Volar plating of distal radius fractures does not restore the anatomy.

INTRODUCTION: The objective of this study was to evaluate whether volar locking plating can restore the anatomical volar tilt of 12° and the anatomical length of the radius relative to the ulna. We retrospectively reviewed the radio-graphic outcome of distal radius fractures treated with two different first-generation locking plate systems; VariAx (Stryker) and Acu-Loc (Acumed). METHODS: Three independent observers evaluated radial volar tilt and ulnar variance (> 2 mm) on radiographs taken preoperatively, immediately after the operation and five weeks later. In addition, the radial inclination, distal radio-ulnar joint incongruity and articular step-off were assessed in order to describe the personality of the fracture. RESULTS: A total of 576 fracture cases were included in the study. Preoperatively, the mean volar tilt was 18 ± 6° and -15 ± 11° for volarly and dorsally displaced fractures, respect-ively. After operation, the mean volar tilt was 4.5 ± 6° without any significant changes after five weeks, p = 0.79 and no significant differences with respect to fracture type or type of plate. Thus, the anatomical angulation of 12° was not achieved at any point in time after surgery (p < 0.001). Shortening of the radius (> 2 mm ulnar variance) was still seen in 9% of the cases immediately after surgery and in 22% after five weeks. CONCLUSIONS: Volar locking plating did not restore the anatomy after distal radius fractures. The clinical implication of these findings is unclear because the functional outcome of the patients was not available. Level of evidence, level IV. FUNDING: none. TRIAL REGISTRATION: not relevant.

Distal radius fractures are difficult to classify.

BACKGROUND: Traditionally, distal radius fractures (DRFs) have been described using eponyms, e.g. Colles, Smith, Barton, Chauffeur. During the last half of the 20th century several classification systems for DRF have emerged. We evaluated the inter- and intra-observer agreement of the AO/OTA, Frykman and Older classification systems. METHODS: Four observers, an intern, an orthopaedic registrar, an orthopaedic consultant and a radiology consultant, independently evaluated DRF radiograms and classified the fractures according to the AO/OTA, Frykman and Older classification systems. After an interval of 6 months, radiograms of 30 randomly chosen patients were re-evaluated by the same observers. RESULTS: Radiograms of 573 DRF patients were evaluated in the study. The inter-observer reliability of the AO/OTA fracture types (A, B and C) was 'weak' (kappa = 0.45). The agreement dropped to 'minimal' (kappa = 0.24) regarding the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3). The reliability of the Frykman classification system was 'weak' (kappa = 0.41), and we observed the lowest inter-observer reliability for the Older classification system (kappa = 0.10). The kappa values for the intra-observer reproducibility of the AO/OTA fracture types (A, B and C) ranged from 0.58 to 0.87. For the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3) the reproducibility was lower ranging from 'minimal' to 'weak'. The intra-observer reproducibility of the Frykman system was 'weak' to 'moderate' and even worse for the Older classification system. CONCLUSION: Based on these findings the AO/OTA classification system seems to be most reliable for routine use, however, with lower kappa values concerning the agreement for the groups. The Frykman and Older classification systems cannot be recommended because of less convincing results.

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up.

BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate. METHODS: Retrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted. RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125) with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed. CONCLUSION: The majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.