[Diagnostics and classification of distal radius fractures]. / Diagnostik und Klassifikation der distalen Radiusfraktur.

Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X­ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

Establishment and preliminary evaluation of CT-based classification for distal radius fracture.

Establish a new classification system of distal radius fracture based on computed tomographic (CT), and evaluate its reliability and reproducibility preliminarily, and provide a new theoretical reference for clinicians to use the clinical classification system. The imaging data and clinical data of 204 inpatients with distal radius fracture during 6 years from January 1, 2014 to January 1, 2019 in orthopaedic department were analyzed retrospectively and classified based on CT. Three observers evaluated the image data of 48 randomly selected cases based on CT at different time nodes of T1 and T2. Cohen's kappa was used to calculate the consistency. At the last follow-up, patients' Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and VAS scores were collected. Among 204 cases, there were 12 cases of type 1, including 6 cases of type 1-D, 4 cases of type 1-V and 2 cases of type 1-R. There were 6 cases of type 2, including 2 cases of type 2-DV, 2 cases of type 2-DR and 2 cases of type 2-VR. There were 186 cases of type 3, including 32 cases of type 3-0, 127 cases of type 3-1 and 27 cases of type 3-2. There was no significant difference in DASH, PRWE and VAS scores among all types (P > 0.05). The results of interobserver reproducibility were kappa = 0.985, ICC = 0.984 in the first evaluation, kappa = 0.986, ICC = 0.986 in the second evaluation. The results of intraobserver reproducibility were O1 = 0.991, O2 = 0.991, O3 = 0.989 respectively. The new classification system of distal radius fracture based on CT has theoretical and practical significance for incision selection, fracture reduction and internal fixation. 123 classification system is clear, comprehensive, easy to understand and remember. Moreover, it has higher interobserver reliability and intraobserver reproducibility than other systems reported at present.

Evaluation of Intra- and Interobserver Reproducibility of the New AO/OTA Classification for Distal Radius Fractures Compared with the Fernandez Classification / Avaliação da reprodutibilidade intra- e interobservador da nova classificação AO/OTA para fraturas distais do rádio comparada com a classificação de Fernandez

Abstract Objective To evaluate the inter- and intraobserver reliability and reproducibility of the new AO/OTA 2018 classification for distal radius fractures and to compare it with the Fernandez classification system. Method A questionnaire was applied in the Qualtrics software on 10 specialists in hand surgery who classified 50 radiographs of distal radius fractures according to the Fernandez and AO/OTA 2018 classifications and, subsequently, indicated their treatment. The questionnaire was applied in time T0 and repeated after 4 weeks (t1). The mean agreement between the answers, and the reliability and inter- and intraobserver reproducibility were analyzed using kappa indexes. Results The mean interobserver agreement in the Fernandez classification was 76.4, and it was 59.2% in the AO/OTA 2018 classification. The intraobserver agreements were 77.3 and 56.6%, respectively. The inter- and intraobserver kappa indexes for the Fernandez classification were 0.57 and 0.55, respectively, and, in the AO/OTA 2018 classification, they were 0.34 and 0.31, respectively. Conclusion The AO/OTA 2018 classification showed a low intra- and interobserver reproducibility when compared with the Fernandez classification. However, both classifications have low intra- and interobserver indexes. Although the Fernandez classification did not obtain excellent results, it remains with better agreement for routine use.

Resumo Objetivo Avaliar a confiabilidade e a reprodutibilidade inter- e intraobservadores da nova classificação AO/OTA 2018 para fraturas distais do rádio e compará-la com o sistema classificatório de Fernandez. Métodos Foi aplicado um questionário no software Qualtrics em 10 especialistas em cirurgia da mão que classificaram 50 radiografias de fraturas distais de rádio de acordo com as classificações de Fernandez e AO/OTA 2018 e, posteriormente, indicaram seu tratamento. Esse questionário foi aplicado em tempo T0 e repetido após 4 semanas (t1). Analisou-se a média de concordância entre as respostas e confiabilidade e reprodutibilidade inter- e intraobservadores utilizando os índices kappa. Resultados A concordância média interobservador para a classificação de Fernandez foi de 76,4, e de 59,2% para a AO/OTA 2018. A concordância intraobservador foi de 77,3 e 56,6%, respectivamente. O índice de kappa inter- e intraobservador para a classificação de Fernandez foram de 0,57 e de 0,55, respectivamente, e a classificação AO/OTA 2018 obteve 0,34 e 0,31, respectivamente. Conclusão A classificação AO/OTA 2018 mostrou uma reprodutibilidade intra- e interobservadores baixa quando comparada à classificação de Fernandez. Porém, ambas as classificações apresentam índices intra- e interobservadores baixos. Embora a classificação de Fernandez não tenha obtido resultados excelentes, ela permanece com melhor concordância para o uso rotineiro.

