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Background: This study aimed to identify the risk factors associated with re-displacement or collapse of distal radius fractures treated using volar locking plates in older adults.

Methods: We conducted a retrospective analysis of 131 patients aged ≥65 years with distal radius fractures who underwent volar locking plate fixation. The collapse was classified into three categories: ‘radial collapse’ was determined as the top decile of patients with the greatest decrease in radial inclination; ‘dorsal collapse’ was defined by volar tilt angle on lateral or 25° tilted lateral views and ‘height collapse’ by radial height. To identify the factors related to these three types of collapses, we compared the clinical and radiological parameters between the wrists with each type of collapsed and non-collapsed wrists.

Results: Dorsal collapse had no significant associated factors and radial collapse had osteoporosis as a significant different factor. The height collapse group was associated with older age, had a higher prevalence of high-energy injury mechanisms and a limited range of flexion–extension at final follow-up and larger distance between the articular surface and distal screws.

Conclusions: The volar locking plate may effectively prevent three types of collapses. Height collapse group included patients with increased age, high-energy injury mechanisms and limited range of flexion–extension at the time of final follow-up. To prevent collapse, the longest possible distal screws must be inserted just beneath the subchondral bone.

Level of Evidence: Level IV (Therapeutic)

We describe our experience of using a volar locking plate for corrective osteotomy and bone grafting combined with early mobilisation in the treatment of distal radius malunions. Corrective osteotomy of the distal radius was performed through a volar approach, and fixated by a volar locking plate associated with corticocancellous iliac bone grafting in three patients aged 16, 71 and 75 years. Two patients had had volarly displaced malunion and one dorsally displaced malunion. Wrist motin was started immediately after surgery. The average follow-up was 15 months (range, 12–20 months). All osteotomies healed at an average 5.7 weeks post-operatively, resulting in a total arc of wrist motion of 133°, forearm rotation of 167°, and grip strength of 70% of that of the contralateral side. This treatment method proved to be effective and safe.

Distal radius fractures are common, and surgeons have in their armament a variety of ways of treating them. In this study, 50 orthopaedic surgeons in the UK were shown five clinical scenarios and radiographs from patients with various fracture patterns of the distal radius, and were asked for their preferred management. There was a wide variation in the preferred treatment for each scenario presented. Across all of the cases, 52% of surgeons preferred to use a volar locking-plate compared with 21% who chose fixation with Kirschner wires. There was very little consensus among surgeons with regard to the optimal method of fixation for patients sustaining dorsally displaced fractures of the distal radius. This disagreement is not surprising as there is currently no high level evidence to guide surgeons as to the best management option for this common and potentially debilitating injury.

Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Our aim was to determine the type and rate of metalwork complications requiring reoperation. In our series, 12 cases (10%) underwent further surgery for metalwork related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. Technical aspects to reduce such complications are discussed.

The purpose of this study was to evaluate the treatment results, with and without internal fixation of ulnar styloid base fractures associated with acute distal radius fractures. A total of 48 patients were enrolled, including 20 patients treated by internal fixation (fixation group) and 28 treated without internal fixation (non-fixation group). The evaluated parameters were postoperative range of motion, grip strength, DASH score, and the presence or absence of ulnar wrist pain over time. The outcome was assessed as "excellent" in 15 patients of the fixation group and 21 patients of the non-fixation group, and "good" in five patients of the fixation group and seven patients of the non-fixation group. There were no significant differences in the clinical outcomes or any of the parameters at the final evaluation between the two groups. However, the grip strength was significantly better in the non-fixation group than in the fixation group until 12 weeks postoperatively. The overall clinical outcome was good in both groups, with no significant difference between the groups.

Currently, volar locking plates are commonly used to treat distal radius fractures (DRF) because of their stable biomechanical construct and because they cause less soft tissue disturbance and allow early mobilisation of the wrist. Complications such as rupture of tendons have been reported to occur with use of volar locking plates. We describe six cases of rupture of extensor pollicis longus (EPL) tendons after the use of volar locking plates. EPL tendon injuries occurred in 2.1% (6/286) of cases after DRF surgery. The causes of EPL rupture after DRF surgery were protrusion of the head tip and insufficient reduction of the dorsal roof fragment of the distal radius. These were considered iatrogenic problems. The cause of EPL rupture was unknown in three cases. We should be extremely careful when determining optimum screw length and reducing displaced dorsal roof fragments to prevent damaging the EPL tendons.

