A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

/pdf/biomechanical-considerations-on-a-ct-based-treatment-2z6dd8fbu3.pdf

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures.

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year. A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off. Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = − 0.18, p = 0.04) and Mayo Score (r = − 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (  2 mm) was not associated with a worse clinical important outcome. Age (  65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year.

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures

The standard therapy of intra-articular and extra-articular distal radius fractures consists of open reduction and stabilization using palmar osteosynthesis with an angularly stable plate. The integrity of the flexor pollicis longus tendon (FPLT) may be mechanically affected by the plate, with rupture rates between 1 and 12% reported in the literature, occurring during a postoperative time period from 4 to 120 months. The aim of this study was to investigate the position of the tendon in relation to the distal edge of the plate using high-resolution ultrasonic imaging. Nineteen patients undergoing osteosynthesis for distal radius fracture in 2015 with the Medartis® APTUS® FPL plate were included in this study. Of these, seven dropped out for various reasons. Therefore,  twelve patients with a median age of 52 years (range 24–82 years) were included in the final analysis. High-frequency ultrasound was performed within a median of 28 (range 10–52) weeks by an experienced radiology specialist to locate the FPLT position in two separate wrist positions: (1) wrist held in 0° position and fingers extended and (2) wrist held in 45° of dorsal extension and actively flexed fingers II to V (functional position). For analysis, we used the axial ultrasound videos. Postoperative X-rays and CT scans were included for the analysis, especially the soft-tissue CT scan window for the exact localization of the FPLT.  Dynamic ultrasound scanning was used to localize the FPLT in relation to the plate in 0° and functional position of the hand. Using CT scanning, the position of the plate relative to the bone was determined. In this way, we were able to correlate the functional FPLT position with the osseous structures of the distal radius. In all cases, the FPLT was positioned closer to the volar distal edge of the FPL plate in functional position than in 0° position. In four cases, the FPLT did not touch the plate at all and was shown to shift diagonally from radio-volar in ulno-dorsal direction during wrist movement from 0° to functional position, similarly to the sliding of the tendon in the assumed physiological motion sequence. In these cases, in the functional position the center of the FPLT was positioned slightly ulnarly of the center of the distal radius (i.e., less than 50% of the distal radius width measured from the radial border of DRUJ), and positioned more ulnarly than in all other cases (i.e., in which the FPLT came into contact with the plate). In the remaining two-thirds of the cases (eight patients), the FPLT touched the plate during wrist movement from 0° to functional position, shifted in dorsal direction and slid into the plate indentation, irrespective of whether the tendon entered the indentation from the radial or the ulnar side, and independent of the ulnoradial position of the plate. No signs of tendinopathy of the FPLT were found in any of the cases. The results show that the indentation of the Medartis® APTUS® FPL plate reduces the tendon-plate contact and ideally even prevents it entirely. In particular, ulnar positioning of the plate lowers the risk of tendon-plate contact. If the FPLT touches the plate, the tendon pulls into the plate indentation, thus lowering the contact. Consequently, the Soong criteria are not applicable when a FPL plate is used.

Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width

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Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width