JOT
JOURNALOF ORTHOPAEDIC
TRAUMA
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OFFICIAL JOURNAL OF
Belgian Orthopaedic Trauma Association
Canadian Orthopaedic Trauma Society
Foundation for Orthopedic Trauma
International Society for Fracture Repair
The Japanese Society for Fracture Repair
Orthopaedic Trauma Association
AOTrauma North America
Special Case Report Series
CASE REPORTS
Sponsorship provided by Acumed
Distal Radius Fragment-Specific FixationLauren M. Shapiro, MD and Robin N. Kamal, MD
Summary: Open reduction and internal fixation is the mainstayof treatment for most unstable, intra-articular distal radiusfractures. Anatomical reduction and maintenance of thereduction can be challenging in the setting of injuries withmultiple fracture fragments and complex intra-articular frac-ture patterns. Although common, volar locking plates cannotadequately address every fracture pattern. Fragment-specificfracture fixation methods are technically demanding, but canbe used alone or in conjunction with other fixation methods toobtain reliable reduction and fixation in complex fracturepatterns. The aim of this report is to illustrate the use of thefragment-specific technique for intra-articular distal radiusfracture fixation.
Key Words: distal radius fracture, fragment-specific fixation,intra-articular fracture
INTRODUCTIONDistal radius fractures are one of the most common skeletal
injuries, with an estimated annual US incidence of more than600,000, second only to hip fractures.1–3 Understanding the mech-anism of injury and the fracture pattern is critical to avoid compli-cations. Most fractures are stable, extra-articular, and may be
treated with closed reduction and immobilization. Those that areunstable and intra-articular typically warrant surgical fixation.4
Historically, dorsal plating was used when operative fixationwith a platewas performed given the advantages of a direct articularreduction and the avoidance of potential damage to the mediannerve and radial artery.5,6 Due to complications involving extensortendon attrition and rupture and the introduction of volar lockedplating, dorsal plating has become less common.5,7 Correspondingto the introduction of volar platingwas a rapid increase in the rate ofinternal fixation for distal radius fractures, with 1 study ofMedicareclaims data finding a five-fold increase in the rate of internal fixa-tion over a 10-year period.7–9 Benefits of locked volar platinginclude direct fracture visualization and neutralization of forcesas a fixed angle construct by transmitting forces from the distalfragments to the volar cortex of the radial shaft.10,11 The lockingscrew construct allows for improved fixation in osteoporotic, shortsegments, and metaphyseal bone by not relying on the bone qualityfor purchase. Although increasingly common, volar locked platingis not a panacea for distal radius fractures. High-energy injurymechanisms may result in articular comminution and complexfracture patterns that produce fragments too distal or too small tobe adequately captured by volar locked plating alone, presentingunique challenges to the surgeon. For example, in a retrospectivereview of 77 AO C3 (articular multifragmentary) distal radius frac-tures treatedwith only a volar locked plate, at an average of 120-dayfollow-up, Earp et al12 found a 10.4% rate of loss of reduction. Becket al,13 in reviewing 52 AO B3 (volar shearing) distal radius frac-tures operatively treated with volar locking plates, found that frac-tures in which the lunate facet fragment had less than 15 mm inlength of the volar cortex available for fixation and lunate facetfragments with greater than 5 mm of initial subsidence were at riskof failure despite proper volar plate placement. Volar locking platesare often placed distally to capture small and distal fragments;however, studies have shown that placing these plates distal tothe watershed line may lead to flexor tendon irritation and rup-ture.11,14–16
Fragment-specific fracture fixation is a technically demandingadjunct with a steep learning curve17,18 that uses low-profile,
Accepted for publication February 8, 2019.
From the Department of Orthopaedic Surgery, Stanford University,Stanford, CA.
The authors report no conflict of interest.
Reprints: Robin N. Kamal, MD, Department of Orthopaedic Surgery, VOI-CES Health Policy Research Center, Stanford University, 450 Broadway StMC: 6342, Redwood City, CA 94603 (e-mail: [email protected]).