In surgical fixation of distal radius fractures with metaphyseal comminution, volar tilt can be restored using an anatomical volar locking plate as a reduction tool. The purpose of our study is to assess the degree of over or under correction of volar tilt that can result with our 'lift' technique and to determine the ratio between theoretical and actual angular correction. We retrospectively reviewed 24 patients who underwent distal radius fracture fixation using this technique and assessed intra-operative radiographs for parameters including pre-'lift' and post-'lift' volar tilt and pre-'lift' plate-shaft angles. The ratio between actual angular correction and theoretical angular correction was calculated. The 'lift' technique is found to be reliable in restoring volar tilt in most fractures. Over- or under-correction does occur due to errors in visual estimation and actual angular correction is generally less than the theoretical angular correction.

Background: Concomitant distal radius and distal ulna metaphysis or head fractures (DRUF) are uncommon and acceptable results have been reported from cast immobilisation and internal fixation.

Methods: We reviewed the charts of 1094 patients treated for distal radius fracture at our institution in a two year period from 2009 to 2010. 24 patients with concomitant DRUF with were treated by cast immobilisation (group 1, n = 11), internal fixation of both bones (group 2, n = 7), internal fixation of radius alone (group 3, n = 2), and internal fixation of radius with distal ulna resection (group 4, n = 4). Patients treated by surgery underwent intraoperative assessment of distal ulna stability to determine the indication for ulna fixation. Post surgical range of motion, clinical parameters, and functional outcome scores (Gartland-Werley and modified Mayo) were measured.

Results: Wrist motion was comparable in each group. Radiographic parameters were better in surgical groups. 23 of 24 patients achieved excellent/good outcomes based on Gartland-Werley scores, while 12 of 24 achieved good modified Mayo wrist score. There was a case of distal ulna non-union in group 1, and another case of delayed distal radius union in group 2.

Conclusions: By evaluating patients’ functional requirement, and dynamic fluoroscopy examination, satisfactory outcomes can be achieved for various presentations of DRUF.

Background: To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate.

Methods: The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles).

Results: Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion.

Conclusions: The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.

Volar locking plate fixation has been widely accepted method for the treatment of unstable distal radius fractures. Although the results of volar locking plate fixation are encouraging, it may cause implant-related complications such as flexor or extensor tendon injuries. In depth understanding of anatomy of the distal radius is mandatory in order to obtain adequate fixation of the fracture fragments and to avoid these complications. This article will review the anatomic characteristics of the distal radius because selecting proper implant and positioning of the plate is closely related to the volar surface anatomy of the distal radius. The number and the length of distal locking screws are also important to provide adequate fixation strength to maintain fracture fixation. We will discuss the pros and cons of the variable-angle locking plate, which was introduced in an effort to provide surgeons with more freedom for fixation. Finally, we will discuss about correcting radial length and volar tilt by using eccentric drill holes and distal locking first technique.

Background: The purpose of our present study was to examine the recovery of the postoperative wrist function, and to compare the range of motion among each direction ofthe wrist joint during the same time periods after surgery for distal radius fractures.

Methods: Twenty patients treated with a volar locking plate were evaluated. The active range of motion and grip strength were assessed at four weeks, six weeks, three months, six months and one year after surgery.

Results: The ratio of the range of motion in pronation and supination recovered significantly earlier than for any other directions within six months after surgery (p = 0.0205), however, the ratio of the range of motion among the six directions was not significantly different at one year after surgery (p = 0.0823). The recovery of the range of motion in flexion was 96.8% compared with the contralateral wrist at one year after surgery, and it was not significantly lower than that in extension, radial deviation or ulnar deviation (97.8%, 93.5%, 94.4%, respectively). The grip strength of dominant hand recovered from 50% after four weeks to 66% after six weeks, 83% after three months, 91% after six months and 106% at the examination performed after one year compared with the uninjured non-dominant hand. The grip strength of non-dominant hand recovered from 52% after four weeks to 59% after six weeks, 79% after three months, 84% after six months and 94% at the examination performed after one year compared with the uninjured dominant hand. The mean DASH score was 5.3.

