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Purpose of Review
High energy distal radius are commonly multi-fragmentary with significant comminution and/or bone loss. They can also be associated with ligamentous and soft tissue injury and neurovascular compromise. As such, reconstruction of these injuries can be challenging. This paper will review the relevant anatomy, different methods of fi...
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Background:
Naso-orbito-ethmoido-maxillary (NOEM) fractures are usually the result of a high or moderate intensity impact to the upper midface. These types of fractures are difficult to treat and are frequently misdiagnosed. Craniometric analysis can be of real aid in the treatment of NOEM complex fractures by establishing midfacial proportions....
Citations
... Dogmatically, skin bridge size between surgical incisions is considered an important determinant of viability, with small skin islands believed to predispose to breakdown and subsequent surgical complications like wound dehiscence and infection [3,4]. While the ramifications of skin incisions on perfusion and viability of the soft tissues around the wrist remains poorly understood, operative dogma continues to maintain that multiple incisions predispose to wound complications [3,5,6]. ...
... Dogmatically, skin bridge size between surgical incisions is considered an important determinant of viability, with small skin islands believed to predispose to breakdown and subsequent surgical complications like wound dehiscence and infection [3,4]. While the ramifications of skin incisions on perfusion and viability of the soft tissues around the wrist remains poorly understood, operative dogma continues to maintain that multiple incisions predispose to wound complications [3,5,6]. A recent clinical review of surgically-managed multi-fragmentary distal radius fractures, treated with multiple incisions, demonstrated minimal soft tissue healing issues of the wrist without an elevated incidence of soft tissue complications [7]. ...
... Superficial reflection of the skin exposed numerous subcutaneous perforators arranged in a linear pattern on both the volar and dorsal surfaces (Figs. [1][2][3][4][5][6]. It was noted that these perforators demonstrated linking vessels that connected to adjacent perforators via multiple vertical and oblique branches that ultimately formed an extensive subdermal plexus (Fig. 1). ...
Purpose
To determine and evaluate the distal forearm and wrist's cutaneous blood supply and vascular territories.
Methods
Four cadaveric upper extremities were injected with a radiopaque, lead-based contrast agent through the brachial artery. After the lead-based contrast agent set, the cadaveric limbs underwent computed tomographic (CT) scanning to assess the perforators to the cutaneous skin of the distal forearm and wrist. High-resolution axial CT and three-dimensional reconstructions were generated to highlight perforating vessels stemming from their parent arteries. Subsequently, anatomic microdissections were performed to identify and trace the perforating vessels identified on CT.
Results
CT analysis and anatomic microdissection demonstrated that the dorsal surface of the distal forearm and wrist are supplied by numerous perforators stemming predominantly from the anterior interosseous artery with some anastomotic contribution from the posterior interosseous, radial, and ulnar arteries. Perforators from the radial and ulnar arteries supply the volar surface. There are large anastomotic networks formed between the perforating vessels.
Conclusions
The distal forearm and wrist have a robust anastomotic blood supply that has contributions from the anterior interosseous, posterior interosseous, radial, and ulnar arteries.
Clinical Relevance
The extensive perforator-derived blood supply to the skin likely accounts for the excellent soft tissue healing potential of the wrist following surgery utilizing multiple incisions.
... Anterior locking plate fixation is the most common method of open reduction and internal fixation, although some complicated fracture patterns may be more suitable to management with fragmentspecific plating (Geissler and Clark, 2016;He and Blazar, 2019;Medlock et al., 2018). ...
Anterior locking plate fixation of the distal radius is a common procedure with reliable results. Failure of fixation is sometimes seen. The aim of the present study was to identify the reasons for failure. In total, 517 cases met the study inclusion criteria. Of them, 23 cases had failure of fixation (4.4%). Failure analysis generated qualitative data. Subsequent thematic analysis identified the primary mode of failure and contributing factors. Primary modes were identified as failure to support all key fracture fragments ( n = 20), wrong choice of implant ( n = 1), failure of union ( n = 1) and poor bone quality ( n = 1). Contributing factors were errors in plate positioning, fracture reduction, implant selection and screw configuration, as well as fracture pattern complexity and poor bone quality. Most failed fixations had a primary mode and two or three contributing factors. Overall anterior plating is reliable with a low rate of surgical failure. Knowledge of failure modes will aid operative planning and prevent failure.
