Clinical Research And Meta-analysis Of The Distal Radius Fractures

Background: Distal radius fractures are common wrist injuries,the incidence of which showed a trend of increasing year by year.The incidence of distal radius fractures was approximately 26/10000 per year,accounting for 72% of all patients with forearm fractures,accounting for 8% to 17% of all patients with upper limb fractures,and accounting for 1/6 of emergency department patients with distal radius fractures.Patients with distal radius fractures showed bimodal characteristics,ie,young patients and elderly patients.Internal fixation with plates is a reliable fixation technique for the treatment of distal radius fractures.An ongoing discussion exists whether volar or dorsal plating is the appropriate technique.In clinical practice,volar plate fixation is usually preferred because of the assumed lower complication frequency.However,recent studies with the newer generation low-profile dorsal plates reported lower complication rates.But in clinical work,we found that the volar plate fixation is not a universal choice,the volar plate fixation to the application of certain types of fractures encountered some internal fixation failure,fracture fragments dislplacement and even wrist dislocation and other serious complications.It deserves our self-examination.Objective: Decision between volar and dorsal plate fixation of the acute distal radius fracture is based on the direction of fragment displacement and the surgeon’s experience and preference.In our practice,we have observed that distal radius fractures appear to have certain characteristics depending on orientation of the wrist at the time of injury.This led us to hypothesize that the surgical strategy could be determined by the the direction of the fracture fragment displacement,and that such a strategy may minimize complications and facilitate good reconstruction of the distal radius fractures.Herein,we report the results of a prospective study designed to test this hypothesis.Simultaneously,in view of the prejudice of the internal fixation of the dorsal plate,we undertook a systematic search and meta-analysis to compare postoperative complications of the volar and dorsal fixation for the distal radius fractures,In order to explore the optimal choice for the treatment of distal radius fractures.Methods: In our department,from October 2012 to October 2015,a total of 34 patients were collected.The distal radius fractures were treated with volar plates(n=15)were used in cases of volar displacement and dorsal plates(n=19)in cases of dorsal displacement.Main observation of the treatment outcome: wrist functional assessment,radiographic assessment,DASH score and postoperative complications.In our meta-analysis,the electronic databases were searched without language limitation,up to January 25,2017.High-quality controlled trials comparing volar plating and dorsal plating for the distal radius fractures.The meta-analysis was completed using Rev Man 5 software.Pooled mean differences were calculated for the various postoperative complications.Results: From October 2012 to October 2015,a total of 34 patients were collected.In this study,16 males and 18 females,aged from 19 to 62 years(mean,40.5 years).The distal radius fractures were treated with volar plates(n=15)were used in cases of volar displacement and dorsal plates(n=19)in cases of dorsal displacement.In both groups,significant differences were observed in grip strength,palmar flexion,and dorsal extension when the values were compared with the contralateral side.Wrist joint function results: compared with the contralateral limb,it is relatively good in ulnar deviation,radial deviation,supination and pronation for the volar group.It is relatively good in pronation function for the dorsal group.Radiographic outcomes: In both groups,no significant differences were observed in radial height.DASH score was 18.2 ± 15.3 in the volar group and 14.5 ± 16.4 in the dorsal group.The DASH score of the two groups were good.There was no significant difference between the two groups.Postoperative complications in volar group: 1 case of tendonitis,2 cases of neurological symptoms,2 cases of carpal tunnel syndrome.In the dorsal group: 1 case of tendon rupture,2 cases of tendonitis,1 case of neurological symptoms.There was no significant difference between the two groups in the postoperative complications.In our meta-anlysis,fifteen articles were included in our meta-analysis.With the random effect model,there was no significant difference for the distal radius fractures in total complications between the volar and dorsal approach.(OR=0.79,95%CI:0.37-1.67;P=0.54).Open reduction internal fixation with volar plate fixation provided statistically more Neuropathy(OR=1.83,95% CI:1.10,3.06;P=0.02)and carpal tunnel syndrome(OR=3.06;95% CI:1.07,8.79;P=0.04).Comparing with the volar plate fixation,dorsal plate fixation provided significantly more tendon irritation(OR=0.33;95% CI:0.16,0.67;P=0.002)for the distal radius fractures.We found the dorsal approach have more probability in tendon rupture(OR=0.51;95% CI:0.22,1.16;P=0.11),CRPS(OR=0.56;95% CI:0.25,1.25;P=0.16)and screw loosening(OR=0.31;95% CI:0.08,1.31;P=0.11),but there was no significant difference.Conclusion: Stretch-type injury with the fracture fragment displacement dorsally,so we use the dorsal approach.The dorsal plate could buttress the the dorsal fracture fragments,and vice versa.Decision for plate type was based on fracture type and biomechanical considerations,In general,dorsal plates were used in cases of dorsal angulation and volar plates in cases of volar angulation.In our meta-analysis,there was no significant difference for the distal radius fractures in total complications between the volar and dorsal approach.Volar plate fixation provided statistically more Neuropathy and CTS,but lower tendon irritations.We found no significant difference in the other complication between the two groups.Therefore,we should abandon the inherent bias on the dorsal plate fixation,and we can not become a blind followers of the volar plate fixation.Volar and dorsal approach plate fixation technology has its own advantages and disadvantages.We couldn’t evaluate which fixation is better,just according to the postoperative complications.Decision between volar and dorsal plate fixation of the acute distal radius fracture must be based on the direction of fragment displacement.