The treatment of complex intra-articular distal radius fractures with turning radius and distal volaris radius plate fixation

This study was approved by the Ethics Committee of Shenzhen People’s Hospital at Jinan University. All volunteers gave informed consent prior to participating in the study.

From 2015 to 2019, 25 patients with intra-articular distal radius fractures accompanied by dorsally displaced free fragments were included in our study. Fifteen of the patients got their fractures from accidental fall, and 10 received their injuries from traffic accidents. All of the patients had closed fresh fractures. The study cohort included 14 males and 11 females with an average age of 34.5 years (21–50 years). According to AO classifications, all patients had type C fractures (Table 1), as determined by the presence of articular surface crushing, a fracture line that spread beyond the “watershed line” and the presence of dorsally displaced fracture fragments (Fig. 1). The patients were first treated with plaster external fixation and detumescence. The average operation time was 68.25 min (42–78 min), and the operation occurred an average of 4.5 days after injury (ranging from 0 to 7 days). The average follow-up time was 12.5 months (ranging from 8 to 22 months) (Table 2).

After anesthesia, an 8 cm long incision was made along the flexor carpi radials (FCR). The skin, subcutaneous fascia and deep fascia were consecutively cut open, and the FCR was pulled toward the ulnar side. The median nerve was protected at the same time. The FCR was moved distally until it reached the level of the scaphoid node to enlarge the space under the palmar tendon of the forearm and expose the pronator quadratus muscle. After these manipulations, we were able to touch the distal radius and identify the palmar margin of the lunate fossa. We then marked both the “watershed line” and the proximal end of the lateral radius with sterile marker pen for later procedures. We used a sharp scalpel to cut both the proximal end of the lateral edge of the radius and the overlying ridge line, release the pronator muscle, cut off the middle support belt from the “watershed line”, peel off and expose the brachioradialis muscle stop, and obliquely disconnect it. Then, we turned the proximal segment of the radius inward, peeled and exposed the distal articular surface of the radius, restored the distal articular surface under direct vision and turned the proximal segment back after confirming satisfactory recovery of the articular surface. We placed the DVR (Zimmer-Biomet) plate on the palmar side. The distal end of the plate was aligned with the proximal side of the “watershed line”. A Kirschner pin was inserted into the medial Kirschner pin hole of the proximal row of pin holes to fix the distal bone block. The correct position of the plate was determined by C-arm fluoroscopy lateral film and oblique lateral film (inclined 20–25°). At this angle, the gram needle should be 2.0–3.0 mm below the articular cartilage. To stabilize the lunar fossa, a 2.0 mm drill bit was used to drill from the ulnar side through a disposable quick guide. The length of the near row of screws was obtained by reading the scale of the round surface on the sounder. After confirming the drilling depth, the quick guide was removed with a screwdriver. Then, we used the same screwdriver to insert screws of the correct length into all distal pin holes, and cortical screws were screwed into the remaining proximal screw holes. After pulling out the temporary fixing Kirschner wire, fracture recovery was satisfactory based on the fluoroscopy observation, and there were no obvious abnormalities in wrist joint movement. After hemostasis, the brachioradialis tendon and the pronator were sutured, and the incision was closed (Fig. 2). All operations were performed by an experienced orthopedic surgeon.

After anesthesia subsided, all patients began to stretch and flex their wrists slightly and move their elbows freely without bearing weight or participating in distance exercise or heavy physical activity of the affected limbs. Patients were suggested to be cautious about twisting exercises within 3 months of the operation.

Preoperative X-ray and three-dimensional computed tomographic (CT) images were used to analyze the fracture types and observe the dorsally displaced fracture fragments far from the “watershed line”. X-ray films of anteroposterior and lateral carpal joints were taken immediately after the operation (Fig. 3).

At the end of the follow-up, X-ray was used to confirm fracture healing, distal radial height, volar tilt, and radial inclination, as well as to assess any evidence of traumatic arthritis (Fig. 4). Radiologic measurements were performed by two orthopedic doctors and a radiologist.

At the end of the follow-up, wrist function—including ROM, MMWs and DASH—was evaluated. ROM (dorsiflexion, volar flexion, ulnar deviation and radial deviation) of the wrist and forearm were measured with a goniometer. Pain visual analogue scale (VAS) was also evaluated.

During the follow-up, we monitored possible postoperative complications, including wound infection, non-unions, malunions, tendon rupture, traumatic osteoarthritis, joint mobility disorders, persistent neuropathy and complex regional pain syndrome.

Statistical analysis was performed using the SPSS statistical version 19.0 in this study. Data was shown as mean ± standard deviation (x ± s). The student t test was used for continuous variables. P-values less than 0.05 were regarded as statistically significant different.