Distal radius fracture characteristics should determine treatment, not current fixation trends

One of the most common fractures a patient can experience is a distal radius fracture. In Europe, orthopaedic surgeons use a variety of operative and nonoperative methods to effectively treat these fractures, according to sources interviewed by Orthopaedics Today Europe.

“Treatment can depend on the patient and a lot of different factors. Treatment of a distal radius fracture can be related to a lot of different things because there are different possibilities related to the technical background of the hospital you are working in, if it has MRI, for example. Then, of course, there is the question of what you can afford for yourself,” Zsolt Szabo, MD, PhD, of Miskolc, Hungary, told Orthopaedics Today Europe. “You have to think of a patient in your decision-making process. Your technique depends on the age of the patient, their profession, and it can depend on the intelligence level of the patient. This can affect the way you deal with the postoperative treatment and how early you can start active mobilization.”

Szabo said another key factor related to how a surgeon treats a distal radius fracture is related to the most current treatment trends.

In the past, “it was high fashion to use dorsal plates and then external fixation; now everyone wants to use volar plating for every type of fracture. It is very interesting how fashion can influence our decision making,” he said.

According to the orthopaedic surgeons interviewed for this article, the “fashionable” treatment for distal radius fractures at the moment is volar plate fixation.

While there is always more than one way to treat a distal radius fracture, and different factors always come in to play with each surgery, Philippe Kopylov, MD, PhD, of Lund, Sweden, told Orthopaedics Today Europe the volar plate and fragment-specific technique is the most one commonly used at his clinic and one of the most effective treatments for distal radius fractures.

Kopylov said if a patient opts for surgery to treat a distal radius fracture, it is important to select and use the best method to give the patient the most stable result.

“To have an absolutely good reposition of all the [fracture] pieces and so on, you need to have a good volar plate with locking screws, or the fragment-specific technique. That gives you the motion almost the same as prior to the injury,” he said. “We do not do pinning here, for different reasons. You cannot believe in the stability of the pinning. So pinning, which has been the ‘easy’ way because you can perform it in an emergency room without good anesthesiology, is not a good solution. If you go for surgery, you have to be sure that at the end of surgery you have a stable system. The pins cannot give you that in all cases.”

Volar plating in older patients

Also, despite what surgeons have believed in the past, the volar plate surgery is one that many elderly patients now opt for when they suffer a distal radius fracture, Kopylov told Orthopaedics Today Europe. Patients in their 70s and 80s are opting for the surgery whereas in the past older patients would frequently choose to have conservative treatment, he said.

Senior citizens are more active today, Kopylov said, and they do not want to lose range of motion or strength. They want to be able to take care of themselves, play golf, to sail, to still be able to participate in the hobbies that make them happy.

“Just to tell old patients to forget [surgery], to just take the young ones because they have a risk to develop secondary arthritis, that is not enough. I think we have to go for surgery and proper surgery for everyone,” Kopylov said.

Although it is his preferred method of distal radius fracture treatment, Kopylov told Orthopaedics Today Europe that like any other surgery, the volar plating and fragment-specific method has its share of potential complications. He said the main complication is malunion, which occurs with nearly every one of these treatment methods.

One of the main complications associated with volar plating techniques is tendon damage. Furthermore, the use of screws to fix these fractures can sometimes irritate tendons in the wrist or even rupture a tendon if it is too long, he said.

Minimal follow-up with volar plates

Despite these complications, Anders Ditlev Foldager-Jensen, MD, of Aarhus, Denmark said the volar plate technique is the most effective for distal radius fractures.

“As many of us have, we have jumped onto the volar plate, the locking volar plate system. We love it because it is a nice system for this type of fracture,” Foldager-Jensen told Orthopaedics Today Europe. “[Patients] can be operated on once, and there are not a lot of complications.”

When complications occur with this approach they are typically because the physician performed the surgery poorly, he said. “If it is a good doctor and a good patient, you will see them once and they will get on with their work and on to their lives quicker than other method,” according to Foldager-Jensen.

Furthermore, there is a quick turnaround from the surgical procedure to full mobility and the time when patients return to their normal lives, back to work, and back to what they enjoyed doing before their wrist injury, Foldager-Jensen said.

