”Effects of treatment of Unstable Distal Radius Fracture With a Palmar Locking-Plate” Lars Soelberg Vadstrup and Nikolaj Winther Department of Orthopaedic Surgery Hillerød University Hospital Hillerød, Denmark
Hypothesis •
The use of Palmar Locking-plate in treatment of unstable, displaced distal radial fractures (AO classification 23-A, 23-B og 23-C) is combined with a low complication rate and a minimal loss of reduction at 1 year follow up.
Lars Vadstrup and Nikolaj Winther
AO classification • 23-A – Extra articular
• 23-B – Partially articular
• 23-C – Complete articular Ref. AO Foundation online Lars Vadstrup and Nikolaj Winther
Treatment in 2006 • Extra articular fracture (AO 23-A): •
K-wire osteosynthesis a.m. Kapandji or palmar locking-plate osteosynthesis.
• Partially and complete intra articular fracture (AO 23-B og 23-C): •
Palmar locking-plate osteosynthesis.
• Aftercare: • • •
Wrist immobilized in below elbow splint for 5 weeks X-ray after surgery and at 2 and 5 weeks Occupational therapy if needed Lars Vadstrup and Nikolaj Winther
Main Outcome Measures • Complications – Hardware failure – Tendon rupture – Tenosynovitis – Soft tissue irritation – CRPS (Complex regional pain syndrome) – Infection – Carpal Tunnel Syndrome
Lars Vadstrup and Nikolaj Winther
Main Outcome Measures • Radiographic assesment – Ulnar variance – Radial inclination – Volar tilt – Fracture union
Lars Vadstrup and Nikolaj Winther
Main Outcome Measures • Objective functional results – Grip strength – Supination/Pronation strength – Active range of motion • Flexion/extension • Supination/Pronation
• Subjective functional results – Wrightington score (function of the operated hand) – DASH score (function of both upper limbs)
Lars Vadstrup and Nikolaj Winther
Patients • Age 18 or above • Consecutive patiens treated for an unstable, displaced distal radius fracture at Nordsjællands Hospital Hillerød in 2006 with a palmar lockingplate.
Lars Vadstrup and Nikolaj Winther
Database
Demography
Injury data
Surgery
2 weeks
Lars Vadstrup and Nikolaj Winther
5 weeks
Follow up
Database Demography
Injury data
Surgery
2 weeks
Gender Age Dominant hand
Lars Vadstrup and Nikolaj Winther
5 weeks
Follow up
Database Demography
Injury data
Surgery
2 weeks
Date of injury Trauma type Fractured hand Radiographi c assesment AO classificatio n Nerve injury Lars Vadstrup and Nikolaj Winther
5 weeks
Follow up
Database Demography
Injury data
Surgery
2 weeks
OP date Bone graft Radiographi c assesment Decompres. N. Medianus
Lars Vadstrup and Nikolaj Winther
5 weeks
Follow up
Database Demography
Injury data
Surgery
2 weeks
5 weeks
Radiographi c assesment
Radiographi c assesment
Complications
Complications
Lars Vadstrup and Nikolaj Winther
Follow up
Database Demography
Injury data
Surgery
2 weeks
5 weeks
Follow up Radiographic assesment Complications
DASH (Disabilities of the Arm, Shoulder and Hand) Wrightington score
Functional results
Grip strength Supination / Pronation strength
Strength
Flexion/extension Supination / Pronation
Active range of motion
Lars Vadstrup and Nikolaj Winther
Patient flow
* Follow up time 12 – 32 months
Lars Vadstrup and Nikolaj Winther
Demography N=43 Gender, male/female
6/37
Mean age, years (range)
65.5 (40-85)
Site of fracture, dominant/non-dominant
Lars Vadstrup and Nikolaj Winther
17/26
Results • Loss of reduction Post OP
5 weeks
Final follow up
Ulnar variance
2 mm (0-4 mm)
1 mm (-4 - 3 mm)
1 mm (-4 - 3 mm)
Radial inclination
18° (10-22°)
17° (8-22°)
17° (8-20°)
Volar tilt
3°
0°
0°
(-5 - 10°)
(-20 - 10°)
(-20 - 10°)
• Loss of reduction increases up to 5 weeks after surgery. No further loss of reduction at final review. Lars Vadstrup and Nikolaj Winther
Results • Mean grip strength at follow up was 85 % (± 22%) of the uninjured side.
Strength as compared with uninjured side at final review, %
Dominant side treated N=15 Mean (±SD)
Nondominant side treated N=26 Mean (±SD)
Difference (95% CI)
p-value
96 (± 27)
78 (± 16)
17 (3-30)
0,04
Lars Vadstrup and Nikolaj Winther
Results • Mean pronation strength at follow up 81 % (± 15%) of the uninjured side. • Mean supination strength at follow up 87 % (± 19%) of the uninjured side.