The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Acumed.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001458
J Orthop Trauma � 2019 www.jorthotrauma.com e1
individualized implants to rigidly restore anatomy. By using tai-lored implants and fixation techniques to address specific frag-ments, success relies on preoperative assessment andunderstanding of the fracture pattern. Fragment-specific fixationcan be used alone or in conjunction with other fixation methodsand may require more than one surgical approach. The purpose ofthis report is to illustrate the use of the fragment-specific techniquefor intra-articular distal radius fracture fixation.
Patient InformationA 42-year-old woman sustained an intra-articular distal radius
fracture after falling off a bike. This was a closed injury, and shewas neurovascularly intact. There was no evidence of acute mediannerve compression. The fracture was reduced in the emergencydepartment, and a short arm splint was placed. Her preoperativeradiographs revealed a three-part intra-articular fracture includinga lunate facet/volar ulnar corner fragment, a scaphoid facetfragment, and a radial styloid fragment. There was no carpalfracture or instability noted on preoperative imaging, nor was therean ulnar styloid fracture (Fig. 1).
Surgical TechniquePreoperative imaging revealed a comminuted intra-articular
distal radius fracture with a shearing type fracture in the sagittalplane involving the volar ulnar corner. In the operating room, thepatientwas placed supine on the operating room tablewith the upperextremity on a hand table. A nonsterile tourniquet was used on theupper arm. A mini c-arm was prepared and was placed at the side ofthe hand table. The upper extremitywas prepped and draped in usualsterile fashion. We used a modified Henry approach, as we felt itwould allow for visualization of both the radial and intermediatecolumns and allow for direct visualization of the fracture reduction.We made a 5-cm longitudinal incision over the flexor carpi radialis(FCR). The epidermis and dermis were sharply dissected, and bluntdissection with Littler scissors was used to dissect through thesubcutaneous tissue to the level of the FCR fascia. Carewas taken toavoid the radial artery. Any branches crossing the field werecauterized with a bipolar. The FCR sheath was incised, the FCRwas retracted ulnarly, and the FCR subsheath was incised revealingthe flexor pollicis longus. The flexor pollicis longus was retractedulnarly revealing the pronator quadratus (PQ). A surgical spongewas unfolded and placed into the space of Parona to improvevisualization of the PQ. We sharply incised the PQ creating
a proximal and ulnarly based flap. The incision started just distalto the watershed line and was carried radially and then proximal tothe proximal aspect of the PQ. This was bluntly elevated witha surgical elevator. Dissecting along the radial aspect of the distalradius, we identified brachioradialis. This was released sharply offof its attachment to the radial styloid to allow for improved fracturereduction, as it is often a deforming force pulling the distal radialstyloid fragment radially. At this point, we had good visualization ofthe fracture. The fracture site was cleared of soft tissue to allow forimproved reduction.We identified 3 main articular volar fragments,including the lunate facet and volar ulnar fragment, the volarmarginof the scaphoid facet, and the radial styloid fragment. Due tocomminution within the lunate facet and concern it would not bereliably captured by screws from the volar plate, we opted fora surgical technique described by Moore and Dennison17 wherek-wires are used for fragment-specific fixation of the lunate facet.A dental pick was used to directly reduce the lunate facet fragment,and this was held with two 0.054 in k-wires that were placed fromdistal to proximal. The volar scaphoid facet fragmentwas reduced ina similar manner and secured with one 0.035 in k-wire also fromdistal to proximal. Reduction was confirmed with fluoroscopy. A0.062 in k-wire was placed through the skin and into the radialstyloid fragment from distal to proximal, and this wire was usedto joystick the fragment under direct visualization. This wire waspassed proximally into the radius. Adequate reduction was againconfirmed with fluoroscopy. The wires (excluding the radial styloidwire) were cut and bent to contour to the volar distal radius. Atten-tionwas then turned to selection of a volar locking distal radius plateplaced over the k-wires. The plate (Acu-Loc 2 Volar Distal RadiusPlate; Acumed, Hillsboro, OR) was placed onto the distal radiussuch that it would not be too distal or too radial, the distal screwswould not be intra-articular, and it would cover the K-wires. A 2.8-mm hole was drilled into the oblong hole and a 3.5-mm nonlockingscrew was placed to hold the plate onto the radius. After the prox-imal to distal and ulnar to radial location of the plate was confirmedon fluoroscopy, locking screws were placed distally with the use ofa locking guide.One screwwas placed into the lunate facet fragmentand a second into the scaphoid facet fragment. After 2 lockingscrewswere placed into the radial styloid fragment, the radial styloidwire was removed. Two locking screws were placed just proximaland distal to the initial nonlocking proximal screw. The reductionand screw lengths were deemed appropriate on 109 tilted posterior-anterior (PA) and 209 tilted lateral. The tourniquet was deflated, and
FIGURE 1. Injury radiographs. PA (A),oblique (B), and lateral (C) demonstratingan intra-articular volar shear type fractureof the distal radius.
