Key Points
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A number of treatment strategies exist for successful management of complex intraarticular distal radius fractures including: immobilization, external fixation, open reduction, and volar or fragment-specific plating as well as dorsal bridging plating. No well-controlled, methodologically strong studies have compared all treatment modalities and thus there is a paucity of evidence to support the use of one treatment modality over another.
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Careful diagnosis, an appropriate understanding of the fracture pattern and the patient physiological requirements will facilitate the selection of a personalized and optimal treatment strategy for each patient.
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Computer tomography facilitates an understanding and appreciation for the fracture pattern and involvement of the articular fracture.
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Final functional outcomes may be similar between treatment options. Radiographic outcomes appear to be improved with more invasive techniques such as open reduction and internal fixation.
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Overall, there is a high rate of posttraumatic arthrosis regardless of treatment modality; however, persistent articular mal-reduction may increase the rate of radiographic degenerative changes present.
A 33-year-old male, right hand dominant, falls off his motorbike at high speed while performing a bike stunt maneuver. Evaluation in the Emergency Department demonstrates a visibly deformed, swollen neurovascularly intact wrist and hand. He has associated long bone, chest and head injuries that require surgical management. Radiographic imaging demonstrates a highly comminuted intraarticular distal radius fracture. The patient is eager for a full return to normal function in his wrist and to avoid development of wrist arthritis. A friend of his was placed in an external fixator for a similar injury and the patient would like to know if he will need something similar. He also wants to know what the ideal type of treatment. Would an alternative treatment strategy be more effective?
Importance of the Problem
Comminuted, intraarticular distal radial fractures present a substantial management challenge. Typically, the result of higher energy injuries they can also occur during fractures in osteopenic bone. Although frequently the focus of our efforts is directed at the bony injury, the surgeon must consider associated bon and soft-tissue injuries and their impact on the patients overall clinical picture. While all injuries have the potential for ongoing disability and functional impairment, overall fracture severity of the distal radius has been shown to be correlated with inferior health-related quality of life and radiographic outcomes. During the assessment of these injuries, radiography remains the mainstay of initial management. Radiographic examination alone, however, may inaccurately predict the amount and location of intraarticular pathology and thus additional cross-sectional imaging modalities may provide valuable information to guide management. Computer tomographic (CT) evaluation improves assessment of the articular involvement and provides a more reliable, reproducible assessment of the fracture pattern ( Fig. 1 ).
Once diagnosed treatment goals are to restore the wrist to as near anatomic as possible. Ultimately radiographic parameters for reconstruction focus on :
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Radial tilt between 20 degrees volar and 15 degrees dorsal
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Restoration of radial inclination > 15 degrees
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Minimized radial shortening < 5 mm
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Minimized radiocarpal articular step-off or gap < 2 mm
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Minimized sigmoid notch articular congruency < 2 mm
In the setting of complex articular fracture pattern, a number of approaches and techniques have been described. Regardless of treatment modality, surgical goals remain the restoration of alignment, length, and re-establishing articular congruency. Additionally, the congruity and stability of the articular component of the lunate facet fragment and sigmoid notch generate a stable central column for reconstruction. The lunate facet serves as the central component for force transmission and fulcrum of motion for the wrist. In this role, the re-establishment of stability and alignment of the intermediate column plays a critical role in eventual outcome. Despite a variety of available surgical techniques to aid in the management of these complex intraarticular distal radius fractures, strong evidence to support the superiority of any one technique remains limited, however. Each technique brings with it specific advantages and complications. Despite a lack of scientific consensus, volar plating has become the mainstay of conventional treatment for distal radius fractures. However, highly comminuted articular fractures may present specific challenges for this technique. This is particularly the case when complex articular comminution, and shear patterns are present where higher rates of complications and poorer radiographic outcomes have been reports.
Interestingly, despite evidence to support improved radiological restoration of articular congruency using many of these techniques, inferior functional outcomes regardless of reduction are common in these complex injuries. This finding likely represents the inherent chondral injury present despite radiographic osseous reduction. Further complicating the issue is the lack of clear a relationship between radiographic outcome and functional/clinical outcomes, particularly in the elderly.
Main Question
How are comminuted articular DRF most effectively treated?
Current Opinion
Comminuted intraarticular fractures can be successfully managed with a number of techniques each with specific advantages and disadvantages. While no single technique has documented superiority, an understanding of the merits of each technique allows the surgeon to select the most appropriate strategy for a particular fracture pattern and patient.
