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

Distal radius fractures have an incidence rate of 17.5% among all fractures. Their treatment in case of comminution, commonly managed by volar locking plates, is still challenging. Variable-angle screw technology could counteract these challenges. Additionally, combined volar and dorsal plate fixation is valuable for treatment of complex fractures at the distal radius. Currently, biomechanical investigation of the competency of supplemental dorsal plating is scant. The aim of this study was to investigate the biomechanical competency of double-plated distal radius fractures in comparison to volar locking plate fixation. Complex intra-articular distal radius fractures AO/OTA 23-C 2.1 and C 3.1 were created by means of osteotomies, simulating dorsal defect with comminution of the lunate facet in 30 artificial radii, assigned to 3 study groups with 10 specimens in each. The styloid process of each radius was separated from the shaft and the other articular fragments. In group 1, the lunate facet was divided to 3 equally-sized fragments. In contrast, the lunate in group 2 was split in a smaller dorsal and a larger volar fragment, whereas in group 3 was divided in 2 equal fragments. Following fracture reduction, each specimen was first instrumented with a volar locking plate and non-destructive quasi-static biomechanical testing under axial loading was performed in specimen's inclination of 40° flexion, 40° extension and 0° neutral position. Mediolateral radiographs were taken under 100 N loads in flexion and extension, as well as under 150 N loads in neutral position. Subsequently, all biomechanical tests were repeated after supplemental dorsal locking plate fixation of all specimens. Based on machine and radiographic data, stiffness and angular displacement between the shaft and lunate facet were determined. Stiffness in neutral position (N/mm) without/with dorsal plating was on average 164.3/166, 158.5/222.5 and 181.5/207.6 in groups 1–3. It increased significantly after supplementary dorsal plating in groups 2 and 3. Predominantly, from biomechanical perspective supplemental dorsal locked plating increases fixation stability of unstable distal radius fractures after volar locked plating. However, its effect depends on the fracture pattern at the distal radius

Standard imaging of complex intra-articular distal radius fractures consists of posterior-anterior, lateral and oblique x-rays. Recently the liberal use of CT scan in this area became widely accepted as an additional imaging tool in pre-operative evaluation. The aim of this study was to evaluate whether CT scanning of complex distal radius fractures changed the management of these fractures compared to plain films. A series of 20 closed distal radius complex intra-articular fractures AO 12-C which had both plain PA, lateral and oblique films and CT scans were selected from our long bone trauma database. The plain films were blindly reviewed by five observers. A management plan was then formulated. Options provided were: closed manipulation, closed manipulation with percutaneous K wire fixation, open reduction and internal fixation, external fixature or bone graft/substitute. The same patients' CT scans (in randomised order) were blindly reviewed at the one week interval by the same clinicians with the same management options decided upon. Kappa statistic was used to measure the intra-individual agreement between x-ray and CT, as well as inter-individual agreement within each imagining modality. The agreement between individual observer's management decisions, based on the x-rays and on the CT scan was poor; with an average Kappa score of 0.038 (range 0.006 to 0.19). A regression model with management as a graded 5 level variable ranging from least invasive to most invasive and imaging modality as the predictor gave an estimated coefficient of 0.163, (p=-0.267); this indicates a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared to the plain x-rays. The agreement on management decisions between the observers based on x-ray alone was higher than that based on CT alone (kapa=0.174 vs 0.03). This study indicates a very poor level of agreement between decision-making, based on x-ray and on CT. Even within individual's ‘interindividual’ agreement appears higher with x-ray than CT. This study also raises the possibility that the use of CT scans increases the level of invasiveness in the surgical management of complex distal radius fractures

There is ongoing debate regarding the optimal management of displaced distal radius fractures in the elderly. The aim of this review was to compare outcomes of operatively versus non-operatively managed displaced extra-articular or undisplaced intra-articular distal radius fractures in patients 65 years and older. All patients over the age of 65 years with displaced extra-articular or undisplaced intra-articular fractures seen in Tauranga Hospital between 1. st. January 2009 and 31st December 2009 were included in the study. Patients from out of town, with incomplete radiographs or who had since passed away were excluded as were patients with comminuted intra-articular or undisplaced/minimally displaced extra-articular fractures. Patients attended follow-up where clinical assessment was carried out by a single Hand Therapist who was blinded to the side of injury and previous management, completed the Patient Rated Wrist Evaluation (PRWE) and DASH questionnaires and a visual analogue satisfaction score. There were 91 distal radius fractures in patients 65 years and older seen in Tauranga Hospital over this 1 year period. 44 were excluded leaving 47 patients. 6 declined follow-up and 5 failed to attend. 36 patients (3 males, 33 females, average age 74.7 years) were included in the study – 23 had been treated non-operatively with casting +/− manipulation while the remaining 13 patients had undergone open reduction and internal fixation. Comparing the injured with the uninjured wrist in the operatively managed group there was an average loss of 5.8 degrees flexion, 1.2 degrees extension, 1.7 degrees ulnar deviation and 3.8 degrees supination with a gain of 0.7 degrees radial deviation, no change in pronation and a loss of 1.2kg in grip strength. These operatively managed patients had an average PRWE score of 6.5, DASH score of 31.5 and satisfaction score of 8.8. Conversely, in the non-operatively managed group there was an average loss of 17.5 degrees flexion, 9.4 degrees extension, 11.3 degrees ulnar deviation and 10.9 degrees supination with a gain of 0.1 degrees radial deviation, no change in pronation and a loss of 4.7kg in grip strength. These non-operatively managed patients had higher PRWE (42.5) and DASH (56) scores and were in general less pleased with their outcomes (mean satisfaction score – 5.6). Patients in the operatively managed group at 12–24 months post-injury had less significant loss of function as well as lower PRWE and DASH scores and higher satisfaction outcome scores