASH, Mayo scores, grip strength, complications and reoperations in older and younger individuals. Range of movements was globally marginally better in patients above the age of 55 years.

Limitations of our study include retrospective study, no comparative group with other treatment methods, bias and various grades of surgeon.

The treatment of unstable displaced distal radius fractures in older patients is controversial. In summary, the results of our study demonstrate a satisfactory functional outcome in older individuals and no significant difference in complications and reoperations between older and younger individuals thus strengthening the argument that volar locking plate is a reliable option in treatment of unstable distal radius fractures in appropriate older individuals.

5. Conclusion

We conclude that open reduction and internal fixation of unstable displaced distal radius fractures in older independent patients is an effective modality.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Muhammad Ali Fazal: Conceptualization, Methodology, Investigation, Writing - original draft, Writing - review & editing, Visualization, Supervision. Christopher Denis Mitchell: Formal analysis, Data curation, Writing - review & editing, Software, Visualization. Neil Ashwood: Methodology, Investigation, Writing - review & editing, Formal analysis.

Declaration of competing interest

None.