Finding the Evidence
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Cochrane Database search: Comminuted intraarticular Distal Radius fracture
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PUBMED: (“Complex intra-articular distal radius” [Mesh] OR “Distal radius articular fracture”)
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Bibliography of eligible articles
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Foreign language articles not written in English were excluded from review
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Nonscientific review manuscripts were excluded
Quality of the Evidence
Level I:
Metaanalysis/Systematic Reviews: 3
Level II:
Randomized trials with methodological limitations: 6
Level III:
Retrospective/Cohort studies: 66
Level IV:
Consecutive case series/Bio-mechanical studies: 35
Findings
Multiple treatment options are reported in the literature including nonoperative cast immobilization, K-wire fixation, external fixation, internal bridging fixation, conventional volar plating, and fragment-specific techniques. The overall management of distal radius fractures has continued to evolve. Predicting which technique is superior for each injury pattern requires an understanding of the reported risks and benefits of each technique as well as the individual patient characteristics and comorbidities. Despite an exhaustive list of publications on distal radius fractures, high-level well-constructed randomized controlled trials and metaanalyses are lacking. Additionally, the majority of the published literature does not substratify distal radius fractures by severity or pattern making larger conclusions regarding the impact of intraarticular fracture patterns difficult. As a result, Cochrane and other metaanalyses evaluating operative and nonoperative strategies for complex intraarticular distal radius fractures have failed to detect differences in functional outcomes between treatment modalities. Intraarticular distal radius fractures are associated with a high rate of posttraumatic arthrosis (65% at 7 years), however the clinical importance of this radiographic finding is unclear. Any residual articular step-off, regardless of fixation technique, leads to early radiographic posttraumatic arthritis. Given the lack of consensus within the literature, it is paramount that the surgeon considers patient, fracture, and technical factors in the determination of an overall treatment plan for an individual patient.
Cast Immobilization
Only two large randomized trials have formally evaluated cast immobilization for the treatment of intraarticular distal radius fractures. One additional randomized trial compared plate fixation with cast immobilization in all variations of distal radius fractures. They included a significant proportion (70%) of patients with intraarticular fracture patterns and reported modest early advantages in patient reported outcomes which were not maintained beyond 3 months. Complications however were significantly higher in the operative group. A number of retrospective reviews have also addressed the same question with similar results suggesting cast immobilization for intraarticular distal radius fractures may produce similar clinical outcomes when compared to surgical fixation technique. Importantly, many of these studies have focused on the elderly population (over 60 years old) and no evidence currently evaluates the use of this technique in younger age groups, although an ongoing randomized trial hopes to address this in the near future. Predictive models for re-displacement and the effect of articular reduction on functional outcome following distal radius fractures appear to have limited reliability which further cloud the picture for an evidence-based treatment algorithm. However, the current evidence does suggest that in the older, low-demand patient population deformity appears to be well tolerated often despite articular involvement. Final healed position frequently mimics that of their initial displacement. Malunion is therefore an expected outcome.
External Fixation
External fixation once a commonly employed tool in the management for distal radius fractures has largely fallen out of contemporary use except in specific circumstances. Despite this, the clinical and radiographic outcomes have been well described and objectively reported as similar to other techniques. Although a reliable and simple tool for the management of complex wrist injuries, the complication rate (24%–62%) has been well described and contributes to the limited widespread adoption. Despite these concerns and recent trends toward alternative fixation methods, a number of randomized control trials have demonstrated no difference in outcomes when external fixation was compared to volar locked plating, and fragment-specific fixation when used in the management of complex articular fractures of the distal radius. In comparison to nonoperative management small cohort and retrospective series have demonstrated improved radiographic and clinical outcomes with the use of external fixation. In complex comminuted articular fractures bridging external fixators are traditionally used over nonbridging techniques. For nonarticular fractures nonbridging external fixation have been shown in two well performed studies to have improved function and radiographic outcomes. In articular fractures, bridging fixation through distraction and ligamentotaxis obtain the alignment and allow for the reduction to be maintained. When compared to volar plate fixation there is conflicting evidence regarding the differences in clinical and radiograph outcomes between these modalities. Overall measurable clinical outcomes appear similar, however, there may be an improved range of motion when plate fixation is utilized. A secondary advantage of external fixation is the use of additional augmentation of fixation which can be employed to achieve and maintain reduction such as K-wires, direct reduction, and supplemental plate fixation ( Fig. 2 ). Overall, it appears that external fixation continues to remain a suitable option for the treatment of complex intraarticular distal radius management. Despite this a number of complications are well documented that merit careful attention. Care must be used to prevent overdistraction which can lead to complex regional pain syndrome (CRPS) and pin-site irritation or infection requires frequent pin-checks. If percutaneous K-wires are utilized, they should be promptly removed at 6–8 weeks to prevent the development of pin-track infection.
