Within the myriad distal radius fractures treated at level one trauma centers, two groups of patients have injuries that represent a unique treatment challenge: (1) patients whose high-energy wrist injuries have fracture extension into the radius and ulna diaphysis, and (2) patients with multiple injuries that require load bearing through the injured wrist to assist with mobilization. In addition to the fracture reduction and fixation, the second group of patients requires skeletal support that bypasses the injured wrist bridging from hand to forearm.
Recent advances in wrist fracture treatment present specific solutions to single extremity injuries, emphasizing the benefit of specific fragments fixation, the use of fixed angle devices and orthogonal placement of implants.8,10,15 The advent of volar fixed-angle distal radius plating has quickly changed the treatment of comminuted distal radius fractures by avoiding dorsal wrist incisions, having to deal with the extensor tendon irritation from implants and circumventing the need for dorsal subcutaneous implants.13 The volarly placed fixed angle plates support the subchondral bone and articular fragments, provide fixation for highly comminuted metaphyseal fractures. When the metaphyseal bone stock is insufficient the implant transfers the load to the intact diaphysis.14 Similar to volar fixed angle devices, subchondral support and fixation rigidity can be enhanced with a combination of small implants designed to address particular distal radius fracture fragments, placed on the various surfaces of the radius. This fragment specific fixation takes advantage of the increased rigidity provided by implants placed in orthogonal positions.18 The biomechanical advantage of combined external fixation and K-wire placement has been demonstrated in laboratory studies, and the early clinical advantage of combined pin fixation and external fixation compared to internal fixation, using implants developed in the 1980s, has been demonstrated in a double blind randomized multicenter study.11,21 As exciting as these advances are, there are no available clinical studies comparing newer implant designs among themselves or comparing these newer techniques to combined external fixation and K-wire fixation.9 There are biomechanical studies that compare various fixed angle implants but these deal with metaphyseal bone loss and an intact diaphysis. It is not surprising that these studies demonstrate that the largest implants provide the greatest resistance to bending.7,16 There are no publications that specifically address the patient with a distal radius fracture and multiple extremity injuries and only one publication addresses distal radius articular fractures with extension of the fracture into the diaphysis.19
The patient with multiple injuries, especially those with injuries to the pelvis and lower extremities require use of upper extremities for transfers and for weightbearing. There is no evidence that the newer fixation techniques can support such activities. Perhaps when combined with external fixation, that spans the wrist joint, weightbearing can be improved but this is clinically unproven. In addition external fixation presents a set of problems that are particularly vexing for patients being cared for in intensive care units. These include the burden of pin tract care and an increased incidence of pin tract contamination and infection.2,17
The ideal fixation device in this setting would assist with and maintain reduction, require no nursing care and would allow use of the extremity for mobilization. In an article discussing wrist fractures associated with metaphyseal and diaphyseal comminution, Ruch and his coworkers19 present a technique, introduced by Burke and Singer5 that has application in the care of the patient with multiple injures. These authors used a 3.5-mm plate (Synthes, Paoli, PA) that spans from the intact radial diaphysis to the third metacarpal. The plate provides optimal fixation, allows distraction across the impacted articular segment and can be combined with articular fracture fixation. This "internal fixator' or “bridge plate” is removed after fracture consolidation. The radiographic and functional results were excellent or good in twenty of twenty-two patients and fair in two patients.
We present our experience with a variant of this technique using 2.4 mm ASIF plates passed extraarticularly through the second dorsal compartment and secured onto the dorsal-radial aspect of the radius proximally and the second metacarpal distally.
MATERIALS AND METHODS
From August 25, 1999 to March 31, 2005, the senior author (DPH) treated 466 distal radius fractures that required some form of internal or external fixation. Within that group of patients, 62 were treated with bridge plates (Table 1). Twenty-three of these patients sustained polytrauma injuries to lower extremities. A retrospective chart review of this patient cohort was performed. Fifty-two patients had completed treatment and could be documented for final followup, including radiographic confirmation of healing and occupational status. In 52 of the 62 patients (84%) a 2.4 mm titanium mandibular reconstruction plate (Synthes) was used. Since September 2004, 10 patients were treated with a 2.4-mm stainless steel plate (Synthes) specifically designed for this purpose.