The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence.

PURPOSE: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. METHODS: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. RESULTS: The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48). CONCLUSIONS: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. CLINICAL RELEVANCE: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Common Fractures of the Radius and Ulna.

Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures. A fall onto an outstretched hand is the most common mechanism of injury for fractures of the radius and ulna. Evaluation with radiography or ultrasonography usually can confirm the diagnosis. If initial imaging findings are negative and suspicion of fracture remains, splinting and repeat radiography in seven to 14 days should be performed. Incomplete compression fractures without cortical disruption, called buckle (torus) fractures, are common in children. Greenstick fractures, which have cortical disruption, are also common in children. Depending on the degree of angulation, buckle and greenstick fractures can be managed with immobilization. In adults, distal radius fractures are the most common forearm fractures and are typically caused by a fall onto an outstretched hand. A nondisplaced, or minimally displaced, distal radius fracture is initially treated with a sugar-tong splint, followed by a short-arm cast for a minimum of three weeks. It should be noted that these fractures may be complicated by a median nerve injury. Isolated midshaft ulna (nightstick) fractures are often caused by a direct blow to the forearm. These fractures are treated with immobilization or surgery, depending on the degree of displacement and angulation. Combined fractures involving both the ulna and radius generally require surgical correction. Radial head fractures may be difficult to visualize on initial imaging but should be suspected when there are limitations of elbow extension and supination following trauma. Treatment of radial head fractures depends on the specific characteristics of the fracture using the Mason classification.

Combined palmar and dorsal plating of four-part distal radius fractures: Our clinical and radiological results.

OBJECTIVES: This study aims to investigate the radiological and clinical outcomes of four-part intraarticular distal radius fractures treated with a volar anatomically locked plate and 2 mm low-profile plates using both the volar and dorsal approaches. PATIENTS AND METHODS: This retrospective study included 20 patients (8 males, 12 females; mean age 47±12.1; range, 25 to 67 years) who received open reduction and internal fixation with combined volar and dorsal plating to treat complex four-part distal radius fractures (shaft, radial styloid area, dorsal medial facet, volar medial facet) between May 2016 and January 2019. According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, all fractures were 2R3-C3. According to Melone classification, one fracture was type 1, seven fractures were type 2a, three were type 2b, three were type 3 and six were type 4. The mean follow-up time was 21±7.5 (range, 12 to 36) months. RESULTS: Union was achieved in all fractures. The mean tourniquet time was 103±12 (range, 90 to 130) minutes. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 10±9, and the mean Visual Analog Scale score was 2.1±0.9. According to Mayo wrist score, five patients had excellent, six had good, six had satisfactory and three had poor results. The mean grip strength was 25.2±9.2 (range, 15 to 40) kg and 78% of opposite side. Mean wrist flexion was 48.7°±15.3° (range, 30° to 80°), extension was 52.2°±17.2° (range, 25° to 80°), radio-ulnar deviation arc was 40.7°±6.9° (range, 30° to 55°), and mean forearm rotation arc was 152.3°±11° (range, 130° to 170°). CONCLUSION: Plating method with a dual approach may be an alternative for four-part intraarticular distal radius fractures given its early mobility advantage and satisfactory functional and radiological results.

Fracture-dislocations of the forearm joint: a systematic review of the literature and a comprehensive locker-based classification system.

