Clin Orthop Surg.  2018 Jun;10(2):135-141. 10.4055/cios.2018.10.2.135.

Juxta-articular Plate Fixation in Distal Radius Intra-articular Fractures with Accompanying Volar Free Fragments beyond the Watershed Line

• Lee JK
• Lee SH
• Sim YS
• Kim TH
• Baek E
• Han SH

• KMID: 2411737
• DOI: http://doi.org/10.4055/cios.2018.10.2.135

Abstract

BACKGROUND
Although distal radius fractures (DRF) are common fractures, intra-articular comminuted DRF with volar free fragments are uncommon. There is considerable difficulty in the fixation of free fragments beyond the watershed line using the existing volar locking plate. We aimed to examine the efficacy and potential complications associated with the use of juxta-articular volar plates in intra-articular DRF accompanied by free fragments beyond the watershed line.
METHODS
The patients were enrolled in a consecutive manner between 2007 and 2016. In cases of DRF with free fragments beyond the watershed line, we employed a 2.4-mm small fragment juxta-articular volar locking compression plate using a volar Henry approach. A total of 32 patients were included in this study. There were 15 males and 17 females with a mean age of 52.3 years (range, 33 to 69 years). The mean follow-up period was 14.5 months (range, 10 to 24 months). Preoperative radiographs and three-dimensional computed tomography images were used to analyze fracture patterns and assess the free fragments beyond the watershed line. The mean number of free fracture fragments beyond the watershed line was 2.33. Plain radiographs of immediate postoperative and last follow-up were used to confirm fracture union, incongruence, radial height, volar tilt, radial inclination, and arthritic changes. For functional assessment, we measured grip strength, range of motion (ROM), modified Mayo wrist score (MMWS) and determined Disabilities of Arm, Shoulder and Hand (DASH) scores at the last follow-up. Postoperative complications were monitored during the follow-up period.
RESULTS
All patients obtained sound union without significant complications. At the last follow-up, 16 cases presented with an articular step-off of more than 1 mm (mean, 1.10 mm). The mean MMWS was 76.3 (range, 55 to 90), mean DASH score was 15.38 (range, 9 to 22), mean visual analogue scale score for pain was 1.2 and mean grip strength was 75.5% of the opposite side. The mean ROM was 74.3° for volar flexion and 71.5° for dorsiflexion.
CONCLUSIONS
In cases of intra-articular DRF with free fragments beyond the watershed line, a volar approach with use of a juxtaarticular plate provided favorable outcomes without significant complications.

Keyword

Wrist joint; Watershed line; Radius fractures; Intra-articular fractures; Fracture fixation internal

MeSH Terms

Arm
Female
Follow-Up Studies
Hand
Hand Strength
Humans
Intra-Articular Fractures*
Male
Postoperative Complications
Radius Fractures
Radius*
Range of Motion, Articular
Shoulder
Wrist
Wrist Joint

Figure

• 

  Fig. 1 Juxta-articular volar plate (A) and clinical application in a distal radius fracture (B).

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  Fig. 2 Operative procedures. (A) With a Freer elevator inserted through the volar fracture site and positioned under the subchondral bone of the radiocarpal joint, the joint surface was elevated and restored using the leverage technique. (B) After temporary K-wire fixation at adequate reduction, proximal cortical screw fixation for compression was followed by proximal locking screw fixation with the plate appropriately positioned. Anteroposterior (C) and lateral (D) C-arm images after final fixation: 2.4-mm locking screws were inserted into the distal fixed locking holes of the plate.

• 

  Fig. 3 A 53-year-old female fell from a height, resulting in a left comminuted distal radius fracture with volar free fragments beyond the watershed line. (A, B) Initial anteroposterior and lateral plain radiographs. (C, D) In computed tomographic assessment, we observed a transverse fracture located beyond the watershed line, extending into the joint space with dorsal displacement, and dorsal cortex comminution. (E) Freer leverage reduction and temporary fixation were conducted after fracture exposure. (F, G) Ten months after surgery, at the final follow-up, plain radiographs showed complete bony union on plain anteroposterior and lateral radiographs. (H) The patient achieved volar flexion of 70° and dorsal flexion of 80°. The Disabilities of Arm, Shoulder and Hand scores was 12.0. The pain visual analogue scale score was 1. The modified Mayo wrist score was 85.

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