He noted the volar plate fixation method for distal radius fractures has almost eliminated the use of external fixation at his clinic. While they can be expensive, Foldager-Jensen said volar plates might be the same cost as an external fixation method when the number of postoperative visits a patient has with their physician considered. A volar plate is basically just one and done, he said, but a patient with an external fixation device requires several follow-up visits.

“We often need to consider the economy when regarding using a volar plate, but it actually might be cheaper in the end if you look at all the expenses. But we don’t have any data on this right now,” he said.

External fixation needs consideration

The volar plate technique, however, is one of many surgical methods orthopaedic surgeon use to treat distal radius fractures. Frederic Schuind, MD, PhD, Chief of the Department of Orthopaedics and Traumatology, Erasme University Hospital, in Brussels, told Orthopaedics Today Europe the fracture type is the driving factor to determine which method of treatment to use.

Schuind said surgeons at his clinic frequently use an external fixation method for patients with distal radius fractures.

For most fractures, “the choice is either external fixation or volar plate. I think, in many centers, a volar plate is the technique that is used most frequently. But, it is a technique that requires high precision surgery, especially in comminuted fractures,” he said. “If you do not perfectly apply the plate, there is a risk of extensor tendon rupture, flexor tendon rupture, carpal tunnel, and there is a risk of percutaneous screws in the joint. There are a lot of complications if the technique is not perfect. Sometimes it is difficult when the fracture is highly comminuted in an osteoporotic bone in older patients. So, we continue to use a lot of external fixation” in those cases.

To achieve the best results with external fixation, Schuind told Orthopaedics Today Europe the method must be completed as soon as possible after injury, preferably the night the fracture occurred or the day after that.

Indicated for comminuted fractures

He said external fixation is an easy to use technique and offers great protection for patients with distal radius fractures.

“Probably, it is the best technique when the fracture is highly comminuted,” according to Schuind. “It is easy to get a good reduction, while that is hard to do with the plate method.”

Complications can occur related to external fixation, but Schuind said most of them have to do with the patient’s ability to keep the pins used with the fixation clean.

The pins also can lead to infection or irritate the skin, he said, but if the patient keeps the pins clean then most of these complications can usually be avoided.

Schuind said the data have shown the external fixation methods and volar plate techniques can be equally effective after 6 months. Volar plating surgery, however, can restore a patient’s motion quicker than an external fixation method, typically at about 3 months postoperatively. But, by the 6-month follow-up the results are usually equivalent to one other, he said.

“We believe it is at least equivalent. It is efficient especially in the most difficult fractures. It is a good technique,” Schuind said of external fixation. “I believe it has its advantages and disadvantages, but it is not clearly better.”

One of the downsides of external fixation procedure is it takes longer to recover from, Schuind said, but he noted many patients opt for this treatment simply because they do not want to have that scar that results from volar plate surgery.

“‘Interestingly enough, in a prospective study presently conducted in my department comparing locked volar plate and radiometacarpal external fixation for the treatment of closed, comminuted distal radius fractures, the majority of patients who refused to participate in the study opted for external fixation, fearing the open palmar approach for plate fixation and seeing external fixation as less invasive,” he said.

Not one treatment for all patients

Each patient, each type of fracture, each different injury scenario deserves its own technique and method of treatment, Szabo told Orthopaedics Today Europe.

Szabo noted he does not have a preferred technique for treating distal radius fractures, but said each treatment method has its own advantages and disadvantages based on the fracture type and other factors.

“I have had the chance to travel all around the world. I have seen fantastic results in countries where they are using only plaster to treat these injuries,” Szabo said.

Focus on anatomy

He discussed the three factors he says are more important to the orthopaedic surgeon who treats distal radius fractures than the method or the high-tech implant used. They are a surgeon’s anatomical knowledge, proper follow-up after whatever method is chosen and used, and the surgeon’s ability to master one method perfectly for distal radius fracture fixation.