Lars Vadstrup and Nikolaj Winther
Results Dominant side treated N=15 Mean (±SD) Pronation strength 85 (± 15)
Nondominant side treated N=26 Mean (±SD)
Difference (95% CI)
p-value
78 (± 16)
7 (-5 - 19)
0,269
83 (± 21)
9 (-5 - 23)
0,176
as compared with uninjured side at final review, %
Supination
92 (± 15)
strength as compared with uninjured side at final review, %
Lars Vadstrup and Nikolaj Winther
Results • Active Range of Motion
ROM as compared with uninjured side at final review, %
Pronation
Supination
Flexion
Extension
81 (±14)
89 (± 5)
80 (± 9)
85 (± 15)
Lars Vadstrup and Nikolaj Winther
Results • Subjective functional results: – DASH score (physical function of the arm) • 14 (0-34) – Wrightington score (physical function of the hand) • Mean 10 (8-20)
Lars Vadstrup and Nikolaj Winther
Results • Complication rate:
27% (n=12)
– Non-union – Infection, deep – CRPS – Tendon rupture (EPL) – Hardware related
0 0 0 7% (n=3) 16% (n=7)
• Loosening of locking screw (n=5) – All non-symtomatic
• Soft tissue irritation (n=2) – Plate removal
– Carpal tunnel syndrome, secondary – Plate removal and decompression of the median nerve. Lars Vadstrup and Nikolaj Winther
5% (n=2)
Complication, soft tissue irritation plate removed
Lars Vadstrup and Nikolaj Winther
Complication, EPL rupture
Lars Vadstrup and Nikolaj Winther
Screw loosening 5 weeks 1 year
Lars Vadstrup and Nikolaj Winther
AO 23-C3 fracture post op
Lars Vadstrup and Nikolaj Winther
AO 23-C3 fracture 5 weeks after surgery
Lars Vadstrup and Nikolaj Winther
References • Rohit Arora et al. 2007 J Orthop Trauma – 114 patients treated with volar fixed angle plate (LCP Distal radius plates) – Follow up mean 15 month. – Flexion/extension 72/82 % of uninjured side – Pronation/supination 95/95 % of uninjured side – Grip strength 70 % of uninjured side – DASH mean 13
Lars Vadstrup and Nikolaj Winther
References • Rohit Arora et al. 2007 J Orthop Trauma – no non union – Loss of ulnar variance: 1,2 mm (0-6 mm) – Loss of radial inclination: 0,4° (0-2°) – Loss of volar tilt: 3,4° (0-8°) – Complication rate: 27% (31/114) • Tenosynovitis, EPL ruptur, CTS, CRPS,
– Neither clinical outcome nor complication rate were dependent on fracture type Lars Vadstrup and Nikolaj Winther
References • Tamara D. Rozental et al. 2006, J Hand Surg – 41 patients treated with volar fixed angle plate (LCP, DVR). – Follow up mean 17 month. – Flexion/extension 72/82 % of uninjured side – Pronation/supination 95/95 % of uninjured side – Grip strength 70 % of uninjured side – DASH gennsn. 14 Lars Vadstrup and Nikolaj Winther
References • Tamara D. Rozental et al. 2006, J Hand Surg – Loss of ulnar variance: 0 mm (11,1 11 mm) – Loss of radial inclination: 0° (21 21°) – Loss of volar tilt : 1° (5° post op 4° follow up) – Complication rate: 22% (9/41) • Fracture kollaps, tenosynovitis, wound infection, MCP stiffness
Lars Vadstrup and Nikolaj Winther
Conclusions • Minimal loss of reduction at follow up after treatment with palmar locking plate. • Good recovery of grip, pronation and supination strength at final review. • High subjective functional outcome.
Lars Vadstrup and Nikolaj Winther
Thank you for your attention
Lars Vadstrup and Nikolaj Winther
Plate positioning
Ref. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin. 2005; 21:347–354
Lars Vadstrup and Nikolaj Winther
Wrightington score • Activity – – – – – – – –
•
Can use the back pocket of the trousers Personal care Can use a screwdriver Can place the hand flat to the face Can take up coins offered as change Can lift object with hand gripping Can use the hand to rise from a chair Can do usual work
Activities are graded for function – 1= normal; 2 = with difficulty, 3 = aid needed, 4 = unable to complete – Best score possible = 8 Worst score possible = 32 (Cannot complete any of the activities)
Lars Vadstrup and Nikolaj Winther