These common injuries are highly studied, yet questions on standard treatment remain
Distal radius fractures are common injuries in the United States. Despite the high frequency of occurrence, treatment is not standardized. In 2009, the Academy provided 29 recommendations for treatment of distal radius fractures. None of these recommendations were graded strong and only five were graded moderate. The moderate recommendations included:

• Surgical fixation for fractures with postreduction radial shortening > 3 mm, dorsal tilt > 10 degrees, or intra-articular step off > 2 mm
• Use of nonremovable orthotics or casts for nonsurgically treated fractures
• Obtain true postreduction lateral radiograph to assess distal radioulnar joint (DRUJ) alignment
• Initiation of early wrist motion following stable fixation
• Consideration of vitamin C 500 mg daily for 50 days as prophylaxis against complex regional pain syndrome (CRPS)

Only weak recommendations were made regarding surgical method of fixation. However, research on distal radius fractures remains abundant with numerous studies published this past year.

VLP fixation
Surgical treatment options include open reduction and internal fixation (ORIF) with plating, spanning internal fixation with bridge plating, intramedullary fixation, closed reduction percutaneous pinning with Kirschner wires, and external fixation. Volar locked plating (VLP) has increased in popularity over time and is one of the most common surgical methods. However, the increase in use of this technique has not been related to scientific evidence demonstrating its superiority.

In a meta-analysis comparing percutaneous wire fixation versus VLP, no difference was found in functional outcomes based on Disabilities of the Arm, Shoulder, and Hand (DASH), grip strength, and range of motion. In radiographic measures, only palmar tilt had statistical difference. Plate fixation was favored regarding superficial infection but was no different in terms of repeat surgery, tendon injury, neurological injury, or deep infection. The randomized control studies included in the meta-analysis demonstrated earlier return to function with plate fixation but without a difference in intermediate or long-term outcomes.

A meta-analysis comparing VLP fixation versus external fixation resulted in a statistically significant better DASH score with VLP at all time points; however, the clinical significance was only apparent at the three-month time point. These results suggest that functional outcomes are better in the early postoperative time period with VLP fixation but otherwise are similar. Grip strength and early range of motion were favored with VLP fixation and complication rate remained similar.

Despite the popularity of VLP fixation, there are fracture patterns that should prompt alternative fixation, including a volar ulnar fragment, fracture dislocation, dorsal comminution without volar involvement, and a distal volar fracture line. Various approaches and implants may be needed to reduce and stabilize these fracture fragments. A volar ulnar approach may be necessary for certain lunate facet fractures.

Perioperative imaging
Preoperative imaging for distal radius fractures includes standard wrist radiographs. A computed tomography scan may be indicated when evaluating a large intra-articular component, there is a high degree of comminution, evaluating the volar lunate facet, and when attempting to rule out a scaphoid fracture. Magnetic resonance imaging is rarely used but may be indicated if there is concern for a complete scapholunate injury.

Intraoperative imaging is of great importance for fixation of distal radius fractures. Various views should be utilized to decrease the rate of postoperative complications associated with VLP fixation. Anteroposterior, lateral, and radial inclination views are used to evaluate construct position, fracture reduction, the tear drop angle for restoration of the volar lunate facet, and intra-articular extension of screw fixation. A skyline view or dorsal tangential view has become more popular in the literature as it evaluates dorsal screw penetration (Fig. 1). A retrospective review of 25 patients utilizing this technique resulted in two cases in which dorsal penetration of screws was not apparent on other imaging techniques. Although dorsal screw prominence has been linked with extensor tendon rupture, use of this view has not yet been proven to decrease the incidence of extensor tendon complication.