“The majority of the problems relating to operations of the distal radius were not related to surgical techniques, or the surgery, but to the anatomical knowledge of the surgeon. We learn anatomy the first and second year of medicine, and then we like to forget it. We think we know it, but in reality we do not know it. For the distal radius, it is important to have this knowledge of the three columns — the radial, ulnar and the intermediate column — and the stability of them. It is important to understand this. It is not so much the importance of the methods or the implants. The implants are always changing,” Szabo said. – by Robert Linnehan

• For more information:
• Anders Ditlev Foldager-Jensen, MD, can be reached at the Aarhus University Hospital, Nordre Ringgade 1, 8000 Aarhus C, Denmark; email: anders.ditlev@aarhus.rm.dk.
• Philippe Kopylov, MD, PhD, can be reached at the Hand and Upper Extremity Unit, Department of Orthopedics, Lund University Hospital, Lund, Sweden; email: philippe.kopylov@med.lu.se.
• Frederic Schuind, MD, PhD, can be reached at Department of Orthopaedics and Traumatology, Erasme University Hospital, Brussels, Belgium; email: Frederic.Schuind@erasme.ulb.ac.be.
• Zsolt Szabo, MD, PhD, can be reached at can be reached at Traumatology and Hand Surgery Department, Szenpeteri Kapu 72-76, 3501 Miskolc, Hungary; email: zsoltszabo@axelero.hu.

Disclosures: Foldager-Jensen, Kopylov, Schuind and Szabo have no relevant financial disclosures.

When is surgical fixation of a stable distal radius fracture contraindicated?

Almost always contraindicated

Surgical stabilization of stable distal radius fractures is almost always contraindicated because these fractures are typically treated with closed reduction and cast fixation. The basic parameters used to decide for a conservative management are whether or not the fracture is reducible with closed manipulation and if it remains stable after reduction; in other words, those fractures in which the tendency to re-displace in plaster is minimal.

By definition stable fractures are those with minimal displacement that do not require reduction or displaced fractures that can be stabilized and maintained in plaster provided the technique of casting is meticulous respecting the rules of 3-point contact as proposed by Sir John Charnley.

The only indications for open reduction and internal fixation of stable fractures are: extra-articular types with axial impaction and significant shortening that leads to disruption of the distal radioulnar joint and ulnocarpal impingement; those with unacceptable intra-articular disruption; and stable fractures associated with carpal ligament injuries.

Finally, surgical stabilization is not contraindicated in those patients with stable fractures that require early low demand use of the hand.

Diego L. Fernandez, MD, is at the Orthopaedic Department, Lindenhof Hospital, in Berne, Switzerland. He is also a professor of orthopaedic surgery at the University of Berne.
Disclosure: Fernandez has no relevant disclosures.

If mobilization is possible, surgery can be contraindicated

Stable fractures are generally considered to be those that remain in a reduced position after manipulation. Therefore, if a successful reduction can be obtained and the patient can tolerate immobilization for the approximately 6 weeks required to obtain union, surgical treatment is usually unnecessary but not necessarily contraindicated. Some patients are unwilling to accept down time for professional or lifestyle reasons, such as professional athletes, pilots, surgeons and patients with no family support. These patients often elect internal fixation over conservative treatment as the modern types of internal fixation allow early functional use of the hand. Other patients are unable to tolerate immobilization for various reasons such as having an open wound in the forearm that requires treatment or having an associated injury in the ipsilateral extremity that requires surgical treatment and rehabilitation (such as a serious elbow fracture) or perhaps the patient is claustrophobic and for psychological reasons cannot be immobilized. In those cases, surgical stabilization of stable fractures can be performed. Relative contraindications to surgical stabilization in these patients are the presence of open physis, severe medical conditions that increase the risk of anesthesia and rarely metal sensitivity.

Elderly patients, especially those of low functional demand, are tolerant of deformity and often not treated surgically. A fracture may present considerable deformity but be “stable” in the sense that because of mechanical impaction it will not displace to a greater degree than at presentation. These patients can often be treated nonoperatively by immobilizing them in the position of initial presentation and accepting the deformity. For elderly patients unwilling to accept deformity or with displaced unimpacted fractures, surgical stabilization is often performed. Because of the stability provided by the modern angle-stable implants, osteoporosis is no longer a contraindication for surgery.

Jorge L. Orbay, MD, is the director of the Miami Hand Institute, in Miami.
Disclosure: Orbay is the CEO of Skeletal Dynamics.

Certain conditions limit surgery

Surgical correction of a stable distal radius fracture is not performed when the patient has a condition where general or regional anesthesia is risky, when there is a dermatologic condition making an incision in the skin perilous, when the activity demands of the patient does not require good hand function, such as stroke or brachial plexus injury, and in psychiatric patients who cannot tolerate surgery.

David Seligson, MD, is from Louisville, Ky., USA, and is a member of the Orthopaedics Today Europe Editorial Board.
Disclosure: He is a consultant to Stryker.