Level of evidence: V
... 5,8 Radius along with lateral carpus carries 80% of the load and ulna with medial carpus via triangular fibrocartilage complex (TFCC) carry 20% of the axial load. 9,10 When treating comminuted intra-articular lower end radius fractures, it may be favorable to consider of these structures inform of three columns: radial, intermediate and ulnar maintained by the shaft or pedestal. 9 Several classification systems have been proposed for lower end radial fractures, like Gartland and Werley's system, Frykman, Melone, and Fernandez classifications, the last one is more applicable classification. ...
... 9,10 When treating comminuted intra-articular lower end radius fractures, it may be favorable to consider of these structures inform of three columns: radial, intermediate and ulnar maintained by the shaft or pedestal. 9 Several classification systems have been proposed for lower end radial fractures, like Gartland and Werley's system, Frykman, Melone, and Fernandez classifications, the last one is more applicable classification. 2,11 Radiographic evaluation is important in the diagnosis, classification, treatment and follow-up, 8,12 including Radial, 12 Radial inclination, 6,12 Ulnar variance, 6,12 Volar tilt. ...
Objective: To compare the radiological and functional outcomes of patients of Comminuted intra-articular distal radius fractures treated with or without bone marrow injection along with external fixator ligamentotaxis. Methodology: This prospective comparative study on 41 patients with comminuted intra-articular lower end radius fractures distributed patients randomly into two groups depending on whether an aspirate of bone marrow was injected at the fracture site two weeks after fracture management with external fixation ligamentotaxis. Results: The mean age was 35.8 years, with male predominance. The radiological parameters (radial height, radial inclination, and volar tilt) at the 6 th month follow up were lower in the group who did not receive a bone marrow aspirate injection but was not significant statistically. Moderate deformities developed in half of the patients who did not receive bone marrow aspiration according to Lidstorm scores modified by Sarmiento et al. The functional outcome was excellent to good in all patients who received marrow aspiration, according to the demerit system of Gartland and Werley. Conclusion: The injection of bone marrow aspirate to the fracture site might have a potential role in the management of comminuted intra-articular lower end radius fractures treated by external fixation ligamentotaxis.
... Otro grupo de autores como He y otros, (30) Sanhuezo y otros (31) y Rhee y otros, (32) refieren en base a sus experiencias que para realizar un diagnóstico correcto y aplicar un tratamiento adecuado en las fracturas del radio distal, lo importante es contar con un conocimiento adecuado de la anatomía, el manejo adecuado de las diferentes variables (género, actividad física, edad, mecanismo de producción), la interpretación adecuada de las imágenes radiográficas y de la experiencia del cirujano en este tipo de afección. ...
Introducción:
Una clasificación es necesaria para la correcta orientación del cirujano ortopédico en cuanto a diferenciar los tipos de fracturas del extremo distal del radio, su pronóstico en base a su complejidad, la importancia de la radiografía, las variables demográficas de cada caso y qué tipo de proceder será el más indicado para el paciente.
Objetivo:
Actualizar las clasificaciones para fracturas del extremo distal del radio.
Desarrollo:
Se procedió a la búsqueda en las bases de datos Pubmed/ Medline, SciELO, BVS, Scopus, Ebsco y Cochrane, se emplearon los descriptores “fractura distal del radio”, clasificación de fractura del extremo distal del radio, fractura de la muñeca, consenso sobre fractura del extremo distal del radio, radiología en la fractura de muñeca, guías terapéuticas actuales para el tratamiento de las fracturas distales del radio, solo y con las siguientes cadenas “clasificación”, “radiología”. Fueron incluidos 19 artículos originales, 10 de revisión, 4 guías terapéuticas, 2 de investigación y 2 libros de la especialidad. Se examinaron los sistemas de clasificación de las fracturas del extremo distal del radio.
Conclusiones:
No existe consenso en el sistema de clasificación. Se comprueba el pobre aporte al ortopédico de la clasificación de Frykman y que el sistema AO demuestra ser más fácil de interpretar. Se evidencia la utilidad de la radiografía con tracción esquelética para un diagnóstico útil y de ayuda al cirujano en la toma de decisiones para el tratamiento del paciente.
... [1][2][3][4] Although most DRF management strategies involve nonoperative methods, a significant trend toward surgical treatment has been noted, 5,6) largely explained by the introduction of volar locking plate (VLP) fixation, which is associated with advantages such as stable fixation, short immobilization period, and few complications. [7][8][9] In open DRFs, there is no consensus regarding operative treatment modalities, and the effectiveness of surgical fixation and its timing have been controversial and are based on the surgeon's preference. 10,11) Infection after open DRFs is a primary concern for determining the appropriate treatment methods. ...
