Immediate mobilization of distal radius fractures stabilized by volar locking plate results in a better short-term outcome than a five week immobilization: A prospective randomized trial.

OBJECTIVE: To evaluate the impact of immediate (first day after surgery) mobilization compared to standard five weeks cast immobilization on the functional outcome after volar locking plate fixation of distal radius fractures. DESIGN: Prospective randomized parallel group comparative trial. SETTING: Trauma Hospital, Austria. PARTICIPANTS: Patients with isolated unstable distal radius fractures, stabilized with volar angular stable locking plate. INTERVENTIONS: The immediate mobilization group received a removable forearm splint for one week and active supervised group physiotherapy and home exercises for the shoulder, elbow, wrist, and fingers from the first postoperative day. The cast immobilization group received a non-removable cast for five weeks. In the first five weeks supervised group physiotherapy and home exercises were performed for shoulder, elbow, and fingers. Thereafter additional supervised and home exercises for the wrist were started. MAIN MEASURES: At regular intervals of six and nine weeks, three and six months, and one year post surgery range of motion, grip strength, and x-rays were evaluated. Additionally, the shortened disabilities of the arm, shoulder and hand (QuickDASH) score, Patient-rated Wrist Evaluation, Mayo Wrist score, and pain according to the Visual Analog Scale score were analyzed. RESULTS: One hundred and sixteen patients were prospectively randomized into two study groups. At the one-year follow-up, patients in the immediate mobilization group showed a significantly higher range of motion in extension/flexion (mean difference 10.2°, 99% confidence interval 0.6-19.8), grip strength (mean difference 5.1 kg, 99% confidence interval -0.5 to 10.7), and Mayo Wrist score (mean difference 7.9 points, 99% confidence interval 2.3-13.5) than the cast immobilization group. Range of motion in supination/pronation (mean difference 13.4°, 99% confidence interval 1.5-25.3) and in radial/ulnar deviation (mean difference 6.3°, 99% confidence interval 0.9-11.7) differed significantly up to nine weeks favoring the immediate mobilization group. The Patient-rated Wrist Evaluation revealed significantly better scores after three months (mean difference 9.3 points, 99% confidence interval 0.5-18.1) and QuickDASH after six months (mean difference 7.3 points, 99% confidence interval 0.3-14.3) in the immediate mobilization group. All other subsequent follow-up examinations indicated no significant differences in respect of pain, range of motion, and patient-reported outcome measurements between the study groups. There were no significant differences in respect of radiological loss of reduction and complications between the groups. CONCLUSIONS: Immediate mobilization in combination with supervised physiotherapy of the wrist after volar locking plate fixation of unstable distal radius fractures results in a significantly improved range of motion and grip strength after one year compared to cast immobilization. No increased risk for loss of reduction and other complications was observed.

Volar Radioscapholunate Arthrodesis and Distal Scaphoidectomy After Malunited Distal Radius Fractures.

PURPOSE: The purpose of this study was to assess range of motion (ROM), pain, and incidence of radiographic degenerative joint disease (DJD) after volar radioscapholunate (RSL) arthrodesis and distal scaphoidectomy (DSE) following malunited distal radius fractures (DRF). METHODS: Fourteen patients with malunited DRF and DJD limited to the radiocarpal joint underwent RSL arthrodesis and DSE between 2006 and 2014. These were retrospectively analyzed both clinically and radiologically. Eleven patients with a mean follow-up of 63 months (range, 30-97 months) were included in the final analysis because 1 was unavailable and 2 had died. The outcome was evaluated using parameters of pain, ROM, grip strength, nonunion rate, and DJD of the adjacent joints. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Patient-Rated Wrist Evaluation score, and Michigan Hand Outcomes Questionnaire. To investigate DJD and union, a computed tomography (CT) scan at the final follow-up visit was performed. RESULTS: All patients showed union and no midcarpal DJD in the CT scans at final follow-up. The mean ROM in extension was 53°, flexion 42°, supination 81°, pronation 85°, radial deviation 10° and ulnar deviation 25°. The ROM in extension, extension/flexion arc, and supination improved significantly after surgery. Patients achieved a mean of 80% of grip strength compared with the other hand. CONCLUSIONS: Volar angular stable plate RSL arthrodesis with resection of the distal scaphoid pole is a safe and effective method for treating malunited DRF. This leads to an improved ROM and low pain level. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Results of dynamic treatment of fractures of the proximal phalanx of the hand.

BACKGROUND: The treatment of fractures of the proximal phalanx in three-phalanx fingers has for a long time been the domain of conservative static treatment in a plaster cast. After removal of the plaster, there was usually limitation of mobility of the interphalangeal joints. Fractures of the proximal phalanx are managed with conservative functional treatment in our clinic. The aim of this method is to achieve bony healing and free mobility at the same time and not in succession. We evaluated our treatment outcomes in a follow-up study. METHODS: The dressing consists of a dorsopalmar plaster splint and a so-called finger splint. The wrist and metacarpophalangeal joints are immobilized with the plaster cast. The wrist is dorsiflexed 30 degrees, and the metacarpophalangeal joints are flexed 70 degrees to 90 degrees. In this intrinsic plus position, the extensor aponeurosis is taut and covers two-thirds of the proximal phalanx, thus leading to firm splinting of the fracture. RESULTS: Sixty-five patients (46 men and 19 women) with 78 proximal phalanx fractures were followed up after an average of 23 months (12-69 months). The average age of the patients was 41 years (18-93 years). Among our patients, the ring finger was affected most often, with transverse fractures predominating. As regards the location, fractures in the proximal third were most frequent (51%). All fractures consolidated. Delayed fracture healing or pseudarthrosis was not observed. Sixty-seven fingers (86%) showed full range of motion at follow-up. In 11 cases (14%), there was limitation of finger joint movements, with inhibition of extension of the proximal interphalangeal joint in nine patients up to a maximum of 20 degrees. Two patients had limitation of flexion with a fingertip-palm distance of 1.1 cm. CONCLUSION: The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility at the same time and not in succession. Active exercises in the proximal and distal interphalangeal joints prevent limitations of mobility and the subsequent occurrence of rotational and axial deformities.

