Clinical Treatment Strategy And Imaging Study Of Complex Distal Radius Fractures

The first part:Clinical results of treating complicated unstable distal radial fractures by using ORIF combined with three-column theoryObjective To explore and prove the clinical results of treating complicated unstable intra-articular distal radial fractures by using ORIF combined with three-column theory.Methods From August 2008 to January 2010,16 patients,of which 9 were males and 7 were females with an average age of 54 years(23 to 71 years),were treated in our traumatic center.Among these patients,10 had fractures on their left limbs,whereas 6 had fractures on their right limbs.According to the AO/ASIF classification,7 of these cases can be categorized as type C1,6 cases as type C2,and 3 cases as type C3.One patient underwent an emergency operation for opening fracture,whereas the others were operated four to seven days after their injury.Among these patients,two received bone grafting,six received auxiliary radial column fixation,four received ulna styloid fixation,and two received assisted dorsal fixation.Results All patients followed up 2 to 15 months(average of 6.3 months)after their operation.The volar tilt,radial inclination,and radial shortening of these patients significantly improved during the follow up period compared with the pre-operation period.According to the GW functional assessment system,13 of these patients achieved excellent results,whereas 3 achieved good results.Conclusion Guided by three-column theory,a stable ORIF for three columns can free the wrist of the patients,allow them to perform active functional exercises early,and avoid reduction loss and joint stiffness,thereby leading to outstanding clinical results.The second part:Preliminary exploration of the correlation among different treatments for the dorsoulnar fragment of distal radial fractures and functional recovery of wrist jointsObjective To study and compare the functional recovery of the wrist by using different treatments for the displaced dorsoulnar fragment of distal radial fractures.Methods A retrospective analysis of wrist function and distal radioulnar joint stability was performed from January 2009 to December 2012.Patients classified under stages VII and VII according to the Frykman classification were enrolled and treated by open reduction and internal fixation.A total of 40 patients followed up after the treatment.Based on their fixation status,these patients were divided into a dorsoulnar-fragment-fixation group and a dorsoulnar-fragment-nonfixation group.After achieving bone union,all patients received anterior-posterior and lateral X-rays combined with a 2 mm-slice computer tomography scan.A detailed wrist functional evaluation was then performed by using grip strength and range of motion(extension-flexion and pronation-supination)assessments and the Gartland-Werley scoring system(GW score).The distal radioulnar stability of the two groups was also assessed.Results All patients followed up 3 to 22 months(average 7.5 months)after treatment.Bony union was observed among all patients after an average of 2.3 months.No infection,hardware loosening,carpal tunnel syndrome,tendon irritation,or rupture were observed.Based on their GW scores,the results for those patients who received reliable fixation were superior to those for the patients in the non-fixation group.A significant difference was also reported between these groups according to the rank-sum test.Conclusion A specific fixation of the dorsoulnar fragment in distal radial fractures can improve the stability of the distal radioulnar joint and help to achieve an excellent rate.The third part:Application of the bone mass specific fixation technique for treating complex distal radius fracturesObjective Fragment-specific fixed technology was applied to Mayo ?-? type distal radial fractures and to observe clinical significance.Methods A review and analysis of 33 cases of Mayo ?-? type distal radial fractures were conducted between January 2011 and February 2014.Among these cases,15 were male and 18 were female with ages ranging from 19 to 74 years(average of 57.5 years),13 cases had fractures on the right side,and 20 cases had fractures on the left side.Intraoperative bone mass was targeted for internal fixation,a post-operative image measurement was performed,and the wrist joint function was evaluated by using the GW scoring system.Results All patients followed up 4 to 26 months(average of 7.8 months)after their treatment.The X-ray films showed that the inclination angle of palms and the ulnar declination angle both recovered well,and no obvious shortening of radius was observed.The CT scan results showed steps on the articular surface of lunate fossa in 3 cases,sigmoid notch articular surface separation in 1 case,and radial styloid rotation and displacement in 1 case.Based on the GW scores,23,7,2,and 1 of the cases were rated as excellent,good,medium,and poor,respectively,with an excellent and good rate of 90.9%.Conclusion Fragmnet-specific fixation can promote the reduction and internal fixation effects of distal radial fractures,prevent later displacement,and restore wrist function.The fourth part:Operative strategy and clinical results for treating complex four-part