Aims of study. To assess and compare the functional, radiological and cosmetic results as well as patient satisfaction in patients treated with the IMN Device Vs Volar Locking Plate. Method. All patients who presented to our institution with extra articular distal radius fractures and met the inclusion criteria were invited to take part in the study. The patients were randomly allocated to two groups, those who underwent intramedullary (IMN) distal radius fixation using the Sanoma Wrx Distal radius nail and those who underwent fixation using a volar locking plate. The patients were then followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year. The radiological parameters, ie radial height, inclination and tilt were compared as well as the functional outcomes by means of DASH score. The range of motion of the wrist was compared as well as the scar size. Complications were reviewed. Results. We present our early results. Currently we have included 9 patients in the IMN group and 7 patients in the volar plate group with follow-ups longer than 3 months. Results show smaller scars (2.5 vs 6.7cm), comparable flexion and extension (40 vs 40 and 45 vs 40), slight improvements in pronation and supination (80 vs 75 and 85 vs 80) in the IMN compared to the volar plate. Radial and ulnar deviation is comparable. The radiological parameters showed slight improvements in the radial height (2.5 vs 2.2 mm), inclination (3.6 vs 3.2 degrees) and tilt 13,7 vs 12 degrees) with the IMN. Dash scores will be compared at 6 months. Conclusion. Intra medullary nailing of the distal radius seems to compare to volar plating in terms of radiological parameters and rotational stability but has the added benefit of early range of motion, minimal invasive technique, less post op pain and less complications such as tendon irritation. NO DISCLOSURES

Extensor tendon ruptures have been reported in up to 8.8% of patients after volar plating and long screws have been implicated. The dihedral dorsal surface of the distal radius hinders accurate screw length determination using standard radiographic views (lateral; pronation and supination). A ‘dorsal tangential’ view has recently been described, but has not been validated. To validate this view, we mounted a plate-instrumented sawbone onto a jig. Radiographs at different angles were reviewed independently by 11 individuals. Skyline views clearly demonstrated all screw tips, whereas only 69% of screw tips were identifiable on standard views. With screws 2mm proud of the dorsal surface, skyline views detected 67% of long screws (sensitivity). The best of the standard views achieved only 11% sensitivity. At 4mm long, skyline sensitivity was 85%, compared with 25% for standard views. At 6mm long, 100% of long screws were detected on skylines, but only 50% of 8mm long screws were detected by standard views. Inter and intra-observer variability was 0.97 (p=0.005). For dorsal screw length determination of the distal radius, the skyline view is superior to standard views. It is simple to perform and its introduction should reduce the incidence of volar plate-related extensor tendon rupture

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were

Premature growth arrests are an infrequent, yet a significant complication of physeal fractures of the distal radius in children and adolescents. Through early diagnosis, it is possible to prevent clinical repercussions of the anatomical and biomechanical alterations of the wrist. Their true incidence has not been well established, and there exists no consensual systematic monitoring plan for minimising its impacts. The main objective was to evaluate the prevalence of growth arrests after a physeal distal radius fracture. The secondary objective was to identify risk factors in order to better guide clinicians for a systematic follow-up. All patients seen between 2014–2016 in a tertiary orthopaedic clinic were retrospectively reviewed. Inclusion criteria were (one) a physeal fracture of the distal radius (two) adequate clinical/radiological follow-up. Descriptive, Chi-square and binary logistic regression analyses were carried out using SPSS software. One hundred ninety patients (mean age: 12 ± 2.8 years) fulfilled the inclusion criteria. Forty percent (n=76) of the fractures were treated by closed reduction. Premature growth arrest was seen in 6.8% (n=13) and diagnosed at a mean of 10 months post trauma. The logistic regression showed that the initial translation percentage (>30%) (p 25) (p increase the risk of growth arrest. After adjusting for concomitant ipsilateral ulnar injuries, a positive association between physeal complications and fracture manipulation was detected (76.9%, p=0.03). A non-significant trend between premature growth arrest and associated ulnar injury was observed (p=0.054). No association was identified for trauma velocity, fracture type, gender and age, and growth complications. A prevalence of 6.8% of growth arrest was found after a physeal fracture of the distal radius. Fractures presenting with an initial coronal translation > 30% and/or angulation > 25 from normal, as well as those treated by manipulation, have been shown to be at risk for a premature growth arrest of the distal radius. This study highlights the importance of a systematic follow-up after a physeal fracture of the distal radius especially for patients with a more displaced fracture who had a closed reduction performed. An optimal follow-up period should be over 10 months to optimize the detection of growth arrest and treat it promptly, thereby minimizing negative clinical consequences

