Introduction: In recent years both patients and clinicians have benefitted from using volar locking plates (VLPs) to treat otherwise difficult to stabilise displaced distal radius fractures. However, it is not clear whether the newer VLP systems offer real clinical advantages over the original systems. AIM: To assess the clinical outcome of patients treated using two VLP systems.

Methods: Two cohorts of patients treated with a distal radius VLP were assessed prospectively by an independent assessor at 6 months following surgery using Visual Analogue Scales (pain & function), range of movement, grip and pinch strength. Complications were also recorded. 68 patients treated with the original Synthes VLP and 51 with a Periloc VLP (Smith & Nephew) were available for clinical review. There were no differences in patient demographics or injury types between the groups.

Results: Treatment with both VLP systems resulted in good or excellent clinical outcomes for both patient groups. Using either the median or the mean results, there were no differences between either of the VLP groups with respect to pain, subjective function, grip or pinch strength, palmar flexion, dorsiflexion, radial or ulnar deviation, or forearm rotation. The complication rates were also very similar, the most common problem relating to prominent metal work necessitating removal after fracture healing in 7 – 9% of out patients. Conclusion: VLPs are excellent implants for restoring wrist function and reducing longterm symptoms. The potential advantages of the newer generation of VLPs over the simpler original VLP designs remain unproven.

Proximal Humeral fractures are common injuries that are difficult to treat satisfactorily despite the variety of operative and conservative treatment options that are available. To make any real sense of the literature concerning the treatment of these injuries, it is important that the tools that clinicians use to assess clinical outcomes accurately reflect each patient’s level of symptoms and function.

Aim: To assess how well commonly used subjective, and composite clinical scoring systems reflect patients’ perceptions of pain and functional recovery.

Methods: We invited all patients who had sustained a proximal humeral fracture that had been treated using a PHILOS (Synthes) Locking plate to attend for review. All patients were reviewed at a minimum of 14 months following surgery by which time they had all been discharged from regular clinical review months before. All patients completed subjective Visual Numerical Scales (VNSs) for pain, and for function, that were used to compare more commonly used shoulder/upper limb scores (UCLA, Modified Constant, Oxford, and Quick DASH scores).

Results: 33 patients were available for review. 55% were women. Age range 25–83 years (Ave. 57 years). Timing of review after index procedure (Range 14–58 months, ave. 30 months). Patients appeared to find the numerical VNSs easier to understand, and interestingly, analysis of the pain component of the each of the commonly used scores were answered inconsistently when the scores were compared. With respect to patient perception of pain and subjective level of function, both the Oxford and Quick DASH scores consistently overscored both parameters placing the majority of patients in higher (clinically better) categories, while the Constant score underscored the majority of patients placing them in lower categories (satisfactory or poor). The UCLA score was marginally better than the Constant score in relation to the VNSs for pain and function.

Discussion: Despite our dependence upon the more commonly used Clinical Outcome Scoring systems to help guide us with choosing the best treatment options for our patients with proximal humeral fractures, our study confirms our suspicions that none of these outcome scores truly reflect our patients perception of function and pain. In addition, the terminology and sentence structure that is used in all of the commonly used scoring systems may bias the results by confusing many of our patients.

Conclusion: Currently, none of our commonly used shoulder outcome scores truly reflect the clinical outcome of patients who have sustained proximal humeral fractures. Instead, it may be better to use subjective VNSs that are easy for patients to understand and are quick to use.

Despite advances in Locking Plate (LP) design, distal femoral fractures remain challenging injuries to treat especially in the elderly where approximately 15–30% develop nonunions secondary to failure of fixation.

Aim: To establish the mechanisms of nonunion in our patient population using two different LP systems.

Methods: Between December 2002-May 2008, we prospectively collected data on all 67 patients with distal femoral fractures who were treated using a suitable distal femoral LP (LISS, 35 cases, or Periloc, 32 cases). 72% of the patients were female; ages ranged from 25–94 years (ave. 67 years). Many of our patients had a number of significant co-morbidities.

Results: The presence of significant co-morbities e.g. Rheumatoid arthritis, long term systemic steroid use, cerebrovascular accidents resulting in ambulatory problems, previous major joint arthroplasty including ipsilateral knee replacements, paralysis, and severe dementia, did not appear to influence fracture union significantly. However, old age was strongly correlated with nonunion with all failed cases (7 patients - 10% of the study group) presenting with failure of fixation. 2 of the LP system failures resulted in malunion and the 5 other cases required revision surgery. Of note, all 7 patients were elderly, 6 being over 80 years of age. The mechanism of fixation failure was specific to each of the LP systems. All 4 of the failures treated with LISS, resulted from poor proximal stability as a consequence of unicortical screw fixation. Two patients required to have the proximal fixation revised through the insertion of bicortical screws which subsequently resulted in successful union. The other two patients were treated in long leg casts as the varus deformities were considered acceptable given each patient’s needs. All 3 of the failures who had been treated with a Periloc LP, resulted from fracturing of the plate at the metaphyseo-diaphyseal junction at the level of the main extra-articular component of the fracture. The plates all fractured through the unfilled screw holes, and all 3 patients required revision of fixation to bring about union.