Dorsal Bridge Plating/Dorsal Distraction Plate
Originally described as a technique to provide the soft tissue benefits of external fixation and internal fixation in the poly-trauma patient. This technique provides immediate stability while minimizing soft tissue disruption and avoiding the complications associated with external fixation, such as pin-site infection and stiffness. The dorsal plate can be applied percutaneously and generates a buttress type effect for complex comminution of the dorsal cortex ( Fig. 3 ). This technique has demonstrated similar clinical outcomes to those of other fixation methods. As a tool it is particularly useful in fractures with severe articular comminution when traditional plate fixation may be deemed inadequate. In this technique the plate is placed within the second or the fourth extensor compartment floor and traction is applied. Distraction provides ligamentotaxis and helps restore the anatomic relationships of the distal radius through indirect reduction. Distal fixation can then be placed on the second or third metacarpal with the plate fixed proximally after distraction. Traditionally, the location of distal fixation was surgeon’s choice. More recently a number of studies have suggested advantages and disadvantages for both the second and third metacarpal. Fixation to the second metacarpal may facilitate grip strength if the wrist is positioned in ulnar deviation, improve radiographic alignment parameters, and reduce tendon irritation in the fourth compartment. Additionally, it allows for a straight line of pull however, it is associated with an increased risk of superficial radial nerve injury and a less anatomic restoration of the radiocarpal relationship. Plate fixation to the third metacarpal appears to increase the stiffness of the construct however, there is a greater risk of tendon entrapment. Overall stability of the bridging locked plate appears more stable than traditional external fixation biomechanically. Wolf et al. also demonstrated adequate stability of the construct requires only three locking screws proximally and three distally in a biomechanical model. Additional construct rigidity may be obtained with screw fixation into the lunate facet. Typically, the bridging plate is removed at approximately 12 weeks when consolidation is demonstrated. Overall, outcomes in the setting of distraction bridge plating for complex intraarticular fracture patterns suggests outcomes can be good to excellent in most patients [> 80%]. A recent metaanalysis of dorsal distraction plating suggests most patients treated with this technique gain nearly 80% of contralateral grip strength with functional return of range of motion and radiographic restoration of alignment (mean volar tilt [3.6 degrees], mean radial height [10.5 mm] and radial inclination [19.4 mm]). While most complications associated with dorsal bridge plating are minor, extensor lag and finger stiffness are well documented and specific complications from the technique. Rates of infections [~ 1.6%] appears to be significantly lower than that seems in external fixation or volar plating techniques. Although this evidence suggests dorsal bridge plating may be a useful tool, the evidence remains limited to predominantly small case series and retrospective reviews. Further high-level comparative studies are needed.
Arthroscopic Techniques
Wrist arthroscopy techniques may help provide additional evaluation of intraarticular fractures and minimize soft tissue trauma. Only one study has compared reduction using arthroscopic evaluation with conventional fluoroscopy. Burnier et al. in this small consecutive series found a statistically significant improvement in reduction when arthroscopy was employed intraoperative. Our understanding and appreciation of intraarticular reduction and fracture morphology is poor when compared to advanced imaging modalities (computer tomography) and arthroscopy may prove to be a useful intraoperative adjunct to evaluate reduction. Various arthroscopic techniques are described to improve articular reduction beyond that which can be obtained with fluoroscopy however robust studies have yet to confirm any clinical or long-term benefits to these techniques.
Volar Locking Plate Fixation
Volar locking plate fixation is currently the mainstay of surgical management for distal radius fractures and good results have been reported in the setting of complex intraarticular distal radius fracture ( Fig. 4 ). Locking technology allows for the generation of a stable fixed angled construct. With more complex fracture patterns however, the standard volar approach and fixation technique may need to be augmented with additional extensile exposures and techniques. In the context of comminuted articular fractures, a small number of randomized and numerous retrospective studies have evaluated volar plating for comminuted intraarticular fractures. When compared to conservative management with cast immobilization volar locked plating offers improved articular congruity, and reduced rates of mal-union radiographically. Chaudhry et al. demonstrated the superiority of volar locking plate techniques statistically but not in a clinically relevant capacity in a recent metaanalysis on the topic. Marcheix et al. documented excellent wrist motion and good radiographic results in a randomized controlled trial of comminuted articular fractures managed with volar plating. In their study there was less loss of reduction and improved clinical motion in those treated with volar locking plates compared to K-wire fixation, which has also been demonstrated by others. This finding was similarly demonstrated by Lutz et al. who demonstrated a reduction in postoperative arthritic changes (Grade I and II) in those patients with improved articular reduction as a result of volar plating. This finding has also been demonstrated by a number of other authors. Despite promising radiographic improvements, the evidence for any potentially improved clinical outcomes is mixed as radiographic arthrosis does not appear to correlate with functional outcomes. Challenges with locked volar plating are well documented. In more heavily comminuted intraarticular fractures difficulties in obtaining a reduction or maintaining a reduction can occur with a single plate. Finally, volar plate fixation of the distal radius appears to be associated with a documented higher complication rate compared to nonoperative and other modalities.
