Combined Volar and Dorsal Approach for Fixation of Comminuted Intra-Articular Distal Radial Fractures

Abstract

Purpose Multifragmentary intra-articular fractures displaced in multiple planes are a challenge. We use a reproducible technique of fracture and articular reduction using an initial volar approach targeting reduction in the volar lunate facet first with plate and unicortical locking screws. This creates a template for reduction in dorsal fragments through a dorsal approach. Our study investigated the radiological, clinical, and functional outcomes of patients treated with this technique.

Materials and Methods We reviewed the postoperative radiographs and notes of 18 patients that had this method of fixation between the years 2008 and 2015, the mean age being 43. These patients were reviewed functionally on average 2 years and 3 months following their definitive operation.

Results Normal alignment and length to the distal radius were restored with on average a 0.6 mm articular step. The average range of motion was 64% and preservation of grip strength was 71% compared with the uninjured wrist. Functional assessment averages were 29 for both the quick Disabilities of the Arm, Shoulder and Hand (DASH) and for Patient Rated Wrist Evaluation. The modified system of Green and O'Brien had results of good in 10, fair in 7, and poor in 1. With respect to the Gartland and Werley system, three patients had an excellent result, four had a good result, six had a fair result, and five had a poor result. The mean arthritic grading was 1 (grading 0–3) according to Knirk and Jupiter.

Conclusion This reproducible technique provides an option for these devastating fractures providing a functioning wrist with all of the patients returning to their original form of employment.

Keywords

distal radius fracture - internal fixation - dual approach - fracture specific

Note

Our local ethical board was contacted prior to evaluating the patients and felt ethical approval wasn't required because assessment was no different to our normal clinical assessment. Patients signed consent forms following an informed consent process for their operation.

• References

• 1 Ng CY, McQueen MM. What are the radiological predictors of functional outcome following fractures of the distal radius?. J Bone Joint Surg Br 2011; 93 (02) 145-150
• 2 Downing ND, Karantana A. A revolution in the management of fractures of the distal radius?. J Bone Joint Surg Br 2008; 90 (10) 1271-1275
• 3 Plate JF, Gaffney DL, Emory CL. , et al. Randomized comparison of volar locking plates and intramedullary nails for unstable distal radius fractures. J Hand Surg Am 2015; 40 (06) 1095-1101
• 4 Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N. Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: a randomised, prospective trial. J Bone Joint Surg Br 2008; 90 (09) 1214-1221
• 5 Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986; 68 (05) 647-659
• 6 Stewart HD, Innes AR, Burke FD. Factors affecting the outcome of Colles' fracture: an anatomical and functional study. Injury 1985; 16 (05) 289-295
• 7 Melone Jr CP. Articular fractures of the distal radius. Orthop Clin North Am 1984; 15 (02) 217-236
• 8 Mellstrand Navarro C, Ahrengart L, Törnqvist H, Ponzer S. Volar locking plate or external fixation with optional addition of K-wires for dorsally displaced distal radius fractures: a randomized controlled study. J Orthop Trauma 2016; 30 (04) 217-224
• 9 Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg Am 2004; 86-A [phone]
• 10 Ryu JY, Cooney III WP, Askew LJ, An KN, Chao EY. Functional ranges of motion of the wrist joint. J Hand Surg Am 1991; 16 (03) 409-419