Distal radius fractures are the most common upper extremity fracture. The incidence is significantly higher in elderly females with osteoporotic bone. When surgery is indicated, volar locking plates (VLPs) allow for rigid fixation particularly in comminuted fractures with poor bone quality. Although numerous studies have shown the importance of plate placement to avoid soft tissue complications associated with volar plate fixation, there has been little evidence on the anatomic fit of current VLPs. Moreover, the effect of gender differences in distal radius morphology on anatomic fitting of VLPs has not been studied. The aim of this study was to evaluate the gender difference in distal radius morphology and the accuracy of the fit of a current VLP to CT-based distal radius models. Segmented CT models of ten female (mean age, 89 ± 5 years), and ten male (mean age, 86 ± 4 years) cadaveric wrists were obtained. Micro-CT models of the DePuy-Synthes 4-hole extra-articular (EA) and 8-hole volar column (VC) distal radius VLPs were created. A 3D visualization software was used to simulate appropriate plate placement on to the distal radius models by a fellowship-trained hand surgeon. Volar cortical angles (VCA) of the medial, middle and lateral portion of the distal radius were measured and compared between genders. The accuracy of the fit of the two VLP designs were quantified using the percentage of the watershed line (WSL) overlapped by the plate (WSL overlap), the distance between the WSL and the most distal aspect of the posterior plate (prominence distance) and the percentage of contact between the plate and bone. There were statistically significant gender differences in medial, middle and lateral VCAs (p=.003 medial, p=.0001 middle, p=.002 lateral). VCA ranged from 28° to 36° in females and from 38° to 45° in males. The WSL overlap did not show statistically significant gender differences (male: 5.9%, female: 13.6%, p=.174). However, the difference in prominence distance between different genders approached statistical significance (male: 3.5mm, female: 2.6mm, p=.087). Contact mapping between the plate and bone did not demonstrate a perfect contact in any of our specimens. Thus, contact measurements were categorized into 0.1mm, 0.2mm, and 0.3mm threshold contacts. There were no statistically significant gender differences in any of the threshold categories (0.1mm: p=.84, 0.2mm: p=.97, 0.3mm: p=.99). Our results confirm that there are gender differences in distal radius morphology. Current plate designs incorporate a VCA of 25° which does not match the native VCA of the distal radius in males or females. Although the difference in prominence distance approached statistical significance, there were no statistically significant gender differences in the WSL overlap or the contact threshold values. This lack of statistical significance may be related to the small sample size. This study proposes novel methods of assessing the anatomic fit of current VLPs in a 3D CT-based model that may be used in future studies with a larger sample size. Moreover, this study demonstrated the importance of considering gender differences in distal radius morphology in the design of future generations of implants