Discussion: The LISS failures can all be attributed to poor proximal fixation that is associated with the use of unicortical screws in osteoporotic bone and confirms the need for bicortical screw fixation. However, modern LP systems manufactured from stainless steel offer increased implant stability that may in turn stress any fracture bridging segments of the LP.

Conclusion: Although we are aware of the importance of bicortical screws in osteoporotic patients, it is also seems likely that excessive plate rigidity should be avoided, by using long plates with well spaced out screws.

Aim: The use of volar plates in the management of distal radius fractures has increased dramatically over the last decade. Our aim was to ascertain if long term outcome could be predicted at clinical review four months following operation.

Patients and Methods: Between January 2003 and January 2005, all patients presenting with unilateral distal radius fractures and treated with volar locking plate fixation (Synthes) were invited to participate in long-term follow up. The decision to use a volar plate and the operative procedure itself was undertaken by the on-call consultant and his team. Patients who agreed to enter the study were evaluated at 4, 6 and 12 months following operation. Patient demographics, hand dominance and fracture type were recorded. Assessment of grip strength and wrist movements were undertaken and expressed as a percentage of the contralateral, uninjured side.

Results: A total of 76 out of 100 eligible patients agreed to participate in the study. Of those patients, 23 (30%) failed to attend all their follow-up appointments, leaving a dataset of 53 patients (70%) available for analysis. There were 28 females (53%) and the mean patient age was 55 years (range 28–83).

Grip strength, pinch grip, wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation and supination all showed graded improvement in the year following fracture, achieving a mean range of 73% to 95% of function compared to the contralateral side at 12 months. Wrist flexion and ulnar deviation showed near maximum improvement by 6 months, whereas the other variables continued to show significant improvement between 6 and 12 months.

Logistic regression analysis suggested that improvement in wrist extension at four months was the best predictor of a good outcome at one year.

Discussion: Use of volar plate fixation is an increasingly common method of managing distal radius fractures. Our study suggests that good functional results can be achieved by this method of treatment. Failure to regain reasonable wrist extension by four months appears to predict higher risk of poor outcome and therefore patients in this group should be followed up more closely.

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures.

Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery.

Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side.

Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures.

Aims: In recent years, volar locking plates have increased in popularity for the treatment of displaced distal radial fractures. The angular stability of the screws help maintain reduction permitting early mobilisation. The aim of this study was to assess functional outcome using both subjective and objective methods.

Methods: The study was a prospective cohort study. Over a 2 year period 110 patients with closed, displaced distal radial fractures were considered suitable for treatment with the distal radius volar locking plate. Of these, 51 patients were followed up for a full 12 months. One year post-operatively all patients were reviewed and both subjective and objective measurements made:

Subjective:

Pain – visual analogue scale (VAS) (0 = no pain, 10 = worst pain ever).

For the purpose of this analysis, the fractures were divided into intra- and extra-articular fracture patterns based on the initial pre-operative X-rays.

Results: The mean age was 55 years (28 – 83), 36 were female and 15 male. Of the fractures, 26 were extra-articular and 25 intra-articular. 28 of the 51 patients had a period of physiotherapy post-operatively. 23 patients were either not referred to physiotherapy or failed to attend.

Subjectively 75% of patients had an excellent result with a pain VAS score of 0–1/10 (mean 0.9 for extra-articular and 1.2 for intra-articular) and an overall function VAS score of 9–10/10 (mean 92% for extra-articular and 86% for intra-articular).

Objective outcome measures were also very good. The results for the extra-articular group showed a mean grip strength of 85%, a mean pinch grip of 91%, a mean flexion of 82%, a mean extension of 88%, a mean pronation of 98% and a mean supination of 98%. The results for intra-articular fractures showed a mean grip strength of 80%, a mean pinch grip of 88%, a mean flexion of 78%, a mean extension of 83%, a mean pronation of 94% and a mean supination of 93%.

Conclusions: Overall patients made an excellent recovery. The majority of patients had little or no pain and almost complete return to function at 12 months post-operatively. Interestingly, individual patient demographics (age, sex, fracture type, physiotherapy) did not make a statistically significant difference to the outcome measures.

This study confirmed excellent functional results comparable with other methods of fixation for extra-articular fractures, but it also showed good results with the more complex intra-articular fractures.