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bipolar cautery was used to achieve hemostasis. The distal radialulnar joint was evaluated in neutral, full supination, and full pro-nation. This was found to be stable in comparison with the contra-lateral side. The wound was irrigated and closed. The patient wasplaced in a volar resting splint, which was maintained for 10 days.Ten-day postoperative imaging showed maintained fracture andhardware alignment (Fig. 2). She was instructed to not bear weightthrough the operative upper extremity for 2 weeks. After 10 days,the splint was removed, and the patient began hand therapy 2 weekspostoperatively.Three-monthpostoperative imaging showsahealedfracture with maintained alignment and hardware positioning (Fig.3).
DISCUSSIONAlthough a wide variety of fracture patterns and classification
systems exist, the basic principles of surgical treatment remainto minimize complications and promote early return of wrist
function. Fragment-specific distal radius fixation, either alone orin conjunction with conventional techniques, allows for rigidfixation and early range of motion with restoration of articularcongruity, length, alignment, and rotation with minimal soft-tissue trauma. With several mini-fragment plate and screwoptions available to treat other articular fractures (eg, radialstyloid, volar ulnar corner, and dorsal ulnar corner), the currentfragment-specific fixation technique is versatile and effective inachieving a stable reduction in the many complex fracturepatterns.
Good to excellent outcomes at mid-term follow-up have beenreported for fragment-specific fracture fixation in the litera-ture.19–21 In a review of 81 patients with 85 distal radius frac-tures treated with fragment-specific fixation, no patients had lossof reduction or tendon rupture; however, 6% required a secondprocedure for hardware removal.19 Sammer et al,22 in a compar-ative study of 99 patients with distal radius fractures treated with
FIGURE 2. Ten-day postsurgical fixationradiographs. PA (A), oblique (B), and lat-eral (C) demonstrating fracture reductionwith a volar locking plate with 3 wires.
FIGURE 3. Three-month postsurgical fix-ation radiographs. PA (A), oblique (B), andlateral (C) demonstrating fracture reduc-tion and subsequent healing after place-ment of a volar locking plate with 3 wires.
Fragment-Specific Fixation of Intra-articular Distal Radius Fractures
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fragment-specific and volar locking plate fixation, notedimproved radiographic outcomes of volar locked plating(regarding volar tilt and radial length) at 1 year. Although theynoted superior grip and pinch strength, range of motion, andMichigan Hand Outcomes Questionnaire Scores at 6 monthswith volar locked plating, the differences between fixation tech-niques were smaller at 1-year follow-up.22 Importantly, theynoted a 57% complication rate associated with fragment-specific fixation, stemming largely from hardware removal andtendon or nerve irritation. Although this study matched patientsby AO type for their functional and patient-reported outcomeanalysis, it was not randomized, and one may argue that a higherAO type (AO type C: 79% in the fragment-specific cohort, com-pared with 46% in the volar locked plating cohort) may result inmore soft-tissue injury, slower recovery, and more complica-tions. Landgren et al23 conducted a randomized controlled studyof 50 patients with AO types A and C distal radius fractures toevaluate differences between fragment-specific fixation anda volar locking plate. This study was powered to detect a differ-ence in grip strength of 20% compared with the contralateralside. The authors found no difference in grip strength, rangeof motion, or functional outcome scores between the 2 cohorts.They did note a significantly higher rate of complications in thefragment-specific fixation group, primarily attributable to tran-sient radial neuropraxia. These studies consistently suggest anincreased complication rate with fragment-specific fixation;however, there is a need for adequately powered studies to helpbetter recognize the advantages and disadvantages as well asindications for fragment-specific fixation instead of or in con-junction with volar locked plating.