Distal radius fractures are the most common upper extremity injury, and are increasingly being treated surgically with pre-contoured volar-locking plates. These plates are favored for their low-profile template while allowing for rigid anatomic fixation of distal radius fractures. The geometry of the distal radius is extremely complex, and little evidence within the medical literature suggests that current implant designs are anatomically accurate. The main objective of this study is to determine if anatomic alignment of the distal radii corresponds accurately with modern volar-locking plate designs. Additionally, this study will examine sex-linked differences in morphology of the distal radius. Segmented CT models of ten female cadaver (mean age, 88.7 ± 4.57 years, range, 82 – 97) arms, and ten male cadaver (mean age, 86 ± 3.59 years, range, 81 – 91) arms were created. Micro CT models were obtained for the DePuy Synthes 2.4mm Extra-articular (EA) Volar Distal Radius Plate (4-hole and 5-hole head), and 2.4mm LCP Volar Column (VC) Distal Radius Plate (8-hole and 9-hole head). Plates were placed onto the distal radii models in a 3D visualization software by a fellowship-trained orthopaedic hand surgeon. The percent contact, volar cortical angle (VCA), border and overlap of the watershed line (WSL) were measured. Both sexes showed an increase in the average VCA measure from medial to lateral columns which was statistically significant. Female VCA ranged from 28 – 36 degrees, and 38 – 45 degrees for males. WSL overlap ranged from 0 – 34.7629% for all specimens without any statistical significance. The average border distance for females was 2.58571 mm, compared to 3.52411 mm for males, with EA plates having a larger border than VC plates. The border distances had statistically significant differences between the plate types, and was approaching significance between sexes. Lastly, a maximum percent contact of 21.966 % was observed in specimen F4 at a 0.3 mm threshold. No statistical significance between plate or sex populations was observed. This study investigated the incoherency between the volar cortical angle of the distal radius, and the pre-contoured angle of volar locking plates. It was hypothesized that if the VCA measures between plate and bone were unequal then there would be an increase in watershed line overlap, and decrease in percent contact between the surfaces. Our results agreed with literature, indicating that the VCA of bone was larger than that of the EA and VC pre-contoured plates examined in this study. With distal radius fracture incidences and prevalence on the rise for elderly female patients, it is a necessity that volar locking plates be re-designed to factor in anatomical features of individual patients with a particular focus on sex differences. New designs should focus on providing smaller head sizes that are more accurately tailored to the natural contours of the volar distal radius. It is recommended that future studies incorporate expertise from multiple surgeons to diversify and further understand plate placement strategies

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score. There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05). The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score

Purpose. Intra-articular fractures of the distal radius are common injuries. Their pathogenesis involves a complex combination of forces, including ligament tension, bony compression and shearing, leading to injury patterns that challenge the treating surgeon. The contribution of the radiocarpal and radioulnar ligaments to articular fracture location has not previously been described. Computed tomography (CT) scanning is an important method of evaluating intra-articular distal radius fractures, revealing details missed on plain radiographs and influencing treatment plans. Methods. We retrospectively reviewed CT scans of acute intra-articular distal radius fractures performed in one institution from June 2001 to June 2008. Forty- five of 145 scans were deemed unsuitable due to poor quality or presence of internal fixation in the distal radius, leaving 100 fractures for review. Fracture line locations were mapped to a standardised distal radius model, and statistically analysed in their relationship to ligament attachment zones. Results. Distal radius articular fracture lines are significantly less likely to occur in the regions of ligament attachment. Conversely, fracture lines are more likely to occur in the gaps between major ligament attachments. Conclusion. Articular fracture locations in the distal radius are significantly related to radiocarpal and radioulnar ligament attachments. This may aid treating surgeons in understanding the personality of a fracture and the role of ligamentotaxis in fracture reduction

Introduction. Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan. Method. One hundred consecutive MRI scans of wrist were reviewed by two of the authors on two occasions. All MRI scans were performed for different wrist pathologies except distal radius fractures or tumours. An axial image, two cuts proximal to the last visible articular surface, was selected. Sagittal length at 5 different widths, maximum volar width, radial overhang over distal radio-ulnar joint and the distance between dorsal bone edge and extensor tendons were measured. Results. A total of 120 MRI scans were included of which 74 were women and 46 were men. Mean volar width was 32mm and longest sagittal length was 22 mm (at Lister's tubercle). Length radial to Lister's tubercle was the shortest (17mm) and ulnar sides were 21mm and 29mm. Male measurements were mean 3mm longer than females. Mean radial overhang over DRUJ was 4mm. Distance from bone to tendons was within 2mm of dorsal radius edge. Conclusion. The study provides a reference guide to average screw lengths at different widths of distal radius in males and females. EPL tendon is closest to bone although all the extensor tendons are within 2mm of bone edge and carry a risk of injury from drill and screw placement. DRUJ is also at risk of injury if screws are placed within 4mm of ulnar edge of distal radius

