Elsevier

Injury

Volume 50, Supplement 1, June 2019, Pages S50-S55
Injury

The use of dorsal distraction plating for severely comminuted distal radius fractures: A review and comparison to volar plate fixation

https://doi.org/10.1016/j.injury.2019.03.052Get rights and content

Highlights

  • The current evidence suggests that patients treated with dorsal distraction plating for distal radius fractures regain 48° of flexion and 51° of extension. Furthermore, patients were able to achieve 76° of supination and 74° of pronation. Grip strength was found to be 80% compared to the contralateral, uninjured limb.

  • Radiographic outcomes of distal radius fractures treated with dorsal distraction plating are also comparable to those treated with volar plate fixation. Patients treated with dorsal distraction plating have a restoration in their normal distal radius radiographic parameters with a mean volar tilt of 4.8°, radial height of 10.5 mm, radial inclination of 19.4° and ulnar variance of 0.3 mm. The current body of evidence analyzing radiographic outcomes following volar plate fixation show similar measurements to this.

  • Complication rates of dorsal plating are exceedingly low. Reported infection rates of dorsal plating has been quoted to be 1.6% compared to 52%–63% seen with external fixation and 3.7% seen with volar plate fixation. Other complications such as extensor tendon rupture, adhesions, and extensor lag are also low.

Abstract

Introduction

Optimal fixation for highly comminuted distal radius fractures remains a major treatment challenge for orthopaedic surgeons. Dorsal distraction plating can serve as an improved fixation technique by allowing reduction under ligamentotaxis, providing a dorsal buttress, addressing proximal comminution, and allowing for early weightbearing in polytrauma patients. The aim of this study was to review current literature regarding treatment of distal radius fractures treated with dorsal distraction plating.

Methods

We performed a literature search in Pubmed and EMBASE databases to identify all studies analyzing use of dorsal distraction plating. Case reports, biomechanical and anatomic cadaver studies were excluded from analysis. Primary outcome measures were range of motion (ROM) at final follow up, grip strength, and radiographic parameters.

Results

Eight studies were included in the final analysis. Pooled mean ROM after dorsal distraction plating was found to be 47.6° of flexion, 50.5° of extension, 76.0° of pronation, and 74.2° of supination. Pooled mean grip strength was 79.1% compared to the uninjured contralateral limb. Pooled mean volar tilt was 3.6°. Overall radial height was maintained at an average of 10.5 mm with a pooled mean loss of only 3.8 mm in length. Mean radial inclination was found to be 19.4 mm with patients having a mean ulnar variance of 0.5 mm.

Discussion & conclusion

Treatment of comminuted intra-articular distal radius fractures with dorsal distraction plating yielded excellent outcomes with very low complication rates, and has several advantages over volar plating and/or external fixation for these fractures. Necessity of plate removal remains a negative feature of this technique.

Introduction

Distal radius fractures are the most common long bone fracture and the incidence appears to be increasing worldwide [[1], [2], [3], [4]]. They have been found to account for approximately 17% of all fracture-related emergency department visits [5,6]. These types of injuries have a bimodal age distribution. The first peak represents young patients involved in high energy traumas, and the second peak represents elderly patients with lower to moderate energy injuries secondary to osteoporosis.

Surgical treatment for distal radius fractures varies, as there are numerous techniques for fixation. The goals of fixation are anatomic reduction and stability, as this has been shown to result in improved chances for functional recovery [7]. The use of volar locking plates has become the standard for treatment of the majority of distal radius fractures requiring surgery [8,9]. However, adequate fixation for high energy comminuted fractures with or without metadiaphyseal extension remains a major treatment challenge. Severely comminuted articular fractures are technically challenging in terms of obtaining an adequate reduction and achieving stabilization with a standard periarticular volar plating technique. The small fracture fragments are often not able to be stabilized with the screws from the volar plate, and the proximally-oriented tension from the forearm musculature acts to pull on the carpus causing further collapse of the articular surface. As an alternate to the volar plate, these types of injuries have been historically treated with an external fixator with or without Kirschner wires. However, it has been reported that highly comminuted distal radius fractures are associated with a 52%–63% complication rate when treated with external fixation [10]. Therefore, despite poor fixation capabilities with these fracture types, the volar plate remains the go-to device for most surgeons when faced with comminuted articular distal radial fractures.

In these circumstances, the dorsal distraction plate (also called dorsal “bridge” plating technique) can serve as an improved fixation technique by allowing comminuted articular fragments to reduce under ligamentotaxis and provide a buttress for the dorsal cortex of the distal radius. In addition, a long dorsal plate can bridge past metaphyseal comminution, which cannot be so easily addressed with standard volar plating [11]. The bridge plate can also be left in place for an extended period of time without the risk of the aforementioned complications of prolonged external fixation use [12]. Finally, the dorsal distraction plate is technically a much easier operation to perform than volar plating for complex articular fractures. Recently, there has been increased use of dorsal distraction plating for these types of injuries [10,[12], [13], [14], [15], [16]].

The purpose of this study is to review the current literature pertaining to the treatment of distal radius fractures with dorsal bridge plating. Furthermore, this study will compare these outcomes with standard open reduction internal fixation using volar plate fixation.

Section snippets

Literature search

With the assistance of a clinical librarian, a literature search was performed in Medline (Pubmed) and EMBASE. No limitations on publication date and type were applied.

Inclusion/exclusion criteria

Only clinical studies assessing patients with a distal radius fracture treated with dorsal distraction plating were included in the study. Basic science and/or cadaveric studies were excluded. Studies were excluded if they were case report studies or had less than five (5) patients.

Data collection and outcome measures

For all included articles, we assessed study

Results

We identified 16 eligible citations through PubMed and the EMBASE databases (Fig. 1). Of the 16 relevant titles that underwent abstract and full text review, 8 studies were eligible for final review. Two of these studies were prospective cohort studies, and six of these studies were retrospective reviews or case series analyses. Of the 8 citations that were excluded, 3 of these involved cadavers rather than live patients, 3 were case reports involving a single patient, and 1 was a biomechanical

Discussion

Burke and Singer [12] were the first to describe use of internal distraction plating for treatment of comminuted, displaced distal radius fractures in 1998. Since then, the literature on outcomes after dorsal distraction plating has been limited to retrospective reviews except for two prospective series, the first published by Ruch et al in 2005 [13] and the second by Jain et al in 2016 [17]. The rationale for an internal spanning plate is multifactorial. Firstly, it is an extremely stable

Conclusions

The currently available evidence on dorsal distraction plating demonstrates that this technique has very good results in the treatment of severely comminuted intra-articular distal radius fractures. Complication rates are lower than with external fixation, while clinical and radiographic outcomes are comparable to historical evidence of gold standard fixation techniques (volar plating) for these fracture types. Although initially used as an alternative to external fixation, there is evidence to

Conflicts of interest

None.

Acknowledgements

The paper is part of a supplement based on the 2017 workshop on “External Fixation and Percutaneous Pinning.” Support for the publication of this supplement was provided by the Osteosynthesis and Trauma Care Foundation (OTCF) sponsored by a research grant from Stryker.

References (24)

  • M. Bonafede et al.

    The direct and indirect costs of long bone fractures in a working age US population

    J Med Econ

    (2013)
  • M.L. Kilgore et al.

    Healthcare expenditure associated with skeletal fractures among Medicare beneficiaries, 1999-2005

    J Bone Miner Res

    (2009)
  • Cited by (0)

    View full text