distal radius fractures via combined palmar and dorsal internal fixationObjective The combined dorsal and palmar internal fixation for treating complex four-part distal radius fractures was used to formulate a structured protocol for reconstructing the congruity and rigidity of both radiocarpal and distal radioulnar joints and to assess the clinical results.Methods From May 2009 to October 2016,38 patients(39 sides)who suffered from complex four-part distal radius fractures were subjected to open reduction and internal fixation via a combined dorsal and palmar approach in our center.Among these patients,22(22 sides)were males and 16(17 sides)were females with ages ranging from 25 to 79 years(average age of 53.5 years).According to the Melone classification,34 sides were of type of ?,5 were of type V.According to Frykman classification,there were 15 sides of type VII,24 sides of type VIII.All cases were of type C3 according to the AO/OTA classification.Before the operation,we identified the key articular fragments in the four-part distal radius fractures and analyzed the individual fracture patterns from conventional X-rays and CT scans.All patients were given combined volar and dorsal fixation.First,we adopted a palmar approach to access and fix the palmar-ulnar and radial styloid fragments.Second,we adopted a limited dorsal approach across the third extensor compartment to access the dorso-ulnar fragment and to perform a limited dorsal arthrotomy to visualize the radiocarpal joint when necessary.Through the dorsal approach,we can access the dorso-ulnar fragment,free the intra-articular fragment,and directly visualize the joint.Using a retinacular flap was recommended to help prevent tendon irritation and rupture.In the follow-up control,conventional X-rays,range of motion,grip strength,disabilities of the arm,shoulder,and hand index(DASH),and patient-rated wrist evaluation(PRWE)score were used to evaluate the functional outcomes at 6 and 12 months.Results A total of 33 patients(34 sides)followed up at least 12 months after their operation.The wounds healed well in all cases two weeks after the operation,and no soft tissue infections,necrosis,or neurovascular complications were reported.All fractures of 38 cases(39 sides)healed after an average of 3.6 months(2.5 to 5.7 months),and no loss of reduction occurred postoperatively.Anatomic reconstruction with a step or gap of<1 mm was observed in 37 cases(38 sides),and 5 patients failed to follow up 12 months after their operation.The range of motion and grip strength of the unaffected sides recovered up to over 85%(except for the bilateral patient).The median DASH index and PRWE were 6.5(0 to 17)and 9.3(0 to 20),respectively.Conclusion Combining the volar and dorsal approaches allowed an anatomic reconstruction of complex four-part intra articular distal radius fractures and reported good functional outcomes at the intermediate follow up.The fifth part:Application value of carpal shoot through view in the palmar plating of distal radius fracturesObjective To explore the application value of carpal shoot through view in the palmar plating of distal radius fractures.Methods From March 2015 to May 2016,62 patients with acute distal radius fractures received various operations in our department.Volar locked plating was only administered to 48 of these patients,among which 21 were males and 27 were females with ages ranging from 17 to 75 years(mean 43.6± 10.6 years).According to the AO/OTA classification,15 of these cases were type A,11 were type B,and 22 were type C.All operations were performed between the radial artery and flexor carpi radialis by using the modified Henry's approach.After achieving a satisfactory reduction,a rigid fixation of the distal radius was performed by using anatomical locking plates.Bicortical drilling was also performed in all cases.A screw length of 1 mm to 2 mm less than the depth gauge number was selected to avoid dorsal cortex penetration.After the plate fixation,standard posteroanterior and lateral radiographs and the carpal shoot through view were obtained.To obtain this view,the forearms of the patients were maximally supinated,their elbows were flexed by approximately 60° to 70°,and their wrists were maximally dorsiflexed.The image intensifier beam was directed over the base of the thenar eminence.The ratios of dorsal protrusion between the standard view and carpal shoot through view were compared,and then a statistical analysis was performed.After the operation,a CT scan was routinely taken to further test the effectiveness of the carpal shoot through view.Results Dorsal cortex screw protrusion was detected in 5 cases by using the standard posteroanterior and lateral views(10.4%,5/48)and in 16 cases(including the former 5 cases;33.3%,16/48)by using the carpal shoot through view.A statistically significant difference was reported between these two fluoroscopy methods.The carpal shoot through view also reported two cases where a screw penetrated the distal radioulnar joint(DRUJ).All improper screws were exchanged and reverified by using the carpal shoot through view.The overall screw exchange rate was 37.5%(18/48).Conclusion Compared with standard AP and lateral fluoroscopy,the carpal shoot through view can reliably reveal dorsal