Perioperative glucocorticoids have been used as a successful non-opioid analgesic adjunct for various orthopaedic procedures. Here we describe an ongoing randomized control trial assessing the efficacy of a post-operative methylprednisolone taper course on immediate post-operative pain and function following surgical distal radius fixation. We hypothesize that a post-operative methylprednisolone taper course following distal radius fracture fixation will lead to improved patient pain and function. This study is a randomized control trial (NCT03661645) of a group of patients treated surgically for distal radius fractures. Patients were randomly assigned at the time of surgery to receive intraoperative dexamethasone only or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course. All patients received the same standardized perioperative pain management protocol. A pain journal was used to record visual analog pain scores (VAS-pain), VAS-nausea, and number of opioid tablets consumed during the first 7 post-operative days (POD). Patients were seen at 2-weeks, 6-weeks, and 12-weeks post-operatively for clinical evaluation and collection of patient reported outcomes (Disabilities of the Arm, Shoulder and Hand Score [qDASH]). Differences in categorical variables were assessed with χ2 or Fischer's exact tests. T-tests or Mann-Whitney-U tests were used to compare continuous data. Forty-three patients were enrolled from October 2018 to October 2019. 20 patients have been assigned to the control group and 23 patients have been assigned to the treatment group. There were no differences in age (p=0.7259), Body Mass Index (p=0.361), race (p=0.5605), smoking status (p=0.0844), or pre-operative narcotic use (p=0.2276) between cohorts. 83.7% (n=36) of patients were female and the median age was 56.9 years. No differences were seen in pre-operative qDASH (p=0.2359) or pre-operative PRWE (p=0.2329) between groups. In the 7 days following surgery, patients in the control group took an average of 16.3 (±12.02) opioid tablets, while those in the treatment group took an average of 8.71 (±7.61) tablets (p=0.0270). We see that significant difference in Opioid consumption is formed at postoperative day two between the two groups with patients in the control group taking. Patient pain scores decreased uniformly in both groups to post-operative day 7. Patient pain was not statistically from POD0 to POD2 (p=0.0662 to 0.2923). However, from POD4 to POD7 patients receiving the methylprednisolone taper course reported decreased pain (p=0.0021 to 0.0497). There was no difference in qDASH score improvement at 6 or 12 weeks. Additionally, no differences were seen for wrist motion improvement at 6 or 12 weeks. A methylprednisolone taper course shows promise in reducing acute pain in the immediate post-operative period following distal radius fixation. Furthermore, although no statistically significant reductions in post-operative opioid utilization were noted, current trends may become statistically significant as the study continues. No improvements were seen in wrist motion or qDASH and continued enrollment of patients in this clinical trial will further elucidate the role of methylprednisolone for these outcomes

Increased use of locking volar plates for distal radius fractures led to a number of reports in literature of flexor tendon injuries from impingement and attrition against hardware. Repair of the pronator quadratus is critical in preventing tendon injury. We present a pronator quadratus sparing approach to the distal radius. The senior author has used a pronator quadratus sparing lateral pillar approach for for the past five years. A lateral incision is used over the radial styloid. The first dorsal compartment is released and APL and EPB tendons retracted. The underlying brachio-radialis tendon and insertion fascia is split and the palmar portion elevated off the distal radius with the pronator quadratus as a single contiguous sheet. The distal edge of the pronator quadratus is elevated from the wrist capsule by sharp dissection. The radial artery is protected by the retracted tissue. Repair of the brachio-radialis tendon and insertion fascia is much more robust than that of the pronator quadratus covering the entire plate. Since 2004, the senior author has used the pronator quadratus sparing approach for volar plating of the distal radius, in 183 cases. At last follow-up there were no instances of flexor tendon injury, which was considered to be one of the outcome measures and end-points. There was no impingement in the first dorsal compartment, except in two cases of lateral pillar hardware impingement from additional lateral pillar plate fixation through the same approach. Nine cases had minor persistent superficial radial nerve parasthesia. One case had a superficial wound infection requiring drainage. The repaired pronator quadratus formed a barrier protecting the plate. The infection was aggressively treated and the plate left in situ for three months till fracture union. Cultures from the retrieved plate showed no organisms. Another implant had two of the locking screws back out. The pronator quadratus fascia was tented with an underlying haematoma. The fascia however only showed minimum screw penetration and no flexor tendon injury. Average wrist dorsiflexion was 72 deg and palmar flexion 65 deg. Average pronation was 81 deg and average supination 69 deg. Supination range was slow to recover in younger patients. One explanation could be the tight pronator quadratus repair. Average PRWE and DASH scores were 19. The quadratus sparing approach to the volar distal radius is easy to perform and protects the flexor tendons at the wrist. Cases demonstrated that an intact pronator quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation

