Distal radius fractures are more common in daily practice, and the trend of treatment in China now is that surgery is basically recommended for young and middle-aged patients who can tolerate surgery; while surgical or non-surgical treatment is basically close for patients with lower functional requirements of the wrist joint.
Although the author’s summary of the above observations is not necessarily correct, it is side evidence of a problem that the treatment of distal radius fractures is still controversial at this stage. The current controversial points related to the distal radius, including diagnosis, imaging assessment, treatment and prognosis, were published in the September 2014 issue of the American Journal of JAAOS, and are presented in Chinese translation for your reference in clinical practice.
Issues related to radius fractures, including radius fracture assessment, diagnosis, treatment and functional prognosis are extremely controversial. The accuracy of various imaging modalities in the assessment of radial fractures has not been validated. In addition, there are various methods of classifying distal radius, and the reliability of most of them across and within the same observer is more questionable.
The main points of controversy in the nonoperative treatment of the distal radius are the setting of the fracture, the use of anesthesia, the duration of braking the fracture, and the position of the forearm during fracture healing. The controversial points in the surgical treatment of distal radius fractures include the indication for surgery, the need for reoperative decompression in the event of carpal tunnel syndrome after surgery, the method of fracture fixation, and whether fracture fixation needs to be reinforced. There are also more controversies in the postoperative rehabilitation strategies, medications, and physical exercise methods for radius fractures. There is no uniform clinical opinion on the criteria used to assess the clinical prognosis of distal radius fractures. All of the above controversies need to be further evaluated in more clinical studies later.
Distal radius fractures are relatively common in clinical practice, with an annual incidence of 600,000 cases. The age of onset is bimodal, with a predominantly young population with high-energy injuries and an elderly population with low-energy injuries. in 2007, medical expenditures for distal radius fractures in the United States approached $170 million.
The appropriate treatment plan for radius fractures requires clinicians to accurately assess fracture morphology, diagnosis, treatment, and familiarity with postoperative functional recovery assessment methods. The first edition of the AAOS guidelines for the treatment of distal radius fractures was published in 2009, but the clinical evidence for these guidelines is not sufficient.
Controversial point: fracture assessment
There are many clinical methods to assess distal radius fractures. Anteroposterior, lateral, and oblique X-rays can assess the inclination, length, and palmar inclination of the radius (Figure 1). Clear distal radial margins on anteroposterior radiographs and a clear teardrop-like distal radius on lateral radiographs are normal anatomic presentations. On the anteroposterior radiograph, the projection of the dorsal edge of the distal radius should exceed the proximal radial cortex by approximately 3-5 mm. on the lateral radiograph, the angle formed by the intersection of the tangent line of the teardrop point and the longitudinal axis of the distal radius is approximately 70 degrees (Figure 3).
The palmar inclination angle will be corrected in cases with a repositioned distal radius fracture, but the intra-articular fracture mass may still be displaced, and the fracture mass at the palmar margin will be more pronounced in dorsiflexion. Oblique radiographs of the radius allow assessment of the degree of extension of the intra-articular fracture of the distal radius. Its clinical validity has been demonstrated.
Figure 1: A, anteroposterior radiograph showing radial tilt; B, lateral radiograph showing palmar tilt
Figure 2: Anteroposterior radiograph showing the dorsal edge of the distal radius (dashed line); the projection of the dorsal edge is approximately 3-5 mm distal to the proximal bone cortex of the distal radius
Figure 3: Lateral x-ray showing the projection of the teardrop point 3 mm palmarly distal to the radial diaphysis projection. The acute angle angle consisting of the teardrop point tangent and the longitudinal axis of the radius is about 70 degrees (A figure); the angle consisting of the teardrop point tangent and the longitudinal axis of the radius is 83 degrees for a distal radius fracture with the fracture fragment displaced palmarly (B figure); the angle consisting of the teardrop point tangent and the longitudinal axis of the radius is 50 degrees for a dorsal displacement of the distal radius fracture (C figure); and the angle returns to essentially normal after internal fixation of the distal radius fracture (D figure).