Conclusions: The range of motion in flexion can achieve similar improvement to that in the other directions by obtaining the appropriate postoperative parameters. The optimal postoperative radiographic parameters were thus identified to be essential for successfully obtaining a recovery of the wrist function for unstable distal radius fractures.

Background: The use of volar locking plate in distal radius fracture can lead to extensor tendon rupture due to dorsal screw penetration. The aim of our study was to investigate the occurrence of dorsal and intra-articular screw penetration using CT scan after volar distal radius osteosynthesis for distal radius fractures.

Methods: Thirty patients who underwent distal volar locking plate for distal radius fracture were included in a retrospective study. In all 30 patients no dorsal and intra-articular screw penetration were detected on standard AP and lateral views of a plain radiograph. CT scan of the operated wrist was performed to determine the number of intra-articular and dorsal screw penetrations. Clinical examination was performed to determine the wrist functions in comparison to the normal wrist.

Results: Nineteen wrists were noted to have screw penetration either dorsally or intraarticularly. The highest incidence is in the 2nd extensor compartment where 13 screws had penetrated with a mean of 2.46 mm. Six screws penetrated into the distal radial ulnar joint and five screws into the wrist joint with a mean of 2.83 mm and 2.6 mm, respectively. However, there was no incidence of tendon irritation or rupture.

Conclusions: This study demonstrated a high incidence of dorsal and intra-articular screw penetration detected by CT scan which was not apparent in plain radiograph. We recommend that surgeons adhere to the principle of only near cortex fixation and downsizing the locking screw length by 2 mm.

Background: The volar locking plate is frequently used in the fixation of unstable distal radius fractures, but despite this there is a paucity of mid to long term outcome studies. The purpose of this study was to investigate the mid-term functional outcomes of elderly patients treated with a volar locking plate for unstable distal radius fractures.

Methods: Thirty-two patients with a mean age of 74.1 (range, 65–85) years were followed for a mean of 39.1 (range, 30–81) months. Patients with follow-up periods of < 24 months were excluded from this study to investigate the mid-term clinical outcomes. The Mayo wrist score (MWS), grip strength and wrist range of motion were retrospectively reviewed at 12 months, 24 months and the latest follow-up (mean 39.1 months). Osteoarthritis status according to the system of Knirk and Jupiter was assessed at 24 months.

Results: Significant improvements in MWS and grip strength were observed between 12 and 24 months but not between 24 months and the final follow-up. There was no significant difference in wrist range of motion between 12 and 24 months. The MWS of 14 patients with radiographic signs of osteoarthritis was not significantly different from that of 18 patients without radiographic signs of osteoarthritis.

Conclusions: Elderly patients treated with the volar locking plate showed improved MWS and grip strength postoperatively after 12 months. Improvement in grip strength was slower than range of motion.

Background: A three-dimensional (3D) digital pre-operative planning system for the osteosynthesis of distal radius fracture was developed. The objective of this study was to evaluate screw choices for three-dimensional (3D) digital pre-operative planning of osteosynthesis of distal radius fractures and to compare with the screw choices for the conventional method.

Methods: Distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. Thirty wrists in the plan group utilized 3D preoperative planning, and nineteen wrists in the control group utilized conventional preoperative assessment. In the plan group, the 3D preoperative planning was performed prior to surgery. The reduction was simulated with 3D image, and the implant choice/placement also simulated on the 3D image. In the control group, standard preoperative planning was performed using posterior-anterior and lateral view radiographs, and CT scan. After the planning, osteosynthesis was performed. During the surgery, the operator performed the reduction and the placement of the plate while comparing images between the pre-operative plan and fluoroscopy. The distal screw lengths and the anteroposterior diameter of the radius along the axis of the distal screws were measured. The ratios of the screw length and radius diameter were evaluated. The screw/radius ratios within the range of 0.75–1.00 were considered appropriate. The screw choices less than 0.75, or greater than 1.00 were considered inappropriate. The rate of appropriate screw choices were compared between plan and control groups.

Results: The results of appropriate screw choices were 86.1% and 74.8% in the plan group and the control group, respectively. The inappropriate screw choices were 14.0% and 25.2% in the plan group and the control group, respectively. The three-dimensional planning significantly increased appropriate screw choices compared to the conventional planning (p < 0.05).