Fragment-Specific Fixation
More recently fragment-specific fixation has been employed to address the issues identified with other more traditional techniques particularly in the face of more complex fracture patterns. Beck et al. identified the presence of extremely distal (< 15 mm remaining distal bone stock) or significantly depressed (> 5 mm) lunate facet fractures as a risk factor for failure with conventional volar locked plating. The presence of and failure to adequately capture the volar lunate facet fragment, commonly referred to as the “critical corner” is well described by Harness et al. and others. Loss of reduction of this key fragment may lead to radiocarpal dislocation despite otherwise successful reduction. With fragment-specific techniques plates may be placed in multiple planes and locations on the distal radius and frequently orthogonal plating is used to increase rigidity of the fixation ( Fig. 5 ). However, biomechanical data suggests this presumed increased rigidity may only be theoretical. Fragment-specific fixation specifically applied focus on the reduction of the intermediate column, sigmoid notch and volar lunate facet allowing for the restoration of carpal alignment and congruity through limited open techniques. Alternatively, dorsal buttress plating has a number of potential benefits in the management of complex articular distal radius fractures. The dorsal approach to the distal radius can facilitate intraarticular visualization and reduction of fragments while a dorsal based plate provides a stabilizing force against dorsal collapse and shear. Ring, Benson, and others have evaluated outcomes using combined fragment-specific fixation for complex distal radius fractures and documented successful clinically and radiological outcomes. Volar rim plating techniques have gained increased interest for dealing with complex fracture patterns, particularly those involving the volar lunate facet of the distal radius. Volar rim plating provides more distal fixed angle support to both capture and hold the reduced critical corner (volar lunate facet) rim fractures. Additionally, these lower profile plates may reduce the complications associated with fixation distal to the watershed line. Although strong evidence is lacking to determine if this technique offers clinically important outcome differences small case and cohort series offer strong support for the techniques potential. Unfortunately, the rate of metalwork irritation can be high and despite combining surgical approaches and the use of multiple plates, congruent and satisfactory articular reduction may not be achieved in a significant proportion (upwards of 30%) of patients. Although no specific fracture patterns have evidence-based indications to endorse the use of fragment-specific plates this technique continues to be a well-described method for the management of complex articular radial fractures.
Complications
The treatment of distal radius fractures using either nonoperative strategies or surgical techniques is associated with a number of complications. In the setting of complex intraarticular distal radius fractures the complications are no less frequent. Metalwork prominence, failure or patient preference may necessitate removal. Additional consideration should be given to CRPS which appears to be linked to excessive distraction through external fixation, bridge plating or conventional plating strategies. Pin tract infections, posttraumatic arthritic change, intraarticular placement of fixation and loss of reduction are all possible complications. Although a common mild symptom pronounced stiffness, a common concern after articular fracture fixation, does not appear to be affected by more prolonged periods of wrist immobilization typically required in higher-energy injuries. Despite these issues, functional improvements overall are typically for most patients; however, they appear more reliable and quicker in the younger patient population.
Recommendations
In patients with an intraarticular displaced distal radius fracture, evidence suggests:
Conclusion
Multiple treatment options are available for the management of intraarticular distal radius fractures, all of which have potential advantages and disadvantages. Individual factors including surgeon familiarity, and an understanding of the fracture personality and patient factors may help in the determination of a preferred technique. For heavily comminuted intraarticular distal radius fractures, internal distraction bridge plating appears to offer satisfactory outcomes with a low rate of complications compared to more conventional treatment techniques. Despite substantial literature evaluating techniques and management strategies for complex intraarticular distal radius fractures, strong evidence-based guidelines are lacking. From the available literature, well selected patients without complications can achieve good functional and radiographic outcomes through the use of multiple techniques including bridging external fixation, volar and fragment-specific plating, and distraction bridge plating. It behooves the surgeon to ensure a carefully understanding of the benefits and potential pitfalls of each technique allowing them to customize care to maximize outcome. Although extensive low and moderate quality literature exists for specific techniques there remains a paucity of reliable, methodologically standardized studies to evaluate the available techniques and thus further investigation is warranted before definitive conclusions can be formed.
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