Anteroposterior radiographs obtained by different methods produced different effects on the distal radius. In the anterior-posterior X-rays of the forearm obtained in the rotated anterior position, the radius is seen to overlap the ulna, at which time the distal radius is shortened by approximately 0.5 mm compared to the neutral X-rays. in addition, the rotated posterior X-rays also reduce the radial deviation of the wrist joint and the angle of palmar tilt. All of these values increase when the forearm is in the posterior rotated position.
The tangential position of the wrist is more commonly used in clinical practice. The radiograph is taken with the wrist flexed at 75 degrees and the forearm placed between the two bulbous tubes, with the dorsal forearm tangential position of the wrist parallel to the ray direction of the bulbous tube (Figure 4). This film accurately assesses whether the wrist screw is excessively penetrating the dorsal cortex.
CT is more commonly used in the evaluation of distal radius fractures.Parrel et al. compared the accuracy of CT and X-rays for the diagnosis of distal radius fractures and found that CT was more accurate in assessing cases where the fracture extended into the articular surface. They recommended CT in all cases requiring incisional reduction and internal fixation treatment or in cases requiring assessment of compression and comminution of the distal articular surface of the wrist. However, there are no studies that confirm that the use of CT to evaluate the distal radial articular surface improves wrist function in patients after surgery.
MRI can be used in wrist injuries to assess the surrounding soft tissues, such as the presence of a concomitant navicular ligament injury. the accuracy and specificity of MRI in assessing tears of these ligamentous structures are 63% and 86%, respectively.
There is a larger body of literature reporting predictive methods for fracture stability of the distal radius. in 1989, Lafontaine et al. found that with increasing fracture instability, there is a progressive loss of fracture repositioning after fracture braking. Factors of instability after fracture repositioning included a dorsal angle of >20 degrees at the time of fracture, dorsal cortical comminution, extension of the fracture into the radial carpal joint, a combined ulnar fracture, and patient age >60 years. However, this study did not report the clinical functional prognosis of these patients after loss of fracture reduction.
In 2004, Nesbitt et al. evaluated 50 patients with unstable fractures of the distal radius based on the Lafontaine criteria. All patients were treated conservatively by closed reduction and cast fixation. At 4 weeks after reduction, 46% of the fracture patients had no loss of position. The authors concluded that in patients with potentially unstable fractures of the distal radius in closed reduction, age >60 years was the only risk factor for secondary displacement of the fracture.
In a study of 4,000 distal radius fractures published by Mackenney et al. in 2006, patient age, comminution of the metaphyseal fracture, and ulnar varus were found to be prognostic factors, whereas dorsal radial angulation at the time of injury was not an influential factor in imaging prognosis. In summary of the results, as of now, the patient’s age is the only reproducible indicator currently associated with the prognosis of distal radius fractures.
Points of contention: diagnosis
The Frykman, Mayo, Melone, and AO/OTA (Figure 5) scores are currently the most clinically used distal radius scores.The interobserver and intraobserver reproducibility of the four distal radius scores mentioned above was evaluated by Andersen et al. Moderate inter- or intra-observer agreement was found for each scoring scale. The authors thus suggested that the four staging criteria described above should not be used as criteria for clinical treatment decisions or for comparing prognosis.
Figure 5: AO distal radius fracture staging. Extra-articular (A), partially intra-articular (B), and intra-articular (C). Each fracture type was further staged according to the degree of fracture displacement and comminution
In 2007, Jin et al. evaluated the interobserver and intraobserver reliability of the Cooney typing criteria. The study collected data from five orthopaedic surgeons who performed Cooney typing on 43 imaging films of distal radius fractures. Inter- and intra-group agreement was found to be good. However, the reliability was poor when subtyping by Cooney typing was performed. This study suggests that Cooney may not be used alone in distal radius fracture typing as a basis for treatment decisions.
In 2010, Kural et al. evaluated the reliability of five subtyping criteria for distal radius fractures (rykman, Mayo, Melone, AO/OTA, and Cooney). Among them, the Cooney typing had the best intra-group agreement of approximately 0.621. Inter-group agreement was poor among all typings. This study concluded that all five current typing systems have not been supported by sufficient evidence in the diagnosis and evaluation of distal radius fracture practice.