In comminuted and intra-articular fracture patterns, the importanceof preoperative imaging and planning should not be overlooked.Standard and adequate PA, oblique, and lateral radiographs takenbefore and after reduction should be evaluated. The use of intra-operative fluoroscopy can be a valuable aid to evaluate adequacy ofreduction. Thiart et al24 arthroscopically evaluated 44 intra-articulardistal radius fractures treated with fragment-specific fixation and fluo-roscopy and were unable to detect an articular gap in 37 patients ora step-off in 33 patients. A 10-degree tilt PA or 45-degree pronatedoblique view can help to evaluate the articular surface of the scaphoidfossa,while a 10-degree tilt lateralmayhelp evaluate the volar rim.25,26
Orthogonal or 10-degree tilt PA and lateral views may assist in visu-alizing intra-articular fragments.27Computed tomography scans thinlysliced and reformatted can provide valuable information regardingfracture pattern and fragment dimensions. An understanding of thefracture pattern and appropriate fixation technique (eg, buttress platefor a sheared partial articular fracture) is critical to prevent intraoper-ative and postoperative complications.
There are several methods, not described above, by which toachieve adequate fixation with the fragment-specific technique,including lower profile plates that can be placed more distally onthe radius to avoid tendon irritation and plates that incorporate sutureholes to capture small articular fragments not amenable to screw orpin fixation. Understanding the principles of fracture fixation, thenature of the fracture at hand, and the fixation options available iscritical. The few studies evaluating fragment-specific fixationtechniques consistently demonstrate an increased rate of complica-tions, primarily attributable to transient neuropraxias and the need forhardware removal.19,22,23 The learning curve for this technicallydemanding fixation method has been described,17,18 and with
experience, the complication profile may change. Future randomizedcontrolled trials, adequately powered for various outcome measures,are needed to better evaluate the indications for fragment-specificfixation techniques as well as risks and benefits of this techniqueinstead of or in conjunction with volar locked plating.
CONCLUSIONSThe presented case illustrates that a fragment-specific technique
may be successfully used for intra-articular distal radius fracturefixation. The fragment-specific technique may be a valuable adjunctor alterative to volar locked plating and other fixation techniques forfixation of comminuted and intra-articular distal radius fractures.Fragment-specific fixation allows for individualized fixation of smalland distal fracture fragments that are critical to maintenance of thereduction and may not be amenable to other types of fixation.
REFERENCES1. Chung KC, Spilson SV. The frequency and epidemiology of hand andforearm fractures in the United States. J Hand Surg Am. 2001;26:908–915.
2. Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. Int J Epide-miol. 1993;22:911–916.
3. Mauck BM, Swigler CW. Evidence-based review of distal radius fractures.Orthop Clin North Am. 2018;49:211–222.
4. Lichtman DM, Bindra RR, Boyer MI, et al. American Academy of Ortho-paedic Surgeons clinical practice guideline on: the treatment of distalradius fractures. J Bone Joint Surg Am. 2011;93:775–778.
5. Ayalon O, Paksima N. Dorsal plating of distal radius fractures. Historicalcontext and appropriate use. Bull Hosp Joint Dis (2013). 2017;75:4–8.
6. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated byinternal fixation and early function: a prospective study of 73 consecutivepatients. J Bone Joint Surg Br. 2000;82:340–344.
7. Chung KC, Shauver MJ, Brinkmeyer JD. Trends in the United States inthe treatment of distal radius fractures in the elderly. J Bone Joint Surg Am.2009;91:1868–1873.