BACKGROUND: Monteggia, Galeazzi, and Essex-Lopresti injuries are the most common types of fracture-dislocation of the forearm. Uncommon variants and rare traumatic patterns of forearm fracture-dislocations have sometimes been reported in literature. In this study we systematically review the literature to identify and classify all cases of forearm joint injury pattern according to the forearm joint and three-locker concepts. METHODS: A comprehensive search of the PubMed database was performed based on major pathological conditions involving fracture-dislocation of the forearm. Essex-Lopresti injury, Monteggia and Galeazzi fracture-dislocations, and proximal and/or distal radioulnar joint dislocations were sought. After article retrieval, the types of forearm lesion were classified using the following numerical algorithm: proximal forearm joint 1 [including proximal radioulnar joint (PRUJ) dislocation with or without radial head fractures], middle radioulnar joint 2, if concomitant radial fracture R, if concomitant interosseous membrane rupture I, if concomitant ulnar fracture U, and distal radioulnar joint 3 [including distal radioulnar joint (DRUJ) dislocation with or without distal radial fractures]. RESULTS: Eighty hundred eighty-four articles were identified through PubMed, and after bibliographic research, duplication removal, and study screening, 462 articles were selected. According to exclusion criteria, 44 full-text articles describing atypical forearm fracture-dislocation were included. Three historical reviews were added separately to the process. We detected rare patterns of two-locker injuries, sometimes referred to using improper terms of variant or equivalent types of Monteggia and Galeazzi injuries. Furthermore, we identified a group of three-locker injuries, other than Essex-Lopresti, associated with ulnar and/or radial shaft fracture causing longitudinal instability. In addition to fracture-dislocations commonly referred to using historical eponyms (Monteggia, Galeazzi, and Essex-Lopresti), our classification system, to the best of the authors' knowledge, allowed us to include all types of dislocation and fracture-dislocation of the forearm joint reported in literature. According to this classification, and similarly to that of the elbow, we could distinguish between simple dislocations and complex dislocations (fracture-dislocations) of the forearm joint. CONCLUSIONS: All injury patterns may be previously identified using an alphanumeric code. This might avoid confusion in forearm fracture-dislocations nomenclature and help surgeons with detection of lesions, guiding surgical treatment. LEVEL OF EVIDENCE: V.

Melone's concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping.

BACKGROUND: There is no consensus in the literature about the ideal classification of the distal radius fracture for the clinical practice. The traditional Melone classification system divides the distal radius into four basic components, the shaft, radial styloid, dorsal medial fragment, and volar medial fragment. The aim of this study was to identify fracture lines in comminuted distal radius fractures using three-dimensional mapping of computed tomography (CT) images to test the hypothesis that fracture fragments can be divided according to the Melone classification. METHODS: Fifty-nine consecutive OTA/AO 23C3 fractures presented at the hospital between January 2018 and October 2019 were retrospectively reviewed. The fracture lines were characterized in the axial, sagittal, and coronal CT planes. After reducing the fractures in a three-dimensional (3D) model, the fracture lines were plotted from the CT images and were then superimposed on one another and oriented to fit a standard template. The area of articular surfaces was measured and compared to quantify the differences between the radial bone fragments. RESULTS: Thirty-five cases (59.3%) in this study fit the Melone classification and 24 cases (40.7%) did not. On the radiocarpal surface, there was a greater concentration of fracture lines in the dorsal area of the radius than in the volar area. On the distal radioulnar joint (DRUJ), the fracture lines were focused around two specific concentrated regions. For the articular surface area, the mean area of the radial styloid, volar medial fragment, and dorsal medial fragment was 141.13 ± 90.16 mm2, 147.79 ± 75.94 mm2, and 79.05 ± 70.73 mm2, respectively. There was a significant difference in articular surface area for the Melone fragments (P = 0.002). CONCLUSIONS: The Melone classification system is not suitable for characterizing all C3 fractures. The findings of this study confirm that the dorsal medial fragments are relatively comminuted and small. Extra care should be given to these small fragments when reducing the fracture.