A fracture of the distal radius may lead to malunion of bone segments, which gives discomfort to the patient and may lead to chronic pain, reduced range of motion, reduced grip strength and finally to early osteoarthritis. A treatment option to realign the bone segments is a corrective osteotomy. In this procedure the surgeon tries to improve alignment by cutting the bone at, or near, the fracture location and by fixating the bone segments in an improved position, using a plate and screws. Standard corrective osteotomy of the distal radius is most often planned using two orthogonal radiographs to find correction parameters for restoring the radial inclination, palmar tilt and ulnar variance, to normal. However, 2D imaging techniques hide rotations about the bone axis and may therefore cause a misinterpretation of the correction parameters. We present a new technique that uses preoperative 3-D imaging techniques to plan positioning and to design a patient-tailored fixation plate that only fits in one way and realigns the bone segments as planned in six degrees of freedom. The procedure uses a surgical guide that snugly fits the bone geometry and allows predrilling the bone at specified positions, and cutting the bone through a slit at the preoperatively planned location. The patient-tailored plate fits the same bone geometry and uses the predrilled holes for screw fixation. The method is evaluated experimentally using artificial bones and renders realignment highly accurate and very reproducible (derr < 1.2 ± 0.8 mm and ϕerr < 1.8 ± 2.1°). In addition, the new method is evaluated clinically (n=1) and results in accurate positioning (derr ≤ 1.0 mm and ϕerr ≤ 2.6°). Besides using a patient-tailored plate for corrective distal radius osteotomy, the method may be of interest for corrective osteotomy of other long bones, mandibular reconstruction and clavicular reconstruction as well. In all of these cases the contralateral side can equally be used as reference for reconstruction of the affected side. The two-step method of predrilling and cutting using a surgical guide, followed by the utilisation of a patient-tailored plate for fixation and accurate 3D positioning at the same time, seems very easy to utilise during surgery, since it does not require complex navigation, robotic equipment or tracking tools. Custom treatment with a patient-tailored plate may reduce the reoperation rate, since repositioning is likely to be better than conventional malunion treatment using 2D imaging techniques and a standard anatomical plate. The patient-tailored plating technology is expected to have a great impact on future corrective osteotomy surgery

Objective. The aim of this retrospective study is to assess the functional and radiological outcome of a multi-planar corrective osteotomy, distraction and locking fixed angle volar plate as the standard of treatment of distal radius mal-unions that require multi-planar correction. Methods. We conducted a retrospective study on 13 consecutive patients – 4 males, 9 females (mean age 49). All patients underwent volar approach, open wedge distraction osteotomy locking fixed angle volar plate and cancellous bone grafting Radiographic measurements and functional assessments were taken preoperatively, 3, 6 months and one year. Results. Time to surgery from the original fracture had a mean of 17.4 months (range 8–36 months). Mean follow-up was 16.4 months (range from 6 to 45 months). Osteotomy healing time was 11.3 weeks on average. All radiographic measurements improved postoperatively, ten patients had an average of 18.84 degrees of dorsal tilt which was corrected to a volar tilt of 9.17 degrees on average. Ulna variance was initially positive in all patients with an average of 2.6 mm which was corrected to less than one (0.96 mm); three patients had radial angulations of 20.6 degrees on average, which were fully corrected postoperatively. Flexion-extension arc has improved with significant difference and so has the grip and pinch strength. The average DASH and SF12 scores has shown figures comparative to the normal population post deformity correction. Complications included one case of low grade wound infection and one case of postoperative symptoms of carpal tunnel syndrome. Conclusion. The described technique is a useful means to correct distal radius anatomy and function; however patients should be aware that it is not always possible to regain full function and anatomy