In 2006, Harness et al. reported on the utility of using imaging, 2D CT and 3D CT in the evaluation of distal radius fractures. four observers evaluated intra-articular fracture imaging data of the distal radius. The results of this study found that 3D CT improved the reliability and accuracy of fracture assessment. In addition, the use of 3D CT can influence clinicians’ treatment decisions and increase the probability of open reduction of the distal radius.
In conclusion, there is no uniform, effective distal radius staging protocol with high reliability in clinical practice.
Controversial point: treatment
Treatment remains the most controversial element of the current radius fracture management process. Controversies in non-operative treatment include fracture repositioning, use of anesthesia, fracture braking, and forearm placement during braking. The controversial points of surgical treatment include the indications for surgical treatment, the late appearance of carpal tunnel syndrome, the need for carpal tunnel release, the manner of fracture fixation, and the need for strengthening after fracture fixation. Postoperative controversies include rehabilitation exercise strategies, medication use, and evaluation of prognosis.
One of the controversial points of treatment: non-operative treatment
Need for repositioning and resetting
Regardless of whether the distal radius fracture is stable or unstable, clinicians have attempted closed reduction, but there is no uniform opinion on closed reduction of distal radius fractures. beumer et al. in 2003 studied 60 patients with distal radius fractures, 53 of whom underwent closed reduction with cast fixation and eventual loss of reduction in elderly patients; 75% of fracture patients had loss of fracture reduction within one week of injury; and Loss of fracture reduction occurred within one week of injury; Mcqueen et al. prospectively evaluated the clinical functional prognosis of patients with re-displaced unstable distal radius fractures after resetting, and approximately 67% of these patients had fracture deformity healing after resetting. Another study found that closed reduction in patients with moderately and severely displaced distal radius fractures was not of much benefit. The effectiveness of closed reduction treatment of distal radius fractures in clinical practice remains to be confirmed by additional studies in the distant future.
Methods of fracture reduction
Non-surgical repositioning is usually manual closed reduction by traction, with some physicians adding finger compression, and Earnshaw et al. compared 225 displaced distal radius fractures and found that traction combined with finger compression did not significantly improve the reduction rate of distal radius fractures.
Choice of anesthesia during resetting
Intrahematoma anesthesia, intravenous regional anesthesia, regional block anesthesia, sedation, and general anesthesia have all been used in the resetting of distal radius fractures. In 2002, a Cochrane systematic review found that intrahematoma anesthesia was slightly less effective than intravenous regional anesthesia in terms of analgesia, and the authors concluded that there is insufficient evidence to support the use of these different anesthetic options in patients with distal radius. Another study found no significant difference in the final outcome of distal radius fracture reduction using intrahematomal or intravenous local anesthesia.
Anesthesia options during surgical treatment
Recent studies have evaluated the role of perifracture injectable anesthetics and intravenous local anesthesia in postoperative pain control of the distal radius. a 2010 study found that perifracture injectable anesthetics did not improve affected limb pain within 2 days postoperatively. In a 2012 study by Egol et al, local anesthesia was found to improve postoperative pain and clinical functional prognosis in distal radius fractures. The authors’ study supports the use of intravenous regional anesthesia for postoperative analgesia for distal radius fractures. However, more relevant studies are needed at a later stage to further clarify the effects of various anesthetic modalities on the prognostic function of distal radius fracture treatment.
Fracture fixation and forearm position
A closed reduction distal radius fracture can be fixed with a splint or cast. There is still more controversy about the type of splint used, the duration of braking, the length of the splint, and the position of the forearm during fixation. In addition, there is no high-level clinical evidence evaluating forearm position during distal radius braking.