First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions.

BACKGROUND: Plate osteosynthesis of the scaphoid, as reported earlier by Ender, has lost its importance in the past few years, after Herbert's introduction of the simple and successful technique of screw osteosynthesis. Only in rare cases does one encounter failed healing or instability of the fragments. Even with a vascularized bone chip, it is not always possible to achieve consolidation. Particularly in these situations, poor interfragmentary stability seems to be the reason for failed healing. METHODS: Between January 2007 and August 2009, we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis. All the patients had fractures of the waist of the scaphoid with established nonunion persisting for at least 6 months after the causative injury, with wrist pain, weakness, or both. All 11 patients had clinical and radiologic follow-up for at least 6 months. RESULTS: All the fractures united at a median time from operation of ∼4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 points. CONCLUSIONS: Scaphoid plate osteosynthesis should be regarded as a salvage procedure, and the indication for the procedure should be established accordingly. It is a simple procedure in terms of technique. The plate can be adjusted very well to the anatomic shape of the scaphoid, and one can achieve a high degree of stability, particularly rotational stability.

Volar fixed-angle plating of extra-articular distal radius fractures--a biomechanical analysis comparing threaded screws and smooth pegs.

BACKGROUND: Distal radius fractures represent the most common fractures in adult individuals. Volar fixed-angle plating has become a popular modality for treating unstable distal radius fractures. Most of the plates allow insertion of either threaded locking screws or smooth locking pegs. To date, no biomechanical studies compare locking screws and pegs under axial and torsional loading. METHODS: Ten Sawbones radii were used to simulate an AO/OTA A3 fracture. Volar fixed-angle plates (Aptus Radius 2.5, Medartis, Switzerland) with threaded locking screws (n = 5) or smooth locking pegs (n = 5) were used to fix the distal metaphyseal fragment. Each specimen was tested under axial compression and under torsional load with a servohydraulic testing machine. Qualitative parameters were recorded as well as axial and torsional stiffness, torsion strength, energy absorbed during monotonic loading and energy absorbed in one cycle. RESULTS: Axial stiffness was comparable between both groups (p = 0.818). If smooth pegs were used, a 17% reduction of torsional stiffness (p = 0.017) and a 12% reduction of minimum torque (p = 0.012) were recorded. A 12% reduction of energy absorbed (p = 0.013) during monotonic loading and unloading was recorded if smooth pegs were used. A 34% reduction of energy absorbed in one cycle (p < 0.007) was recorded if threaded screws were used. Sliding of the pegs out of the distal radius metaphyses of the synthetic bones was recorded at a mean torque of 3.80 Nm ± 0.19 Nm. No sliding was recorded if threaded screws were used. CONCLUSIONS: According to the results of this study using Sawbones, volar fixed-angle plates with threaded locking screws alone are mechanically superior to volar fixed-angle plates with smooth locking pegs alone under torsional loading.

[Palmar radioscapholunate arthrodesis with distal scaphoidectomy]. / Radioskapholunäre Arthrodese mit Entfernung des distalen Skaphoidpols von palmar.

OBJECTIVE: Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint. INDICATIONS: Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II. CONTRAINDICATIONS: Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis. SURGICAL TECHNIQUE: The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K­wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws. POSTOPERATIVE MANAGEMENT: Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks. RESULTS: Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

Early Rehabilitation of Distal Radius Fractures Stabilized by Volar Locking Plate: A Prospective Randomized Pilot Study.

Background Distal radius fractures are very common and an increased incidence of 50% is estimated by 2030. Therefore, both operative and postsurgical treatment remains pertinent. Main aim in treating intra-articular fractures is to restore the articular surface by internal fixation and early mobilization (EM). Questions/Purposes The purpose of this study was to compare functional results between EM immediately after surgery and 5 weeks of immobilization (IM). Patients and Methods In a randomized prospective study, 30 patients with an isolated distal radius fracture were treated by open reduction and internal fixation using a single volar locking plate excluding bone graft. Fifteen patients were randomized in the EM group and 15 in the IM group. At 6 weeks, 9 weeks, 3 months, 6 months, and 1 year postsurgery, range of motion, grip strength and X-rays were evaluated. Additionally, Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Patient-Rated Wrist Evaluation (PRWE), modified Green O'Brien (Mayo) score, and pain according to the Visual Analog Scale score were analyzed. Results Patients in the EM group had a significantly better range of motion in the sagittal plane, in grip strength up to 6 months, in the frontal plane up to 9 weeks, and in forearm rotation up to 6 weeks. Also QuickDASH and PRWE scores were better up to 6 weeks postsurgery. The Green O'Brien score differed significantly up to 1 year. At 1 year, 93% "excellent" and "good" results in the Green O'Brien score with a mean QuickDASH of 5.98 ± 10.94 and PRWE score of 4.27 ± 9.23 were observed in the EM group. No differences regarding loss of reduction, pain, duration of physiotherapy, and sick leave were noted. Conclusion EM of surgically treated distal radius fractures (without bone graft) is a safe method for postoperative aftercare and leads to an improved range of motion and grip strength at 6 months postsurgery compared with an IM of 5 weeks. Level of Evidence This is a level Ib clinical study.