Comparative results of radius distal AO type C1 fractures of elderly women by two different techniques.

ackgrounds: We evaluated clinical and radiographic outcomes of volar locking plates and close reduction with percutaneous pinning treatment approaches for elderly female patients with AO type C1 simple intra-articular distal radius fractures. PATIENTS AND METHODS: We conducted retrospective studies of 72 elderly female patients with AO type C1 simple intra-articular DRFs treated with VLPs or CRPP, from 2012 to 2018. The patients were divided into two groups: There were 38 patients in VLP group and 34 patients in CRPP group. Periodic clinical and radiological evaluation was performed at 2nd, 4th, 6th, 8th weeks and in 6 and 12 months intervals for all patients. We recorded the patient-rated wrist evaluation scores, flexion, extension, supination and pronation degrees and radiographic outcome scores at the end of 6th and 12 months after surgery. RESULTS: A total number of 72 patients were studied. 38 patients were treated with VLP and 34 patients were treated with CRPP .The mean age of the patients was 70,5 years. Comparing the PRWE scores, the VAS scores and the ROM degrees between the 2 groups yielded no significant difference at any time point between 6 months and 1 year. There were no differences in radiographic outcomes at the latest reported follow up between the two interventions and there was no significant difference in the complication between the 2 groups (VLP 6 and CRPP 6) complications. CONCLUSIONS: Complicated surgeries should be avoided because of specific problems in women aged 60 years or older. Our study show that VLP and CRPP techniques had little differences and similar clinical and radiographic results.

Volar, Splitting, and Collapsed Type of Die-Punch Fracture Treated by Volar Locking Plate (VLP): A Retrospective Study.

OBJECTIVE: To compare the results of different types of die-punch fractures treated by volar locking plate (VLP). METHODS: Between January 2013 and February 2018, a total of 71 patients with die-punch fracture of distal radius were treated by VLP and their medical records were retrospectively reviewed. Of them, 18 were classified as volar type, 24 as splitting type, and 28 as collapsed type of fracture, based on the preoperative radiographs and CT scans. The minimum follow-up period was 12 months. Radiological parameters, wrist function, range of motion (ROM), and complications were evaluated and compared. Pearson chi-square test was used to assess the difference of gender distribution, injury side, dominance, mechanism, type and classification of fracture, and postoperative complications, when necessary (P < 0.05), followed by pairwise comparisons using partitions of chi-square test. Two-tailed P value <0.05 was considered as statistically significant. For pairwise comparisons, adjustment of statistical level as P < 0.017 (0.05/3) was used. SPSS 21.0 was used to perform all the analyses. RESULTS: The mean follow-up time was 14.5 months, and at the mean of postoperative 8 weeks all patients obtained bony union, without delayed or non-union. The grip strength was 26.6 ± 7.9 kg for patients in volar fracture group, 27.0 ± 9.4 kg in splitting group, and 26.2 ± 9.4 kg in collapsed group, without significant difference (P = 0.628).The disabilities of the arm, shoulder, and hand (DASH) (9.2 ± 10.0 for volar group, 8.8 ± 7.9 for splitting group, and 10.6 ± 8.7 for collapsed group) or Gartland-Werley score (5.1 ± 2.8 for volar group, 4.8 ± 3.2 for splitting group, and 6.4 ± 2.7 for collapsed group) either did not differ among the three groups (all P > 0.05). There was a poorer ROM in the group of collapsed fractures, but the difference was non-significant for any parameter (P > 0.05). As for radiographic parameters, we did not find any significant difference for volar tilt, radial inclination, radial height, and ulnar variance (all P > 0.05), except for articular step-off (P < 0.001). Pairwise comparisons showed a significantly greater step-off (1.2 mm vs 0.4 mm, 0.5 mm) and higher rate of total complications in group of collapsed fracture (39.3%), compared to either volar (10.5%) or splitting type (12.5%). CONCLUSIONS: The collapsed type of die-punch fracture posed a greater articular step-off and a higher rate of complications, especially secondary wrist osteoarthritis, which deserved more attention in clinical treatment.

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures.

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an observational study of 23,394 fractures from the national Swedish fracture register.