Conclusions: Three-dimensional digital preoperative planning is useful for the optimization of screw lengths in osteosynthesis of distal radius fractures.

Background: This study aimed to identify the effect of the progression of postoperative wrist osteoarthritis on 5 years clinical and radiological outcomes after volar locking plate fixation of distal radius fractures.

Methods: Altogether, 56 patients with distal radius fractures were followed up 5 years after surgery. Clinical assessment was performed using the Mayo modified wrist score, a visual analogue scale of pain, the Japanese version of the Disabilities of the Arm, Shoulder, and Hand score, and Patient-related wrist evaluation. Standardized wrist radiographs were used to assess wrist morphology and the Knirk and Jupiter’s degree of osteoarthritis. Multivariate logistic regression was used to analyze postoperative morphological changes in the wrist and carpal alignment regarding their correlation with progression of wrist osteoarthritis.

Results: Progression of postoperative wrist osteoarthritis was recognized in 37 of the 56 cases (66.1%). Compared with the clinical outcomes at the time of the fracture union completion, almost clinical outcomes improved up to 5 years follow-up time as well as at 1 year after surgery. The range of wrist flexion at 5 years follow-up was significantly less in the progressive osteoarthritis group than in those with non-progressive osteoarthritis. The persistent step-off immediately after surgery significantly affected the postoperative progression of wrist osteoarthritis. Changes in the radial inclination, volar tilt, and radioscaphoid angle correlated with progression of wrist osteoarthritis. The highest correlation was with the change of radioscaphoid angle.

Conclusions: Good clinical results were maintained at 5 years after surgery, but progression of postoperative wrist osteoarthritis interfered with improvement of wrist flexion. Change in the radioscaphoid angle was the factor that was most highly correlated with progression of postoperative wrist osteoarthritis.

Background: The aim of this study was to identify the risk factors for median nerve dysfunctions after volar locking plate (VLP) fixation for distal radius fracture (DRF).

Methods: We prospectively assessed the incidence of median nerve symptoms (MNS) such as numbness, pain, paresthesia, or hypesthesia in the area innervated by the median nerve and evaluated post-operative nerve conduction (NC) in 91 hands of 121 patients after VLP fixation for DRF. Multivariate logistic regression analysis was conducted to identify factors independently associated with MNS and abnormal NC in the injured wrist.

Results: There were 18 cases (20%) of MNS on the injured side, 9 hands (10%) of both MNS and abnormal NC, 11 hands (12%) with only abnormal NC, and 9 hands with only MNS. Sensitivity, specificity, and diagnostic accuracy of abnormal NC for diagnosing MNS were 50%, 86%, and 78%, respectively. Four cases did not respond to conservative treatment and received carpal tunnel release concomitantly with plate removal. Logistic regression examination revealed that volar placement of the plate and short stature were significant independent predictors of MNS, while patient age was the sole independent predictor of abnormal NC.

Conclusions: Our study demonstrated that plate prominence, short stature, and age were significant independent risk factors for median nerve dysfunctions after VLP fixation for DRF.

Background: Postoperative evaluation of wrist joint trauma is divided into patient-reported outcomes (PROs) and clinician-reported outcomes (CROs). We investigated the association of the Q-DASH score as the postoperative PROs and the Mayo wrist score as the postoperative CROs with clinical evaluation in patients with distal radius fractures surgically treated using a volar locking plate (VLP). Moreover, whether PROs and CROs are correlated to the clinical evaluation was investigated.

Methods: The subjects were 109 patients surgically treated for distal radius fractures at our hospital between June 2013 and May 2017. Forty-one patients were male, 68 patients were female, and the mean age was 61.4 (19–86) years old. The fracture type was AO classification A type in 30 patients (A2: 25, A3: 5), B type in 5 (B2: 1, B3: 4), and C type in 74 (C1: 50, C2: 11, C3: 13). All patients were surgically treated using VLP. The range of motion of the wrist, grip strength the Visual Analog Scale (VAS), the Q-DASH score (PROs), and the Mayo wrist score (CROs) were investigated. Each evaluation was compared as the clinical outcome between at 3 months after surgery and the final follow-up. In addition, the correlations of the postoperative PROs and CROs with the clinical evaluation were analyzed.