... The patient's age, occupation, familiarity of the procedure to the surgeon, the comorbidities such as tendon and median nerve injuries should be taken into account, as well as the fracture configuration [5][6][7]. Internal fixation with VLP is the most commonly used treatment for unstable distal radius fractures despite its relatively higher complication rate due to deep dissection of soft tissue around the fracture region, and the need for a removal surgery for intra-articular fracture cases [8]. On the other hand, closed reduction techniques EF and K-wire have the advantages of being less invasive with easy application and lower costs [9]. ...
... Yu et al. reported a 34.5% and 28.2% complication rate in their patients treated with EF and VLP, respectively [13]. The most common complications for surgical management of distal radius fractures include loss of reduction, infection, joint stiffness due to nerve injury, tendon rupture, osteoarthritis, and tendonitis [8,21,22]. ...
... VLP method has numerous functional and structural advantages, including its anatomically shaped design, early mobilization, and well-preserved wrist function. Several reports show that the VLP is related to tendon related complications, even necessitating plate removal and resurgery [8].However, we did not experience such complications in our patient group, possibly as a result of appropriate patient selection, careful soft tissue dissection and precise screw lengths. Farhan et al. reported in their series of patients with AO23C3 distal radius fractures that 16% of the patients required plate removal [23]. ...
Introduction
Distal radius fractures are the most common type of all extremity fractures. It is generally accepted that fractures with more than 2 mm step-off in the radiocarpal joint and greater than 10 degrees dorsal tilt should be treated surgically. However, the ideal technique for surgical management is still a point of debate. We performed cross-sectional data analysis to compare the results of three treatments methods - volar locking plate (VLP), external fixation (EF), Kirschner wire (K-wire) - in patients with distal radius fractures, and compared the clinical, functional, and radiological results
Materials and methods
Forty-four patients with distal radius fractures who underwent fixation with VLP, K-wire or EF between 2011 and 2013 were included in the study. All fractures were classified according to the Müller’s Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Frykman's classifications. Routine radiographs were taken at the postoperative three weeks, six weeks, and three months. Radial inclination, volar tilt, radial length and ulnar variance were assessed on the follow-up visits and additionally at the follow -up for the study. The patient-based Disabilities of the Arm, Shoulder and Hand (DASH) score system and the physician-based MAYO scale were used to evaluate functional outcomes. Radiological and functional outcomes between three surgical modalities were compared and statistically analyzed.
Results
The average age at the time of surgery was 52 years (range = 35-69 years). Of a total of 44 patients, 28 were operated with VLP, 11 were with K-wire and five with EF. Satisfactory reduction was achieved in all fractures, and all of the fractures healed. DASH and MAYO scores were similar in all groups. Regarding radiographic parameters, there was no significant difference in radial inclination, volar tilt, radial length and ulnar variance between the treatment modality groups. When evaluated based on fracture geometry, the DASH score was significantly higher in the patients with AO23A type fracture compared to the patients with AO23B and AO23C type fractures. As for MAYO score, all AO23 groups had similar outcomes.
Conclusions
Surgical treatment options VLP, EF, and K-wire provide adequate fixation, satisfactory radiological, and functional results for the management of distal radius fractures of various severities. The optimal treatment approach depends on individual features, and the choice for an internal fixation or closed reduction method for the restoration of wrist function should be evaluated thoroughly by the operating surgeon considering the patient-related variations.
... Смещение отломков кости при недостаточно адекватной репозиции, стойкий отек, повреждение мышц и тендинит сухожилия сгибателей пальцев могут стать причиной повреждения нервов (прежде всего, срединного) с развитием характерной симптоматики -нарушения чувствительности, невропатической боли, синдрома запястного канала, КРБС. По литературным данным, такие осложнения отмечаются в 2-8% случаев после перелома ЛК [45,46]. ...
Aim:
Evaluate the frequency, nature and course of PTP, as well as the effectiveness and safety of NSAIDs in PTP in real clinical practice.
Materials and methods:
The assessment of the condition and need for NSAIDs (original meloxicam) in 1115 outpatient patients who suffered a fracture of the radius (32.2%), injury to the knee (35.2%) or ligaments of the ankle (32.6%); women/men 51.5 and 48.5%, average age 46.915.5 years. We evaluated the dynamics of pain intensity (on a numerical rating scale NRS 010) at rest and during movement, the preservation of moderate and severe pain, as well as the development of adverse drugs reactions (ADR) to NSAIDs 48 weeks after injury.