BACKGROUND: Distal radius fractures are the most common of all fractures. Optimal treatment is still debated. Previous studies report substantial changes in treatment trends in recent decades. Few nation-wide studies on distal radius fracture epidemiology and treatment exist, none of which provide detailed data on patient and injury characteristics, fracture pattern and mortality. The aim of this study was to describe the epidemiology, fracture classification, current treatment regimens and mortality of distal radius fractures in adults within the context of a large national register study. METHODS: We performed a descriptive study using prospectively registered data from the Swedish fracture register. Included were all non-pathological distal radius fractures registered between January 1st 2015 and December 31st 2017 in patients aged 18 years and above. Nominal variables were presented as proportions of all registered fractures. RESULTS: A total of 23,394 distal radius fractures in 22,962 patients were identified. The mean age was 62.7 ± 17.6 years for all, 65.4 ± 16.0 for women and 53.6 ± 20.0 for men. A simple fall was the most common cause of injury (75%, n = 17,643/23,394). One third (33%, n = 7783/21,723) of all fractures occurred at the patients' residence. 65% (n = 15,178/23,394) of all fractures were classified as extra-articular AO-23-A, 12% (n = 2770/23,394) as partially intra-articular AO-23-B and 23% (n = 5446/23,394) as intra-articular AO-23-C. The primary treatment was non-surgical for 74% (n = 17,358/23,369) and surgical for 26% (n = 6011/23,369) of all fractures. Only 18% of the AO-23-A fractures were treated surgically, compared to 48% of the AO-23-C fractures. The most frequently used surgical method was plate fixation (82%, n = 4954/5972), followed by pin/wire fixation (8.2%, n = 490/5972), external fixation (4.8%, n = 289/5972) and other methods (4.0%, n = 239/5972). The overall 30-day mortality was 0.4% (n = 98/23,394) and the 1-year mortality 2.9% (n = 679/23,394). CONCLUSION: This nation-wide observational study provides comprehensive data on the epidemiology, fracture classification and current treatment regimens of distal radius fractures in a western European setting. The most common patient was an eldery woman who sustained a distal radius fracture through a simple fall in her own residence, and whose fracture was extra-articluar and treated non-surgically.

A retrospective evaluation of reliability and reproducibility of Arbeitsgemeinschaftfür Osteosynthesefragen classification and Fernandez classification for distal radius fracture.

This is a retrospective evaluated. The objective of this study was to test the interobserver reliability and intraobserver reproducibility of fracture classification with Arbeitsgemeinschaftfür Osteosynthesefragen (AO) system and Fernandez system used by 5 senior orthopedic surgeons.Anteroposterior and lateral radiographs of 160 patients hospitalized for displaced distal radius fracture were examined. Independently, 5 orthopedic surgeons evaluated the radiographs according to 2 different distal radius classification systems (3 types of results). Three statistical tools were used to measure interobserver reliability and intraobserver reproducibility. The intraclass correlation coefficient and kappa coefficient (k) were used to assess both interobserver and intraobserver agreement of AO and Fernandez. Kappa value indicated poor agreement (<0), slight (0-0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), and perfect (0.81-1.00).The intraobserver reproducibility of AO system (9 types) and Fernandez system were moderate with a value of 0.577 and 0.438. The intraobserver reproducibility of AO system (27 subtypes) was 0.286. The interobserver reliability of AO system (9 types) was moderate with a value of 0.469 and that of Fernandez was moderate with a value of 0.435. The interobserver reliability of AO system (27 subtypes) was 0.299.Neither of the 2 systems can give us a satisfactory agreement between interobserver reliability and intraobserver reproducibility. In AO system, the interobserver reliability and intraobserver reproducibility of the 9 types decreased with the increase of subgroups.

Clinical and radiological evaluation of surgical management in olecranon fracture-dislocations.

PURPOSE: The treatment of olecranon fracture-dislocations (OFDs) remains challenging. OFDs are often misdiagnosed as Monteggia lesions, and the real frequency is actually higher. However, studies on OFDs are limited. This study aimed to report on the surgical management of OFDs and to highlight the importance of three-dimensional computed tomography (3D CT) evaluation in the treatment of OFDs. MATERIALS AND METHODS: The study participants included 18 patients (11 men, 7 women, mean age 44 years (range 24-78) with OFDs. Each patient's medical records, radiographs, and 3D CT scans were reviewed for demographics, injury details, operative findings, and information about radiological and functional outcomes. The patients were divided into 2 groups according to the direction of the dislocation: the posterior dislocation group (group 1, 7 patients) and anterior dislocation group (group 2, 11 patients). The clinical evaluation was performed according to Broberg-Morrey and the American Shoulder and Elbow Surgeons-Elbow (ASES-E) scoring systems. RESULTS: The mean follow-up period was 39 months (range 25-62 months). The Broberg-Morrey results were excellent in 4, good in 9, fair in 3, and poor in 2 patients. The mean ASES-E score was 84.83 (range 48-100) points. There were signs of ulna-humeral arthrosis in 5 elbows. Arthrosis was graded as grade 1, grade 2, and grade 3 in 3, 1, and 1 elbows, respectively. Partial sensory recovery was observed in one patient with postoperative ulnar neuropathy at the last follow-up visit. CONCLUSIONS: OFDs are complex injuries of the proximal ulna and may involve the radial head, coronoid process, and lateral collateral ligament. The effective treatment of OFDs begins with the proper identification of the injury with 3D CT. A secure fixation including the coronoid process is mandatory for the elbow joint stability. Insufficient restoration of the trochlear notch may lead to problems with loss of motion and arthrosis. Although an application of a pre-contoured locking anatomical olecranon plate can simplify the fixation procedure in most cases, the surgeons' equipment should also include radial head implant, coronoid plates, headless screws, small cannulated screw system, suture anchors, fluoroscopy, and articulated external fixator.