Introduction. The classical Colles fracture (extraarticular, dorsally angulated distal radius fracture) in patients with osteoporotic bone is becoming increasingly more frequent. There still appears to be no clear consensus on the most appropriate surgical management of these injuries. The purpose of this study is to appraise the use of percutaneous extra-focal pinning, in the management of the classical colles fracture. Methods. We retrospectively analysed 72 consecutive cases of Colles fractures treated with interfragmentary K-wire fixation, in female patients over sixty years of age, in two orthopaedic centres, under the care of twelve different orthopaedic surgeons. We correlated the radiographic distal radius measurements (ulnar variance, volar tilt, and radial inclination) at the pre-operative and intra-operative stages with the final radiographic outcome. Result. Mean dorsal angulation was 21° at time of presentation. Closed reduction significantly improved fracture position to a mean of 2.7° volar angulation (p<0.05). Mean angulation at time of k-wire removal was 1.6° dorsal, this was not significant in comparison to post reduction measurements (p< 0.05). Mean ulnar variance at time of presentation was 2.5mm (range 7.4 to -4.2). Reduction improved fracture displacement to a mean of 0mm, which was statistically significant (p<0.05). Mean ulnar variance at time of k-wire removal was 2.4mm (p<0.05). 56.8% of cases demonstrated radial shortening of 2mm or more. Conclusion. In female patients over 60 years of age, the best predictor of radial length, when K-wire fixation is to be used, is the radial length prior to fracture reduction. Thus if there is radial shortening visible in the initial radiographs as measured in terms of ulnar variance, one should consider a method of fixation other than inter-fragmentary K-wires

Distal radius and ulna fractures are a common paediatric injury. Displaced or angulated fractures require manipulation under anaesthetic (MUA) with or without Kirchner (K) wire fixation to improve alignment and avoid malunion. After treatment a proportion redisplace requiring further surgical management. This study aimed to investigate whether the risk of redisplacement could be reduced by introducing surgical treatment guidelines to ascertain whether MUA alone or the addition of K wire fixation was required. A cohort of 51 paediatric forearm fractures managed either with an MUA alone or MUA and K wire fixation was analysed to determine fracture redisplacement rates and factors which predisposed to displacement. Guidelines for optimal management were developed based on these findings and published literature and implemented for the management of 36 further children. A 16% post-operative redisplacement rate was observed within the first cohort. Redisplacement was predicted if an ‘optimal reduction’ of less than 5° of angulation and/or 10% of translation was not achieved and no K wire fixation utilised. Adoption of the new guidelines resulted in a significantly reduced redisplacement rate of 6%. Implementation of departmental guidelines have reduced redisplacement rates of children's forearm fractures at Great Western Hospital