Results: Each evaluation was significantly improved compared with that at 3 months after surgery. There was a significant correlation between PROs and CROs at 3 months after surgery and the final follow-up. However, the range of motion of the wrists was not significantly correlated with PROs or CROs at 3 months after surgery or at the final follow-up.

Conclusions: On evaluation after surgery for distal radius fractures, PROs and CROs improved early after surgery (3 months after surgery) before the final follow-up, and an inverse correlation was present between these scores.

Background: The treatment strategy for distal radius fractures accompanied by volar lunate facet fragment is controversial. In most cases, only the bone fragment size was discussed and a plate for distal placement is selected due to the accompanying volar lunate facet fragment regardless of the direction of bone fragment displacement. In this study, we divided distal radius fractures accompanied by volar lunate facet fragment into dorsal and volar displaced fractures, and treated these surgically based on different treatment strategies.

Methods: The subjects were 25 patients with distal radius fractures accompanied by volar lunate facet fragment treated by reduction and fixation using a volar locking plate (VLP) (male: 14, female: 11, mean age: 57.8 years old). A proximal VLP (PVLP) was selected for 13 dorsal displaced fractures and a distal VLP (DVLP) was selected for 12 volar displaced fractures. The range of motion, VAS, Q-DASH, and Mayo score were evaluated at 12 months after surgery, and compared.

Results: No significant difference due to the difference in the direction of displacement was noted in the range of motion, VAS, Q-DASH, or Mayo score at 12 months after surgery and there were no perioperative complications. In addition, no re-displacement of volar lunate facet fragment was noted after surgery in any patient and bone fusion was observed.

Conclusions: Reduction and fixation with a PVLP are possible even for dorsal displaced distal radius fractures accompanied by volar lunate facet fragment. For the volar displaced distal radius fractures, a favorable postoperative outcome is possible by applying a DVLP to the distal ulnar.

Background: The DePuy Synthes variable angle LCP^® Volar RIM Plate has been designed with its contour to overhang volar rim fragments of the distal radius to prevent secondary displacement after fracture fixation. Therefore, RIM potentially contributes to a risk of flexor tendon rupture due to its plate prominence over the watershed line. This is a retrospective cross-sectional study that aims at describing the occurrence of complications by utilizing RIM as well as three standards VLPs to evaluate the impact of plate design on flexor tendons.

Methods: A total of 84 patients with a volar locking plate fixation were analyzed retrospectively (Far-distal; RIM: 14 cases, Juxta-articular; AcuLoc2 (ACUMED): 20 cases, Dual-Loc V7 (MEIRA): 25 cases, Extra-articular; VA-TCP (DePuy Synthes): 25 cases). Tendinous problems were evaluated with a reported adverse event and flexor tendon appearance examined by utilizing ultrasonography and direct observation during hardware removal. Plate prominence was graded according to Soong’s classification and the distance to flexor tendons was measured to describe the risk that each plate damage the flexor tendons.

Results: The mean follow-up period was 13.0 months. All RIM plates were placed in grade 2 (85.7%) and grade 1 (14.3%). Symptomatic and asymptomatic tendinous problems were barely reported in RIM. The examination of ultrasonography and direct observation during hardware removal showed that tendons smoothly slid without attrition on the curved plate surface of RIM despite their adjacent appositions came from its high and distal plate prominence.

Conclusions: Smooth profile of RIM showed an ability to decrease the potential risk of flexor tendon damage regardless of its prominence over the watershed line. RIM can be applied more to challenging far distal fractures when used judiciously and surgeons need to be even more vigilant for symptoms of tendon irritation as usually recommended without being coward more than necessary.

A 68-year-old man with a right distal radius fracture treated with volar locking plate fixation previously was unable to flex his right thumb and four fingers without experiencing any adverse event. The flexor pollicis longus was reconstructed with a tendon graft using the lengthened flexor digitorum superficialis. The flexor digitorum profundus (FDP) of the ring finger was reconstructed with a tendon graft using the palmaris longus. The FDP of the index and little fingers was reconstructed using the interconnected tendon graft to the ring finger. Postoperatively, active flexion of all fingers and thumb was restored; however, he was unable to grasp thin objects because of the absence of full finger flexion. This is the first case wherein all nine flexor tendons being involved after volar locking plate fixation for a distal radius end fracture. We demonstrated a reconstructive procedure for long-standing multiple flexor tendon rupture after volar locking plate fixation.