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types.

The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P<0.0001). The prevalence of soft tissue lesions secondary to intraarticular fractures of the distal radius was 68.4%. However, there was no statistically significant relationship between the different types of radius fractures and soft tissue injuries. On the other hand, ulnar styloid fracture was predictive of TFCC injury.

Morphological characteristics of different types of distal radius die-punch fractures based on three-column theory.

OBJECTIVE: The aim of this study is to investigate the morphological characteristics of distal radius die-punch fracture (DRDPF) with different types, based on the three-column theory. METHODS: The imaging data of 560 patients diagnosed with DRDPF were reviewed and divided into single-column, double-column, or three-column DRDPF according to the three-column theory, and the types, case distribution of DRDPF, and inter- and intra-agreement of classification were further analyzed. RESULTS: There were 65 cases of single-column DRDPF, 406 cases of double-column DRDPF, and 89 cases of three-column DRDPF. Among the single-column DRDPF, there were three cases of volar, 13 cases of dorsal, 14 cases of split, and 35 cases of collapse type fractures. Among the radius column fracture, there were 130 cases of metaphseal,155 cases of articular surface, and 210 cases of combined type. The inter-observer Kappa coefficient was 0.877-0.937, and the intra-observer kappa was 0.916-0.959, showing high agreement. At the 12th month's follow-up, according to the Gartland-Werley score system for the functionary recovery of the wrist and hand, 519 cases (92.68%) of the patients ranked excellent or good, and 41 cases (7.32%) ranked fair. All the cases were fair results, and the intermediate column of the distal radius was collapse type fractures, showing significant difference between the collapse type and other types (χ2 = 23.460, P = 0.000). The excellent and good rate in the single-, double-, and three-column DRDPFs were 93.85%, 92.16%, and 91.01%, respectively (χ2 = 0.018, P = 0.991). CONCLUSION: Due to the difference of the nature and energy of the forces, the position of wrist, and the bone quality of the patients at the moment of the injury, the loading forces transmitted to the intermediate column of the distal radius could result in different types of DRDPF. The classification method in this study included all types of DRDPF, indicating the mechanism, affected sites, and the morphological characteristics of DRDPF with high consistency, which hopefully could provide insight into the treatment and prognosis of DRDPF patients.

Proximal Radius Fractures in Children.

Fractures of the proximal radius represent 5% to 10% of all elbow fractures in children. These fractures have many treatment options and have a high risk of complication, particularly loss of forearm rotation. Nonsurgical management of minimally displaced radial neck fractures produces excellent results in most patients. For displaced fractures, numerous methods of closed and percutaneous reduction have been proposed, whereas open reduction has been associated with particularly poor outcome. Many additional factors, including fracture angulation, patient age, associated injury, articular involvement, and internal fixation, may lead to worse outcomes. Because the literature is limited to retrospective case series, few studies provide high-level evidence to guide the treatment of pediatric proximal radius fractures; however, certain management principles have been established that are reviewed here.

Biomechanical Comparison of Titanium Locking Fragment-Specific and Volar Locking Plates for AO B1 and B2 Fractures of the Distal Radius.