Background. Angular stable volar locking plates have become increasingly popular for more comminuted fractures of the distal radius. Newer designs of plates have been thicker in profile and incorporate more options for distal fragment fixation. Although they have been shown to be successful at maintaining reduction to allow early mobilisation the main drawback is from screw cut-out. In our practice we have noticed that the newer style of plates that offer more rigid fixation has lead to more instances of screw cut-out. We aimed to quantify the minimum number of locking pegs and or screws need to maintain the operative reduction. Method. We retrospectively looked at a series of 46 patients that had undergone volar plating. We assessed the fracture severity on pre-operative films (according to AO classification) and compared radiographic parameters (volar tilt VT, radial inclination RI and radial height RH) on post-operative films. We calculated the amount of reduction lost from initial post operative x-rays to radiographs taken when union was confirmed. We compared this to the number of locking units used to fix the distal radius and also the configuration they were inserted, i.e. the number in the radial and middle columns. Results. The mean loss of reduction in all plates was 0.9mm of RH, 2.2degs of RI and 2.8degs of VT. There was no difference in mean ‘reduction lost’ between plates that had a total of 2 or 3 locking units (RH 1mm and 1mm, RI 2.0deg and 2.7deg and VT 2.9deg and 3.2 deg respectively). This was also case when sub-analysing more severe OTA Type C fractures. Conclusion. Only one locking peg is needed under each column for adequate stability (i.e. a total of two distal locking units). Any more than this confers no additional benefit in maintaining reduction, ever in more severe fractures. The extra rigidity provided by more locking screws/pegs and also thicker plates: as provided by newer designs of plates, may make them more prone to cut out

This study reports the results of open reduction and internal fixation of 26 unstable, intra-articular, dorsally displaced fractures of the distal radius using a bio absorbable dorsal distal radius (Reunite) plate and calcium phosphate (Biobon) bone substitute. The bio absorbable plate has the advantages of being low profile, easily contourable due to temporary malleability and is angularly stable. It retains its strength for 6 to 8 weeks and undergoes complete mass loss within one year, thereby allowing gradual load transfer to the healing bone. In the majority of cases, this plate produces functional results comparable with metal plates. The Gartland and Werley score was excellent or good in 21 patients. The most important advantage over metal plates is in eliminating the need to remove the plate and hence the need for a second operation if implant related extensor tenosynovitis occurs. Inflammatory tissue reaction to the degradation products of the plate is a potential concern, although the co-polymer ratio used in this plate appears to have reduced the severity of this reaction, which was seen in two patients in this series. The reduction was lost in five patients with severe dorsal comminution. For such fractures, the plate did not retain its strength for long enough to allow adequate healing for satisfactory load transfer. Following this experience, we do not recommend this plating system for fractures with a metaphyseal gap of greater than 7 mm following reduction. For fractures that cannot be treated by closed means but where the metaphyseal gap following reduction is less than 7 mm, this plate provides all the theoretical advantages. Further developments allowing the plate to retain its strength for longer while maintaining the low incidence of inflammatory reactions will make it more universally applicable for the treatment of a greater spectrum of unstable distal radius fractures

Tendon injuries after distal radius fractures Introduction: Tendon injuries after distal radius fractures are a well-documented complication that can occur in fractures managed both operatively and non-operatively. The extensor tendons, in particular the extensor pollicis longus (EPL) tendon, can be damaged and present late after initial management in a cast, or by long prominent screws that penetrate the dorsal cortex and cause attrition. Similarly, a prominent or distally placed volar plate can damage the flexor pollicis longus tendon (FPL). The aim of our study was to evaluate the incidence of tendon injuries associated with distal radius fractures.

We conducted a single centre prospective observational study. Patients aged 18–99 who presented with a distal radius fracture between May 2018 to April 2020 were enrolled and followed-up for 24 months. Tendon injuries in the group were prospectively evaluated. Results: 199 patients with distal radius fractures were enrolled. 119 fractures (59.8%) had fixation and 80 (40.2%) were managed incast. In the non-operative group, 2 (2.5%) had EPL ruptures at approximately 4 weeks post injury. There were no extensor tendon ruptures in the operative group. In the operative group, there were 6 (5%) patients that required removal of metalware for FPL irritation. At the time of operation, there were no tendon ruptures noted. Within the operative group we evaluated plate prominence using a previously described classification (Soong et al.). 5 of the 6 patients (83%) with FPL irritation had Grade 3 prominence.

The incidence of both flexor and extensor tendon injury in our cohort was 4%, extensor tendon rupture was 1% and flexor tendon rupture was avoided by early metalware removal. This study demonstrates tendon injuries are not uncommon after distal radius fractures, and close examination and follow-up are necessary to prevent eventual rupture. Plate prominence at the time of fixation should be minimised to reduce the risk of rupture.

