Aims. Carpal malalignment after a distal radial fracture occurs due to loss of volar tilt. Several studies have shown that this has an adverse influence on function. We aimed to investigate the magnitude of dorsal tilt that leads to carpal malalignment, whether reduction of dorsal tilt will correct carpal malalignment, and which measure of carpal malalignment is the most useful. Methods. Radiographs of patients with a distal radial fracture were prospectively collected and reviewed. Measurements of carpal malalignment were recorded on the initial radiograph, the radiograph following reduction of the fracture, and after a further interval. Linear regression modelling was used to assess the relationship between dorsal tilt and carpal malalignment. Receiver operating characteristic (ROC) analysis was used to identify which values of dorsal tilt led to carpal malalignment. Results. A total of 250 consecutive patients with 252 distal radial fractures were identified. All measures of carpal alignment were significantly associated with dorsal tilt at each timepoint. This relationship persisted after adjustment for age, sex, and the position of the wrist. Capitate shift consistently had the strongest relationship with dorsal tilt and was the only parameter that was not influenced by age or the position of the wrist. ROC curve analysis identified that abnormal capitate shift was seen with > 9° of dorsal tilt. Conclusion. Carpal malalignment is related to dorsal tilt following a distal radial fracture. Reducing the fracture and improving dorsal tilt will reduce carpal malalignment. Capitate shift is easy to assess visually, unrelated to age and sex, and appears to be the most useful measure of carpal malalignment. The aim during reduction of a distal radial fracture should be to realign the capitate with the axis of the radius and prevent carpal malalignment. Cite this article: Bone Joint J 2020;102-B(1):137–143

Various studies report a correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 250 and radiocarpal malalignment with ERLF > 250. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (one week) and late failure (six weeks) in an attempt to predict the final radiological outcome accurately. Radiographic alignment parameters were compared before and after reduction using paired t-tests and then also analysed in a multiple logistic regression analysis. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at one week. Age, gender, presence of dorsal comminution, ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. Late failure group: We found radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome at six weeks. Age, Gender, flattening of radial angle, ulnar styloid fracture as factors for secondary displacement when analyzed independently or in combination were not found to be significant predictors of late failure. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and both at one and six weeks when analysed independently or in combination (p< 0.01). Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

The June 2024 Wrist & Hand Roundup. 360. looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review

The aim of this study was to assess patient-based outcome two years following non-operative management of displaced Colles fractures. 100 patients were evaluated at a minimum of two years after displaced Colles fracture. Fractures were reduced under regional anaesthesia and immobilised in a Colles-type cast for five weeks. The fractures were assessed radiographically by measurement of radial angle, dorsal tilt, radial shortening and carpal malalignment at the time of injury, post-manipulation, and after one and five weeks. The fractures were classified according to Frykman classification. A validated patient-based outcome questionnaire, using a visual analogue score, was used to assess outcome at the end of two years. 7 patients had died, 8 patients were unable to complete the questionnaire because of confusion and 5 were lost to follow-up. Complete outcome data were available on 80 patients. The median age was 61 years. The median pain score was 5 (25%-2 and 75%-12, range 0–100). There was loss of reduction, with more than 5° dorsal angulation and/or 5mm radial shortening in 70% cases. We found that age had no effect on patient outcome except that patients over 50 years complained of more finger stiffness The Frykman classification was an important prognostic factor and a higher grade resulted in worse outcome in a number of areas. Dorsal angulation had no significant effect and carpal malalignment correlated with poor visual appearance. Radial angle and radial shortening were both associated with increased complaints of wrist pain and stiffness. This prospective patient based outcome study has demonstrated that patients make a good functional recovery following nonoperative management of Colles fracture. 70% of our patients had a poor radiological outcome but few reported problems with pain and function at 2 years. Extra-articular malunion due to radial angulation and shortening was common and correlated with wrist pain and stiffness at two years. Frykman classification correlated with pain and functional outcome

We performed a prospective, randomised trial on 120 patients with redisplaced fractures of the distal radius comparing four methods of treatment. The four treatment groups, each containing 30 patients, were remanipulation and plaster, open reduction and bone grafting, and closed external fixation with and without mobilisation of the wrist at three weeks. The radiological results showed improvement in angulation of the distal radius for the open reduction and bone grafting group. Functional results at six weeks, three and six months and at one year, however, showed no difference between any of the four groups. The main influence on final outcome was carpal malalignment which had a statistically significant negative effect on function