screw penetration and provide an excellent visualization of DRUJ.The first part:Clinical results of treating complicated unstable distal radial fractures by using ORIF combined with three-column theoryObjective To explore and prove the clinical results of treating complicated unstable intra-articular distal radial fracture by using ORIF combined with three-column theory.Methods From August 2008 to January 2010,16 patients,of which 9 were males and 7 were females with an average age of 54 years(23 to 71 years),were treated in our traumatic center.Among these patients,10 had fractures on their left limbs,whereas 6 had fractures on their right limbs.According to the AO/ASIF classification,7 of these cases can be categorized as type C1,6 cases as type C2,and 3 cases as type C3.One patient underwent an emergency operation for opening fracture,whereas the others were operated four to seven days after their injury.Among these patients,two received bone grafting,six received auxiliary radial fixation,four received ulna styloid fixation,and two received assisted dorsal fixation.Results All patients followed up 2 to 15 months(average of 6.3 months)after their operation.The volar tilt,radial inclination,and radial shortening of these patients significantly improved during the follow up period compared with the pre-operation period.According to the GW functional assessment system,13 of these patients achieved excellent results,whereas 3 achieved good results.Conclusion Guided by three-column theory,a stable ORIF for three columns can free the wrist of the patients,allow them to perform active functional exercises,and avoid reduction loss and joint stiffness,thereby leading to outstanding clinical results.The second part:Preliminary exploration of the correlation among different treatments for the dorsoulnar fragment of distal radius fractures and functional recovery of wrist jointsObjective To study and compare the functional recovery of the wrist by using different treatments for the displaced dorsoulnar fragment of distal radius fractures.Methods A retrospective analysis of wrist function and distal radioulnar joint stability was performed from January 2009 to December 2012.Patients classified under stages VII and VII according to the Frykman classification were enrolled and treated by open reduction and internal fixation.A total of 40 patients followed up after the treatment.Based on their fixation status,these patients were divided into a dorsoulnar-fragment-fixation group and a dorsoulnar-fragment-nonfixation group.After achieving bone union,all patients received anterior-posterior and lateral X-rays combined with a 2 mm-slice computer tomography scan.A detailed wrist functional evaluation was then performed by using grip strength and range of motion(extension-flexion and pronation-supination)assessments and the Gartland-Werley scoring system(GW score).The distal radioulnar stability of the two groups was also assessed.Results All patients followed up 3 to 22 months(average 7.5 months)after treatment.Bony union was observed among all patients after an average of 2.3 months.No infection,hardware loosening,carpal tunnel syndrome,tendon irritation,or rupture were observed.Based on their GW scores,the results for those patients who received reliable fixation were superior to those for the patients in the non-fixation group.A significant difference was also reported between these groups according to the rank-sum test.Conclusion A specific fixation of the dorsoulnar fragment in distal radius fractures can improve the stability of the distal radioulnar joint and help achieve an excellent rate.The third part:Application of the bone mass specific fixation technique for treating complex distal radius fracturesObjective Bone block specific fixed technology was applied to Mayo parting ?-?targeted type distal radius fractures with fixed clinical significance.Methods A review and analysis of 33 cases of Mayo ?-? type distal radius fractures were conducted between January 2011 and February 2014.Among these cases,15 were male and 18 were female with ages ranging from 19 to 74 years(average of 57.5 years),13 cases had fractures on the right side,and 20 cases had fractures on the left side.Intraoperative bone mass was targeted for internal fixation,a post-operative image measurement was performed,and the wrist joint function was evaluated by using the GW scoring system.Results All patients followed up 4 to 26 months(average of 7.8 months)after their treatment.The X-ray films showed that the inclination angle of palms and the ulnar declination angle both recovered well,and no obvious shortening of radius was observed.The CT scan results showed steps on the articular surface of lunate fossa in 3 cases,sigmoid notch articular surface separation in 1 case,and radial styloid rotation and displacement in 1 case.Based on the GW scores,23,7,2,and 1 of the cases were rated as excellent,good,medium,and poor,respectively,with an excellent and good rate of 90.9%.Conclusion Bone block specific fixation can promote the reduction and internal fixation effects of distal radial fractures,prevent later displacement,and restore wrist function.The fourth part:Operative strategy and clinical results for treating complex four-part distal radius fractures