Background. Percutaneous K-wire fixation is a well-recognised and often performed method of stabilisation for distal radius fractures. However, there is paucity in the literature regarding the infection rate after percutaneous K-wire fixation for distal radius fractures. Aims. To analyse the rate and severity of infection after percutaneous K-wire fixation for distal radius fractures. Material and methods. Between October 2004 and June 2005, 43 patients with closed distal radius fractures had percutaneous K-wire fixation. The wires were left outside the skin in all the cases for easy removal at the end of six weeks at the clinic. They were followed up in the clinic at 1, 2, 4, and 6 weeks. The pin tracts were examined at 2 weeks and six weeks, or if needed earlier. The severity of pin tract infection was graded using modified Oppenheim classification. Results. Out of 43 patients, the male to female ratio was 13:30. The mean age was 49.1 years (range 5-86 years). There were nine cases of pin tract infection, out of which three were grade I, three were grade II, two were grade III, and one was grade IV. In three cases the K-wires had to be removed earlier. Discussion. The infection rate after percutaneous K-wire fixation for distal radius fractures is high (20.9%), which is equivalent to the infection rate quoted in the literature for hybrid external fixators. As the K-wires are used to fix the fractures, the expected implant infection rate in Trauma and Orthopaedics which is less than 1% should be aimed for. However this is not the case. Hence, burying the K-wires under the skin may be an alternative to reduce the infection rate after percutaneous K-wire fixation of distal radius

Background. The distal part of the radius is the most common localisation of fractures of the human body. Dislocated intraarticular fractures of the distal radius (FDR) are frequently treated by open reduction and internal fixation with a volar locking plate (VLP) under fluoroscopic guidance. Typically the locking screws are placed subchondral near the joint line to achieve maximum stability of the osteosynthesis. To avoid intraarticular screw placement an intraoperative virtual implant planning system (VIPS) as an application for mobile C-arms was established. The aim of the study was the validation of the implemented VIPS comparing the intraoperative planning with the actual placement of the screws. The study was conducted as a single-centre randomised controlled trial in a primary care institution. The hypothesis of the study was that there is conformity between the virtual implant position and the real implant placement. Patients/Material and Methods. 30 patients with FDR type A3, C1 and C2 according to the AO-classification were randomised in two treatment groups and allocated either in the conventional or in the VIPS group in which the patients underwent an intraoperative planning before screw placement. The randomisation was performed on the basis of a computer-generated code. After fracture reduction an initial diaphyseal fixation of the plate was done. Then the matching of the three-dimensional virtual plate with the image of the real plate in the fluoroscopy shots in two planes was performed automatically. The implant placement was planned intraoperatively in terms of orientation, angulation and length of the screws. After the placement of four or five locking screws the implant position was verified with an intraoperative three-dimensional mobile C-arm scan. The locking screws near the joint line were examined and compared in relation to the actual and the planned inclination angle, the azimuth angle which is determined analogue to a compass rose and the screw-tip distance. The planned and actual parameters of the locking screws were then statistically analysed applying the Shapiro-Wilk - and the Students t-test. Results. 15 patients with FDR were treated in the VIPS arm. In the VIPS group six fractures type A3 one type C1 and eight type C2 were included. The control group showed a similar fracture distribution with six type A3 and nine type C2 fractures. The discrepancy between the actual and the planned screw-tip distance was 2,24 ± 0,97 mm and did not differ significantly (p>0,05). The angle of the planned and actual screw placement also did not vary significantly (p>0,05). The difference of the actual to the planned azimut angle accounted for 18,69°± 29,84. The planned and real inclination of the screws differed by 1,66° ± 4,46. Conclusion. The analysis shows that the screws were almost placed as planned. Differences between actual and planned placement of the screws were observed but were not statistically significant. Therefore the hypothesis of the study can be accepted. We assume, that the precise planning of the screw placement in FDR with VIPS can be transported into the surgical treatment