In 2006, Bong et al. compared the effectiveness of different splints for radial fractures. found that the different classes of splints were essentially similar in their effectiveness in maintaining the fracture during repositioning. The authors concluded that the use of short-arm splints is still recommended for patients undergoing conservative treatment of distal radius fractures. In 2009, the AAOS published its guidelines for the treatment of distal radius fractures, which recommended that a more sturdy cast braking method would be more effective than removable splints in conservatively treated patients with displaced distal radius fractures. The use of removable splints is still not recommended for nondisplaced distal radius fractures. A Meta-analysis concluded that there is no rigorous evidence to support the optimal method and duration of braking during nonoperative treatment.
Treatment controversy: surgical treatment
Indications for surgical treatment
The 2009 AAOS guidelines for the treatment of distal radius fractures recommend surgery in patients with a shortened distal radius of more than 3 mm after closed reduction, a dorsal angle of more than 10 degrees, and an intraoperative articular surface shift or step change of more than 2 mm, but these recommendations are only moderately strong. For patients older than 55 years, the AAOS recommendations concluded that there was no significant difference between surgical and non-surgical treatment of distal radius fractures. a 2011 Australian study found that surgical and non-surgical treatment of distal radius fractures was essentially similar for patients older than 65 years. However, patients in the surgical group had better grip strength and imaging performance than the nonoperative group at all follow-up time points. Patients treated nonoperatively were more likely to have fracture deformity healing. However, the results of this study were not replicated.
Carpal Tunnel Decompression
Carpal tunnel syndrome can occur in patients with fractures of the distal radius. Some research evidence suggests that surgical reduction can be beneficial in patients with symptomatic carpal tunnel syndrome. However, guidelines published by the AAOS in 2009 concluded that there is still no definitive conclusion on the need for nerve decompression after distal radius fracture surgery for carpal tunnel syndrome.
Modalities of internal fixation
There are many options for internal fixation of distal radius fractures, including percutaneous kerf fixation, external fixation frames, incisional internal fixation, intramedullary nailing, and arthroscopic fixation.
Percutaneous Clinique pin fixation
In earlier years, when internal fixation such as plates were not widely available, two percutaneous Kirschner pins were also common in the treatment of distal radius. dorsal and radial metal pins were used by Kapandji et al. to reposition and fix extra-articular distal radius fractures (Figure 6).
Figure 6: Anteroposterior radiograph showing percutaneous gristle pin fixation of distal radius fracture (A figure); lateral radiograph (B figure)
The 2009 AAOS guidelines for the treatment of the distal radius concluded that there is not enough clinical evidence to prove that two kerf pins are better than three kerf pins. rosenthal et al. compared the prognosis of distal radius fractures treated with percutaneous kerf pins combined with cast fixation and found that the palmar inclination angle of the distal radius was better maintained on review of patients at 3 months after kerf pin fixation. A meta-analysis combining 13 studies found that there are currently more low-grade studies of displaced distal radius fractures using percutaneous kerf pin fixation found to achieve better outcomes, but the above conclusions still need to be supported by more high-grade evidence at a later stage.
External fixation frames: bridging and non-bridging
The current method of fixation of the distal radius external fixator, the need for adjunctive use of the kyphotic pin, the total amount of wrist traction, the timing of external fixator placement, and the indications for external fixators are still more controversial.
Mcquueen et al. reported that joint motion, grip strength, and palmar tilt were better in the non-bridged group than in the bridged group after treatment of distal radius fractures with bridged or non-bridged external fixators. However, a Meta-analysis published in 2008 came to a different conclusion, concluding that there is no evidence that non-bridged external fixators are more effective than bridged fixation in the treatment of distal radius fractures.
Carpal overdraw and clinical functional prognosis have also been studied. In a retrospective study of 26 patients treated with an external fixator, the authors found a significant correlation between wrist overdraw during early repositioning and improved clinical prognosis of the patients, a finding further supported by a study published in 2009. However, to date, no randomized controlled studies have confirmed the reliability of these findings.
A meta-analysis of 46 studies on the effectiveness of external fixation frames found no significant differences between external and internal fixation in terms of grip strength, wrist motion, imaging axis alignment, and pain. In the external fixator group, the incidence of infection, external fixator failure, and neuritis was higher, whereas in the internal fixation group, tendon irritation and the need for early internal fixation removal were more likely.