8. Koval KJ, Harrast JJ, Anglen JO, et al. Fractures of the distal part of theradius—the evolution of practice over time. Where’s the evidence? J BoneJoint Surg Am. 2008;90:1855–1861.
9. Mattila VM, Huttunen TT, Sillanpaa P, et al. Significant change in thesurgical treatment of distal radius fractures: a nationwide study between1998 and 2008 in Finland. J Trauma. 2001;71:939–942.
10. Schneppendahl J, Windolf J, Kaufmann RA. Distal radius fractures: cur-rent concepts. J Hand Surg Am. 2012;37:1718–1725.
11. Berglund LM, Messer TM. Complications of volar plate fixation for managingdistal radius fractures. J Am Acad Orthop Surg. 2009;17:369–377.
12. Earp BE, Foster B, Blazar PE. The use of a single volar locking plate forAO C3-type distal radius fractures. Hand (N Y). 2015;10:649–653.
13. Beck JD, Narness NG, Spencer HT. Volar plate fixation failure for volarshearing distal radius fractures with small lunate facet fragments. J HandSurg Am. 2014;39:670–678.
14. Lucas GL, Fejfar ST. Complications in internal fixation of the distalradius. J Hand Surg Am. 1998;23:1117.
15. Limthongthang R, Bachoura A, Jacoby SM, et al. Distal radius volarlocking plate design and associated vulnerability of the flexor pollicis lon-gus. J Hand Surg Am. 2014;39:852–860.
16. Asadollahi S, Keith PPA. Flexor tendon injuries following plate fixation ofdistal radius fractures: a systematic review of the literature. J OrthopTraumatol. 2013;14:227–234.
17. Moore AM, Dennison DG. Distal radius fractures and the volar lunatefacet fragment: kirshner wire fixation in addition to volar-locked plating.HAND (N Y). 2014;9:230–236.
18. Saw N, Roberts C, Cutbush K, et al. Early experience with the TriMedfragment-specific fracture fixation system in intraarticular distal radiusfractures. J Hand Surg Eur Vol. 2008;33:53–58.
19. Benson LS, Minihane KP, Stern LD, et al. The outcome of intra-articulardistal radius fractures treated with fragment-specific fixation. J Hand SurgAm. 2006;31:1333–1339.
20. Chang HC, Poh SY, Seah SC, et al. Fragment-specific fracture fixation anddouble-column plating of unstable distal radial fractures using AO mini-fragment implants and Kirschner wires. Injury. 2007;38:1259–1267.
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21. O’Shaughnessy MA, Shin AY, Kakar S. Volar marginal rim fracturefixation with volar fragment-specific hook plate fixation. J Hand SurgAm. 2015;40:1563–1570.
22. Sammer DM, Fuller DS, Kim DM, et al. A comparative study of fragment-specific versus volar plate fixation of distal radius fractures. Plast ReconstrSurg. 2008;122:1441–1450.
23. Landgren M, Abramo A, Geijer M, et al. Fragment-specific fixation versusvolar locking plates in primarily nonreducible or secondary resdisplaceddistal radius fractures: a randomized controlled study. J Hand Surg Am.2017;42:156–165.
24. Thiart M, Ikram A, Lamberts RP. How well can step-off and gap distancesbe reduced when treating intra-articular distal radius fractures with frag-ment specific fixation when using fluoroscopy. Orthop Traumatol SurgRes. 2016;102:1001–1004.
25. Smith DW, Henry MH. The 45 degrees pronated oblique view for volar fixed-angle plating of distal radius fractures. J Hand Surg Am. 2004;29:703–706.
26. Medoff RJ. Essential radiographic evaluation for distal radius fractures.Hand Clin. 2005;21:279–288.
27. Rhee PC, Medoff RJ, Shin AY. Complex distal radius fractures: an ana-tomic algorithm for surgical management. J Am Acad Orthop Surg. 2017;25:77–88.
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Fragment-Specific Fixation of Intra-articular Distal Radius Fractures
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