Outcomes
A prospective study from the United Kingdom with 12-month follow up compared radiological and functional outcomes of surgically treated distal radius fractures. Volar tilt and ulnar variance were measured at six weeks and 12 months postoperatively, as previous studies have demonstrated that these measurements are the most important parameters to correct. Patient-reported functional outcomes and physical outcome measures were then assessed at three, six, and 12 months for most of the 50 patients involved in the study. Only a small number of weak correlations were demonstrated between radiographic outcome and functional outcomes. The authors concluded that radiographic measurements were poor predictors of patient-reported functional outcome, health-related quality of life, and physical measures of function in this 12-month follow up.

“Distal Radius Fractures in the Elderly,” in the Journal of American Academy of Orthopaedic Surgeons, reviewed the treatment of distal radius fractures in this at-risk population. The distal radius is the second most commonly fractured bone in the elderly and despite controversy regarding treatment, the goals are to improve pain and restore function. The most recent AAOS clinical practice guidelines could not recommend for or against surgical treatment for this population. Radiographic outcomes worse with nonsurgically treated patients but functional outcomes were similar between surgically and nonsurgically treated patients. Distal radius fractures are related to osteoporosis and because they typically occur prior to osteoporotic hip fractures, they serve as a possible tool to identify at-risk patients. Therefore, elderly patients with distal radius fractures should be assessed and treated for osteoporosis, if necessary.

With studies demonstrating similar functional outcomes despite treatment method and others demonstrating no correlation between radiographic outcome and functional outcome, one must consider potential surgical harms. With VLP fixation of distal radius fractures, a range of complication rates from 3 percent to 36 percent is reported.

A recent article in Injury retrospectively examined 576 patients with VLP fixation of distal radius fractures. The complication rate was 14.6 percent with a reoperation rate of 10.4 percent. There were five flexor tendon ruptures (0.9 percent complication rate), 12 extensor tendon ruptures (2 percent complication rate), and tendon irritation in 1.7 percent. Nerve complications occurred in 5 percent and CRPS in 0.5 percent. AO/OTA type C fractures had an increased complication rate.

Over the past year, multiple studies have been published, but the principles of management have mostly remained unchanged. The goals of surgical fixation remain restoration of anatomy and stability within each column, starting with the simplest technique and advancing to more sophisticated techniques as needed.

Surgical treatment requires an understanding of anatomy, comfort with multiple approaches, and versatility in fixation methods. Complications are frequent and must be considered. Early recognition of complications and prompt appropriate management are imperative.

There are advantages and disadvantages of surgical treatment and the limitations of each approach, implant option, and surgeon skill must be appreciated.

Historically, nonsurgical treatment has done well, particularly in the elderly population. Therefore, patient selection and a discussion regarding long-term goals are crucial in the evaluation and treatment process.

Kirsten Sumner, MD, is an orthopaedic surgery resident at Geisinger Medical Center in Danville, Pa. C. Liam Dwyer, MD, is an orthopaedic hand and upper extremity surgeon at Geisinger Medical Center.

References

1. Anderson MS, Ghamsary M, Guillen PT, Wongworawat MD. Outcomes after distal radius fracture treatment with percutaneous wire versus plate fixation: meta-analysis of randomized controlled trials. J Surg Orthop Adv. 2017 Spring;26(1):7-17.
2. Gouk CJC, Bindra RR, Tarrant DJ, Thomas MJE. Volar locking plate fixation versus external fixation of distal radius fractures: a meta-analysis. J Hand Surg Eur Vol. 2017 Jan 1:1753193417743936.
3. Taylor BC, Malarkey AR, Eschbaugh RL, Gentile J. Distal radius skyline view: how to prevent dorsal cortical penetration. J Surg Orthop Adv. 2017 Nov;26(3):183-186.
4. Plant CE, Parsons NR, Costa ML. Do radiological and functional outcomes correlate for fractures of the distal radius? Bone Joint J. 2017 Mar;99-B(3):376-382.
5. Levin SL, Rozell JC, Pulos N. Distal radius fractures in the elderly. J Am Acad Orthop Surg. 2017 Mar;25(3):179-187.
6. Thorninger R, et al. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury. 2017 Jun;48(6):1104-1109.