Four-Corner Concept: CT-Based Assessment of Fracture Patterns in Distal Radius.

Operative treatment using plate fixation is an important adjunct in the treatment of distal radius fractures, although the evidence for its superiority over other modalities remains limited. We propose a new concept for fractures of the distal radius, based on the three-column model of the distal radius, and on the expanding knowledge about the different fracture patterns obtained by evaluation of the distal radius by computed tomographic (CT) scan. All fracture types can be characterized by subdividing the wrist joint into four corners, each with its own characteristics in terms of mobility, stability, and transfer of forces in the intact distal radius. Recognition of the specific fracture types based on this four-corner concept enables a tailored approach to treatment.

[Distal radius fractures: new concepts as basis for surgical treatment]. / Distale Radiusfraktur: neue Konzepte als Basis für die operative Therapie.

New advances in the biomechanics and pathomechanics of distal radius fractures as well as new generations of plates and improved surgical approaches now make possible the stable management and early functional rehabilitation not only of simple but also of complicated distal radius fractures according to the principles for articular and juxta-articular fractures. Especially for complex articular fractures, the fracture patterns are so heterogeneous that an individual surgical treatment strategy must be developed for each case. The preoperative clarification of articular fractures with computed tomography is particularly useful for planning surgery. Mental exposition with the three-column model and pathomechanics is an important prerequisite for understanding this type of injury and the appropriate choice of operative technique. A decisive factor for success is the subtle surgical procedure in approaching and handling the fine plates.

[Management of complex distal radius fractures]. / Management komplexer distaler Radiusfrakturen.

Complex injuries of the distal radius can be associated with articular comminution, severe soft tissue injury, large metaphyseal and/or diaphyseal bone defects, carpal ligament tears or its combinations. We recommend a standardized three step approach for the management of these severe injuries: external fixation as an emergency procedure; treatment of soft tissue damage and further diagnostics as needed; definitive adapted operative therapy after thorough analysis of the specific injury.

[Dorsal double plating for fractures of the distal radius--a biomechanical concept and clinical experience]. / Die dorsale Doppelplattenosteosynthese am distalen Radius--ein biomechanisches Konzept und dessen klinische Realisation.

This article describes the anatomical and biomechanical rationale for stable internal fixation of distal radius fractures using a dorsal approach. The three column biomechanical model is illustrated. Advances in the understanding of the anatomy, the biomechanical model of the three columns and our clinical experience with dorsal double plating have lead to the development of a new set of precontoured 2.4 mm Titanium plates with the option for head locking screws.

[New concepts for stabilizing proximal humeral fractures]. / Neue Stabilisierungskonzepte bei proximalen Humerusfrakturen.

The treatment of proximal humerus fractures is overshadowed by problems like avascular humeral head necrosis, implant failure in osteopenic bone and moderate outcome, especially in the elderly. More precise imaging, a better understanding of the vascularity of the humeral head leading to indirect reduction techniques and new implants which allow for saver fixation even in osteopenic bone, allowing early functional aftercare, are the new promising factors which have the potential to ameliorate fracture treatment of the humeral head. A prerequisit for sucessful treatment is a thoroughful imaging which allows adequate preoperative planning. The type of stabilisation depends more on the surgeons preference and there are pros and cons with all implants. Functional after treatment however depends on the applied stabilisation principle and should be carefully monitored and adapted according to the bone healing process, monitored by regular postoperative x-ray controls.

[New principles in the surgical treatment of distal radius fractures -- locking implants]. / Neue Prinzipien der operativen Behandlung von distalen Radiusfrakturen--winkelstabile Implantate.

The treatment goal for fractures of the distal end of the radius is full functional recovery of the wrist. Prerequisites are restoration of the anatomy and early functional after treatment in accordance to the treatment guidelines for other articular and juxta-articular fractures. A better understanding of the anatomy and new biomechanical models lead to the development of new implants and operative techniques. The LCP-concept with locking screws had a considerable impact on recent advances in the operative treatment of distal radius fractures.

Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients.

Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50 degrees to 70 degrees apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients. Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one. Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study.

Three different plating techniques were used on experimentally produced dorsally displaced distal radius fractures in cadavers and were tested in 4-point bending: a AO 3.5-mm T plate (group 1), two 2. 0-mm titanium plates 60 degrees to each other (group 2), and the AO pi plate (group 3). A metaphyseal defect was simulated by a dorsally open wedge osteotomy. The tests show that the 2-mm double-plating technique has superior stiffness and statistically equivalent bending and bone gap to failure compared with the AO 3.5-mm T plate or the pi plate when applied to the unstable distal radius fracture model. (J Hand Surg 2000; 25A:29-33.

A new ultrasound-based method for the assessment of torsional differences following closed intramedullary nailing of femoral fractures.

OBJECTIVE: A torsional difference of more than 15 degrees is found in up to 30% of patients following closed intramedullary nailing of femoral fractures. The diagnosis is usually established postoperatively by computed tomography. A torsional deformity of more than 15 degrees should be corrected by early derotation. In order to enable an intraoperative control and possible correction to avoid a second operation for the patient, a new ultrasound-based method suitable for the intraoperative setting has been developed, using the anterior condylar line as a distal reference line. DESIGN AND PATIENTS: In a prospective study the torsional difference after closed intramedullary nailing of femoral fractures was measured postoperatively by ultrasound in 32 patients and compared with standard CT readings. RESULTS: Torsional differences measured by ultrasound and CT showed a high correlation (r = 0.8) and a median difference of less than +/-3 degrees. CONCLUSIONS: By the introduction of the anterior condylar line as a distal reference line femoral torsion can accurately be assessed by ultrasound in a position required for intraoperative control and possible correction.

Long-term results of the external fixation of distal radius fractures.

OBJECTIVE: To evaluate the long-term results of external fixation of distal radius fractures. METHODS: A retrospective follow-up study (median follow-up, 5.3 years) of 49 patients with 50 distal radius fractures treated with an external fixator was carried out. An external fixator (Minifixator, Stratec Medical, Waldenburg, Switzerland) was used. The operative procedure is described in detail. A personal evaluation including clinical and radiologic assessment of both wrists was performed. RESULTS: The functional results, including the parameters strength, daily activities, range of motion, and presence of pain, as well as an anatomic score, the presence of osteoarthritis, the quality of reduction, and complications were recorded. Functional and anatomic results indicated excellent to good ratings in more than 80% of the cases. CONCLUSION: The external fixator is a versatile tool in the treatment of intra-articular and extra-articular fractures of the distal radius. The rate of algodystrophy (reflex sympathetic dystrophy) was 6%, and wrist stiffness was not found in our series.

Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases.

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency. Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the 'lateral' and the 'intermediate' columns of the wrist at an angle of 50 degrees to 70 degrees. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all.