Incisional internal fixation
Incisional internal fixation is usually used to treat unstable fractures of the distal radius. Metacarpal locking plates have become more common for the treatment of unstable distal radius fractures (Figure 7). Other methods of incisional internal fixation include radial plates, dorsal plates, multi-shape plates and special fracture block fixation systems.
Figure 7: Incisional internal fixation with palmar locking plates for four-part comminuted fractures of the distal radius, orthotropic (A) and lateral (B) positions
The current research evidence confirms the effectiveness of the palmar radial locking plate for the treatment of intra-articular comminuted fractures, but there is a lack of sufficient evidence-based medical evidence for its effectiveness compared with other treatment measures.Wright et al. compared the effectiveness of the palmar locking plate and external fixation frame for the treatment of unstable fractures of the distal radius and found that the internal fixation group was better than the external fixation group in maintaining articular surface repositioning, palmar tilt, radial length, and wrist mobility. The results were better in the internal fixation group than in the external fixation group, but the PRWE and DASH scores were basically similar.
Studies have been done comparing the efficacy of palmar locking plates and non-surgical treatment of unstable fractures of the distal radius in patients over 65 years of age. The results of the study found that the DASH score and PRWE score of the surgical group were better than those of the non-surgical treatment group at early follow-up, but these differences disappeared at 1 year after surgery. In addition, imaging examination revealed no significant difference between the surgical group and the non-surgical group in terms of the effect of repositioning at 1 year postoperatively. The healing rate of fracture deformity in the non-operative treatment group was 100%. Patients in the surgical treatment group had better grip strength than the non-surgical treatment group. All patients were satisfied with the clinical outcome.
A retrospective study of the available literature found that there is still some controversy as to whether the long-term efficacy of the palmar locking plate for the treatment of distal radius fractures in the elderly (>65 years of age) is better than other treatment options.
Special internal fixation of the fracture block is performed by fixation of a separate fracture block by means of a microplate. A recent study completed by Konrath et al. found that 27 patients with displaced and unstable distal radius fractures had more satisfactory clinical outcomes at 2-3 years postoperatively after fixation and repositioning of the fracture with microplates.In a retrospective study, Sammer et al. compared microplates and palmar locking plates for distal radius fractures and found that at 1 year postoperative At follow-up, the clinical functional prognosis was essentially similar; however, the complication and reoperation rates were higher with microplates.
Intramedullary fixation
Intramedullary fixation for distal radius fractures involves the placement of an intramedullary nail through the radial styloid to fix the fracture fragment.Tan et al. reported in 2012 that 63 adult patients with distal radius fractures were treated with either intramedullary fixation or plaster fixation.At 12 months postoperatively, the intramedullary fixation group had better flexion and extension and grip strength than the plaster fixation group, and the intramedullary fixation group had better DASH scores and imaging The DASH score and imaging were better in the intramedullary group. There are no randomized, controlled studies on intramedullary nailing and plate fixation for distal radius fractures.
Arthroscopic-assisted fixation
Arthroscopic assistance can be used to visualize the joint surface of the distal radius during fixation of distal radius fractures. In a 2-year follow-up study of 33 patients, Ague et al. found that the use of arthroscopy-assisted joint surface repositioning of distal radius fractures was effective in improving joint surface repositioning and guided the treatment of internal fixation during surgery. In the AAOS 2009 guideline, it was concluded that the clinical evidence for recommending combined wrist arthroscopy and internal fixation for distal radius fractures is currently insufficient and more studies are needed at a later stage.
Fixation of ulnar styloid fractures
Fractures of the ulnar styloid process are more common in fractures of the distal radius. After fixation of the distal radius, the distal ulnar radial joint usually becomes stable. In a stable distal ulnar radial joint, the size and degree of displacement of the ulnar styloid fracture does not affect the patient’s functional prognosis. If the distal ulnar radial joint is unstable, the ulnar styloid process must be fixed. Fixation may include kerf pins, rivets, tension bands, and screw fixation.