We present our experience with correction of Madelung’s deformity by the Ilizarov technique. Seven patients (eight deformities) were treated by osteotomy of the radius with subsequent lengthening and angular correction. They were reviewed at a mean of 30 months (1.5 to 5.5 years). At the time of operation their mean age was 19 years (9 to 44). At follow-up all were free from pain and supination had improved by a mean of 34° and pronation by 9°. Flexion had increased in most cases with a median increase of 15°, but only one patient gained further extension. Radial and ulnar deviation were increased by a mean of 6° and 9°, respectively. Radiographic measurements showed that the mean volar angulation had been reduced from 25° to 11°, ulnar inclination from 45° to 30° and carpal malalignment (volar translation) from 7 to 2 mm. The mean lengthening of the radius was 12 mm (6 to 25). All the patients were satisfied with the functional and cosmetic results

Natural history studies of scaphoid non-unions focus on symptomatic non-unions. As a consequence, neither the real incidence nor the long-term sequels of asymptomatic scaphoid pseudarthrosis have been sufficiently studied. Three adult patients (38, 40 and 79 years of age) with long-standing asymptomatic scaphoid non-union are presented. The lesions were identified in radiographs taken in the accident and emergency department after new injuries. All patients could recall the initial fracture, which occurred 17.5, 20 and 40 years respectively before the index examination. Although all the patients were heavy manual workers and in two the non-union occurred in their dominant upper extremity, none could recall pain during activities. Radiographic evidence of carpal malalignment and/or arthritis was noted in all patients. At the 3-month follow-up after the new injury all patients remained asymptomatic with only mild limitations in the range of motion. With evolving trends of ORIF in unstable scaphoid fractures, there is need for larger-scale natural history studies that include asymptomatic scaphoid non-unions. Such lesions are currently poorly understood and their treatment (if one is needed) remains unclear

Developments in plate technology have increased interest in the operative fixation of Colles' fracture. The vast majority of patients are treated non-operatively, yet there are few medium or long-term outcome studies. The aim of this study was to evaluate medium-term outcome of a cohort of patients who previously received treatment in a plaster cast. 236 patients entered two previous prospective, randomised control studies comparing closed reduction techniques or plaster cast type. Both studies showed no difference in clinical or radiological outcome between groups. 43% of this cohort had a final dorsal tilt of > 10° and 44% had final radial shortening of >2mm. All patients now have a minimum follow-up of five years and 60 have died. The remaining 176 patients were contacted by post and asked to complete two validated patient-based questionnaires: a modified Patient Evaluation Measure and a quickDASH. 112 replies were received. The mean age of patients is 67 years (range 23 – 91 years). 31 patients are employed and 57 retired. 77% of patients had a quickDASH score of less than 20. 59% of patients never experience wrist pain whilst 8% of patients have daily pain. All Patient Evaluation Measures have shown a median score of 12 or less (0=excellent, 100= terrible). The best score was for pain (median 4; IQR 2-12) and the worst for grip strength (median 12; IQR 4 – 41). No radiological outcome 5 weeks after injury correlated with any outcome score, except for dorsal tilt, which correlated with difficulty with fiddly tasks (p=0.04) and carpal malalignment which correlated with interference with work (p=0.04). In conclusion, our results show a good functional outcome five years after non-operative management of Colles' fracture. A degree of malunion is acceptable and in the light of our results the economic impact of surgery must be evaluated

Objective: Deformity post distal radius fracture can be associated with alterations in carpal kinematics. This study presents a review to detect the prevalence and clinical implications of such deformities and the variables that influence the outcome following osteotomy. Material & Methods: 29 patients with distal radius mal-union, and an average age of 43 yrs, were treated by a single surgeon with a corrective osteotomy. Along with pain scales, wrist motion, and grip strength, pre and post osteotomy radiographs were evaluated. Preoperatively, 18 patients had dorsal deformity, 9 volar and 2 shortening and malrotation alone. 20 patients had carpal malalignment and 9 normal carpal alignment. Results: The average follow up was 21 months. 24 out of 29 radial deformities were corrected to normal. Overall 17 patients had post-op normal carpal alignment. Three groups resulted; Group I: 11 patients with pre and post-op “fixed” deformities. Group II: 8 patients with normal pre and post-op carpal alignment; and Group III: 9 patients with “lax” pre-op malalignment converted to normal post-op. 1 patient was normal pre-op and converted to DISI at post-op. There was no statistically difference in outcome with regard to pain, forearm rotation, wrist extension, patient age or time to surgery between the three groups. There was statistically significant greater wrist flexion in Group II and III compared to Group I. Conclusions: Carpal malalignement post radius osteotomy will have a negative effect on the functional outcome compared to those patients with preoperative carpal deformity, which corrects with radius osteotomy. Knowledge of this association will help advice patients of expected outcomes

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Aims

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

Aims

The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an ‘acceptable’ radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.

Aims

The degree of displacement of a fracture of the distal radius is an important factor which can be assessed using simple radiographic measurements. Our aim was to investigate the reliability and reproducibility of these measurements and to determine if they should be used clinically.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive.

At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side.

Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O’Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year.

Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate.

We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid.

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42).

No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores.

While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available.