PURPOSE: This biomechanical study compared the stability of volar locking plates (VLPs) and locking fragment-specific (LFS) dorsal and radial styloid plates for the fixation of dorsal (AO 23-B2) and radial styloid (AO 23-B1) shear fractures of the distal radius, respectively. METHODS: Two groups of 6 composite radii were fixed with a VLP or an LFS dorsal plate over a simulated dorsal shear fracture. Two additional groups of 6 radii received the same VLP or an LFS radial plate to fix a radial styloid fracture. Each plated radius was tested under cyclic axial compression by a servohydraulic testing machine that recorded axial displacement per cycle. Construct stiffness was calculated from the slope of the force-displacement curve. RESULTS: In the dorsal shear fracture model, the dorsal LFS plate exhibited less displacement than the VLP (0.32 ± 0.04 vs 0.43 ± 0.07 mm, respectively) and showed greater average stiffness (645 ± 64 vs 433 ± 88 N/mm, respectively). Plate type was responsible for 53.1% of the variation in displacement and 68.6% of the variation in stiffness. In the radial styloid fracture model, variations due to number of cycles elapsed and plate type were similar for displacement and stiffness in both groups. The average stiffness during cyclical nondestructive testing was 566 ± 45 and 573 ± 60 N/mm for VLP and LFS radial plating groups, respectively. CONCLUSIONS: For AO 23-B2 (dorsal rim) fractures, the dorsal LFS plates exhibited significantly less displacement and greater stiffness in axial loading than VLPs. For AO 23-B1 (radial styloid) fractures, the VLP displayed similar displacement and stiffness to the radial LFS plates. CLINICAL RELEVANCE: All constructs tested could be expected to withstand axial compressive forces typical of early postoperative rehabilitation.

Analyses of fracture line distribution in intra-articular distal radius fractures.

PURPOSE: To assess the association between the fracture line distribution and the location of comminution in intra-articular distal radius fractures by building fracture mapping. PATIENTS/METHODS: Forty cases with intra-articular fractures of distal radius were enrolled in the current prospective clinical study. Fracture lines and comminution zones were identified by reduced three-dimensional computed tomography reconstructions and then graphically superimposed onto a standard template to create two-dimensional fracture maps, followed by the conversion into heating maps. Based on qualitative descriptive fracture mapping analyses, the patterns of intra-articular distal radius fractures were determined. RESULTS: It was observed that the highest fracture line intensity was located as an inverted "T" shape zone in the dorsal aspect of the joint with high incidence of fractures and the prominently intense color in heat mapping. The keystone projected area, the radial styloid process and the metacarpal radial side articular surface were found to be the least involved parts of the fracture. According to the mapping of the number and distribution of fracture lines, a new classification method for intra-articular fractures of the distal radius was redefined. Different surgical approaches and internal fixation techniques were proposed for different types. In this paper, we retrospectively compared the preoperative X-ray findings between different types. Based on the preoperative X-ray prediction, the distal intra-articular radius fractures were classified, so as to develop effective surgical strategies. In this study, a new surgical approach was attempted, but due to the lack of evidence-based evidence, long-term postoperative complications and hand function should be further evaluated. CONCLUSION: This study redefines a new method for the classification of intra-articular fractures of the distal radius, which allows doctors to have a clearer understanding of the characteristics of distal radius fractures. Moreover, the application value in fracture diagnosis is more significant, and the best surgical approach is selected for different types.

Fracture energy threshold in parry injuries due to sharp and blunt force.

Blows with axes, machetes or blunt objects such as baseball bats, truncheons, etc. are often parried, resulting in typical parry injuries, or so-called nightstick fractures to the ulna. In this study, we sought to assess the impact energy required to break the ulna in such parry incidents in an experimental setting using semisynthetic and fully synthetic models. Twenty-seven sheep radii and 33 polyurethane synthetic bones were cast into gelatin prior to being fired at with missiles made of a section of an axe blade or steel rod at different firing velocities using a compressed-nitrogen cannon. Each model was then examined as to the presence of hair-line fractures or complete fractures. Sheep bones and synthetic bones displayed comparable results when struck by the axe missile; here, a clear fracture threshold was evident between 14.00 and 15.26 J. When struck by the rod missile, only the synthetic bones produced significant results, namely a fracture threshold between 20.15 and 23.59 J. In conclusion, our results show an ulnar fracture threshold of approximately 15 J when struck by an axe. The experiments regarding blows with a rod displayed a fracture threshold of around 22 J, but, as this could not be validated with biological bones, this result is questionable.