Results:
The average intensity of pain during movement decreased from 7.031.66 to 2.211.38 (p0.001), at rest from 4.462.07 to 0.710.989 (p0.001). The number of people with pain severity 4 in the NRS in 48 weeks after the radius fracture, injury of the knee and ligaments of ankle was 21.0, 16.9 and 11.9%, with moderate or severe impairment of the injured limb 40.4, 26.2 and 16.3%, respectively. The need for taking NSAIDs up to 7 days was noted in 43.3%, 714 days-in 41.8%, more than 2 weeks or constantly in 14.9% of patients. Weak or moderate ADR were observed in 20.8% of patients, mainly dyspepsia and hypertension. Discontinuation of NSAIDs due to ADR was required in only 2.6% of patients. Pain retention 4 in NRS was associated with initially expressed pain (7 in NRS) OR 2.75 (95% CI 0.834.13; p0.001) and the presence of osteoarthritis of knee and/or hip OR 1.56 (95% CI 1.032.34; p=0.039).
Conclusion:
PTP decreases rapidly in most patients after a radius fracture, injury of the knee, and ankle ligament injury while taking the original meloxicam. However, in a significant part of patients, moderate or severe PTP persists after 48 weeks, which requires prolonged analgesic therapy and active rehabilitation.
Background
The dorsal spanning plate (DSP) is a versatile implant suitable for bridging severely comminuted intraarticular distal radius fractures [AO (Arbeitsgemeinschaft für Osteosynthesefragen) 23-C.1-C.3]. It may be used alone or with supplemental fixation such as a volar locking plate (VLP) or fragment-specific fixation (FSF). Outcomes following DSP fixation with additional implants have not been specifically evaluated.
Methods
We retrospectively reviewed consecutive patients who underwent internal fixation of a distal radius fracture by a single surgeon from 2017 to 2021. Patients were grouped according to implants used: DSP only, DSP + FSF, and DSP + VLP. Preoperative variables, treatment times, and wrist range of motion (ROM) were assessed. Functional wrist ROM was defined as minimum 80° combined flexion and extension.
Results
One hundred fifty-two patients underwent surgery for wrist fracture, 33 of them were treated with a DSP: 8 DSP only, 6 DSP + VLP, and 19 DSP + FSF. Falls from height greater than 10 ft accounted for 52% of injuries, most of which were treated with a DSP + FSF. Treatment times and ROM were similar between subgroups. Wrist ROM did not improve significantly beyond 4 weeks following DSP removal. Overall, DSP patients recovered a mean wrist ROM of 85° (range 0°-130°) within a median 26 weeks total treatment period (range 12-68 weeks).
Conclusion
Regardless of the construct used, if the distal radius articular surface is well reduced and other principles of fracture fixation are applied, most patients treated with a DSP can expect to regain functional wrist ROM.
Level of Evidence
Level IV—Retrospective review of prospectively collected data.
Background Our primary aim was to identify risk factors for subsidence development in nonoperatively treated distal radius fractures (DRFs). Secondary aims of the study included comparisons of subsidence progression over time with respect to DRF radiographic parameters.
Methods A retrospective cohort study of 70 patients with DRFs treated nonoperatively and followed for a minimum of 12 weeks was performed. Of the 70 patients, 29 had subsidence and 41 did not have subsidence. Radiographic measurements assessed the radial height (RH), ulnar variance (UV), volar tilt (VT), and radial inclination (RI). Outcome measures included demographics, injury characteristics, closed reduction, and radiographic measurements.
Results Nearly 95% of DRF subsidence occurred within the first 6 weeks after nonoperative treatment. The mean age of the 41 patients without DRF subsidence was 57.6 ± 16.8 years, and 31/41 (76%) patients were females. Conversely, the mean of the 29 patients with DRF subsidence was 63.8 ± 17.5 years, and 22/29 (76%) patients were females. Fractures requiring closed reduction were associated with more overall subsidence (p = 0.0009) and subsidence within the first 2 weeks posttreatment. Type C and comminuted fractures were associated with DRF subsidence (p = 0.02 and 0.01, respectively). The initial radiographic parameters and step-off measures were not associated with a higher risk of subsidence (p ≥ 0.05). Significant differences between subsidence progressions with respect to RH, UV, VT, and RI were observed.
Conclusion Most DRF subsidence occurs within the first 6 weeks of nonoperative treatment. Closed reduction, comminution, and AO fracture type are predictors of subsidence development. Moreover, DRF subsidence progresses at different rates depending on the radiographic parameter assessed.