Treatment Controversies: Fracture Fixation Augmentation Techniques
In the treatment of distal radius fractures, the bone mass of the distal articular surface can be increased by placing allograft bone in the compressed cavity. However, there is no consensus as to which intraosseous implant is more effective and economical.
Cassidy et al. conducted a comparative study of patients with distal radius external fixation braces or plaster fixation with or without the adjunctive use of calcium carbonate bone cement. At 6-8 weeks post-injury, patients with allograft implants had better grip strength and wrist mobility, finger joint motion, hand use, and wrist edema than patients with non-allograft implants. At 1 year post-injury, there was no significant difference between the two groups. In addition, four of the patients in the cement-injected group experienced leakage of cement from the joint cavity without clinical adverse consequences.
In a prospective study of allogeneic cancellous bone and autologous iliac bone grafting for the treatment of distal radius comminuted fractures, no significant differences were found between the two groups in terms of pain or functional changes at 1 year postoperatively. Patients with autologous iliac debridement experienced complications at the iliac bone, including hematoma, infection at the bone extraction site, pain, and numbness.
The 2009 AAOS guidelines for the treatment of the distal radius state that there is no rigorous high-intensity evidence recommending that bone grafting in the treatment of distal radius comminuted fractures will improve postoperative outcomes.
Treatment controversy point: rehabilitation exercises
There is still no consensus on rehabilitation strategies for patients after surgical or non-surgical treatment of distal radius fractures. Controversial aspects of rehabilitation include the timing of post-injury wrist braking, the timing of initiation of wrist exercises, strategies for home rehabilitation, and the use of ultrasound, ice, and vitamin C.
Plaster braking is usually required when choosing nonoperative treatment for distal radius fractures. A prospective study compared early (within 2 weeks) and late (outside 2 weeks) wrist motion exercises in patients after fracture incision and internal fixation. No significant differences were found in wrist flexion and extension function in patients at 3-6 months postoperatively. In addition, there were no significant differences in other functional aspects. The above-mentioned authors concluded that early wrist motion did not result in better outcomes in patients treated with internal fixation of distal radius fractures.
Several other randomized controlled studies have compared the effectiveness of physical therapy combined with home rehabilitation exercises for distal radius fractures. A 2009 study compared the effect of different treatment strategies on final outcomes after internal fixation of distal radius fractures. This study concluded that home exercise programs had essentially similar treatment outcomes as professional institutional exercise methods.
At least one study has evaluated the role of ultrasound in distal radius fracture healing. This study compared the effectiveness of low-intensity ultrasound and placebo groups in improving fracture healing time in patients treated conservatively. The mean fracture healing time was found to be 61 days in the ultrasound-treated group, compared with 98 days in the control group. However, better healing was not found to be achieved in the ultrasound treatment group in the long term.
Few studies have reported the effectiveness of ice use in distal radius fractures. The AAOS 2009 guidelines for the treatment of the distal radius concluded that there is insufficient evidence to support or oppose the use of ice in patients with distal radius fractures.
Treatment controversy point: medications
Vitamin C is commonly used to treat patients with chronic regional pain syndrome (chronicregionalpainsyndrome).Zollinger et al. studied the relationship between vitamin C and patients with chronic regional pain syndrome in patients with distal radius fractures. found that 500 mg/day was the optimal dose to reduce pain in patients. In contrast, however, Court et al. found that vitamin C use did not reduce post-injury wrist pain, joint mobility, or fracture healing in patients with distal radius. The AAOS guidelines conclude that there is only moderately strong evidence to support the use of vitamin C for the prevention of distal radius pain. Nonetheless, there is still more doubt as to whether vitamin C used in the clinic can promote functional recovery of the wrist after radius fracture surgery.
The use of bisphosphonates after radial fracture is not recommended at this stage because they inhibit bone remodeling by osteoclasts, and a prospective study by Gong et al. found that starting bisphosphonates within 2 or 6 weeks after fracture surgery did not significantly alter the time to fracture healing in patients. More research is needed in the long term to further elucidate the role of this drug in fracture healing.
Summary
There are various controversies related to fractures of the distal radius. More research is needed in the future to further elaborate on the controversial aspects of distal radius fractures.