via combined palmar and dorsal internal fixationObjective The combined dorsal and palmar internal fixation for treating complex four-part distal radius fractures was used to formulate a structured protocol for reconstructing the congruity and rigidity of both radiocarpal and distal radioulnar joints and to assess the clinical results.Methods From May 2009 to October 2016,38 patients(39 sides)who suffered from complex four-part distal radius fractures were subjected to open reduction and internal fixation via a combined dorsal and palmar approach in our center.Among these patients,22(22 sides)were males and 16(17 sides)were females with ages ranging from 25 to 79 years(average age of 53.5 years).According to the Melone classification,34 sides were of type of ?,5 were of type V,15 were of type VII,and 24 were of type VIII.All cases were of type C3 according to the AO/OTA classification.Before the operation,we identified the key articular fragments in the four-part distal radius fractures and analyzed the individual fracture patterns from conventional X-rays and CT scans.All patients were given combined volar and dorsal fixation.First,we adopted a palmar approach to access and fix the palmar-ulnar and radial styloid fragments.Second,we adopted a limited dorsal approach across the third extensor compartment to access the dorso-ulnar fragment and to perform a limited dorsal arthrotomy to visualize the radiocarpal joint when necessary.Through the dorsal approach,we can access the dorso-ulnar fragment,free the intra-articular fragment,and directly visualize the joint.Using a retinacular flap was recommended to help prevent tendon irritation and rupture.In the follow-up control,conventional X-rays,range of motion,grip strength,disabilities of the arm,shoulder,and hand index(DASH),and patient-rated wrist evaluation(PRWE)score were used to evaluate the functional outcomes at 6 and 12 months.Results A total of 33 patients(34 sides)followed up at least 12 months after their operation.The wounds healed well in all cases two weeks after the operation,and no soft tissue infections,necrosis,or neurovascular complications were reported.All fractures of 38 cases(39 sides)healed after an average of 3.6 months(2.5 to 5.7 months),and no loss of reduction occurred postoperatively.Anatomic reconstruction with a step or gap of<1 mm was observed in 37 cases(38 sides),and 5 patients failed to follow up 12 months after their operation.The range of motion and grip strength of the unaffected sides recovered up to over 85%(except for the bilateral patient).The median DASH index and PRWE were 6.5(0 to 17)and 9.3(0 to 20),respectively.Conclusion Combining the volar and dorsal approaches allowed an anatomic reconstruction of complex four-part intra articular distal radius fractures and reported good functional outcomes at the intermediate follow up.The fifth part:Application value of carpal shoot through view in the palmar plating of distal radius fracturesObjective To explore the application value of carpal shoot through view in the palmar plating of distal radius fractures.Methods From March 2015 to May 2016,62 patients with acute distal radius fractures received various operations in our department.Volar locked plating was only administered to 48 of these patients,among which 21 were males and 27 were females with ages ranging from 17 to 75 years(mean 43.6± 10.6 years).According to the AO/OTA classification,15 of these cases were type A,11 were type B,and 22 were type C.All operations were performed between the radial artery and flexor carpi radialis by using the modified Henry's approach.After achieving a satisfactory reduction,a rigid fixation of the distal radius was performed by using anatomical locking plates.Bicortical drilling was also performed in all cases.A screw length of 1 mm to 2 mm less than the depth gauge number was selected to avoid dorsal cortex penetration.After the plate fixation,standard posteroanterior and lateral radiographs and the carpal shoot through view were obtained.To obtain this view,the forearms of the patients were maximally supinated,their elbows were flexed by approximately 60° to 70°,and their wrists were maximally dorsiflexed.The image intensifier beam was directed over the base of the thenar eminence.The ratios of dorsal protrusion between the standard view and carpal shoot through view were compared,and then a statistical analysis was performed.After the operation,a CT scan was routinely taken to further test the effectiveness of the carpal shoot through view.Results Dorsal cortex screw protrusion was detected in 5 cases by using the standard posteroanterior and lateral views(10.4%,5/48)and in 16 cases(including the former 5 cases;33.3%,16/48)by using the carpal shoot through view.A statistically significant difference was reported between these two fluoroscopy methods.The carpal shoot through view also reported two cases where a screw penetrated the distal radioulnar joint(DRUJ).All improper screws were exchanged and reverified by using the carpal shoot through view.The overall screw exchange rate was 37.5%(18/48).Conclusion Compared with standard AP and lateral fluoroscopy,the carpal shoot through view can reliably reveal dorsal screw penetration and provide an excellent visualization of DRUJ.