With the patient anesthetized and supine on the operating table, the involved extremity is centered on a radiolucent arm table. The extremity is draped free and finger traps are applied to the index and middle fingers and 4.5 kg of longitudinal traction is applied to the fingers through a rope and pulley system. With the assistance of image intensification, we perform the closed reduction maneuver described by Agee.1 This step wise reduction employs longitudinal traction, to restore length and to assess the benefit of ligamentotaxis for the restoration of articular step off. The next step, a palmarly directed translation of the hand relative to the forearm, restores sagittal tilt and assesses the integrity of the volar lip of the distal radius. This second step is particularly important in accessing volar shearing fractures especially those involving the medial-volar corner of the radius. The final step of the reduction, pronation of the hand relative to the forearm, corrects the supination deformity that occurs from falls onto outstretched hands or the direct compression sustained on a steering wheel or dashboard. It is important to emphasize that this reduction sequence does not include pronation of the forearm relative to the elbow or wrist flexion as described by Gelberman et al.6 This reduction maneuver does not place direction pressure on the carpal canal.
With the initial reduction completed, the bridge plate is applied.
When this technique was first reported by Burke and Singer,5 a 12-16 hole 3.5-mm dynamic compression plate (DCP) (Synthes), was placed along the floor of the fourth dorsal wrist compartment and secured to the third metacarpal distally and the dorsal radius proximally. The technique presented here differs from the original description by using a 22-hole 2.4-mm mandibular reconstruction plates (Synthes), or a 20-hole 2.4-mm Distal Radius Bridge (DRB) plate (Synthes) placed through the second dorsal compartment. The mandibular reconstruction plate is titanium, has square ends, scalloped edges. Threaded screws can be locked into the plate. The Distal Radius Bridge (DRB) plate (Synthes) is made from stainless steel, has tapered ends, smooth edges and it too has threaded screw heads that can be locked into the plate (Fig 1).
The plate is superimposed on the skin spanning from radial diaphysis to distal metadiaphysis of the second metacarpal. The position is checked with image intensification, and the skin is marked to guide incisions centered over the proximal and distal four screw holes (Fig 2). Before incision, the subcutaneous tissue is infiltrated with 0.25% bupivicaine with epinephrine to promote hemostasis. Tourniquets may be used at this time, but, reflecting the senior authors' preference, none were used in the cases presented here. A 5-cm incision is made at the base of the second metacarpal and continued along the second metacarpal shaft. In the depths of this incision the insertion of the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) are identified as they pass beneath the distal edge of the second dorsal wrist compartment to insert on the second and third metacarpal bases respectively. A second incision is made just proximal to the outcropping muscle bellies, the abductor pollicis longus (AbPL) and the extensor pollicis brevis (EPB), in line with the ECRL and ECRB tendons. The interval between the ECRL and ECRB is developed and the diaphysis of the radius exposed. The distal radius bridge (DRB) plate is introduced beneath the muscle bellies of the outcropping muscles extra-periosteally and advanced distally between the ECRL and ECRB tendons. Some resistance may be encountered as plate emerges into the hand. Usually this is overcome with gentle manipulation of the plate. Occasionally the plate will not pass through the compartment. In these cases a guide wire or stout “suture retriever” is passed along the compartment from distal to proximal. The plate is secured to distal end of the wire and delivered into the hand. In the rare instance that these measures fail, a third incision is made directly over the metaphysis of the radius, the proximal one half of the second compartment incised and the plate passed under direct vision. This third incision also serves as a portal to reduce articular fracture and introduce bone graft.
The plate is secured to the second metacarpal by placing a nonlocking fully threaded 2.4-mm screw placed through the most distal plate hole. The proximal end of the plate is identified in the forearm. If radial length has not been restored then the plate, secured to the second metacarpal, is pushed distally until length is restored and a fully threaded 2.4-mm nonlocking screw is placed in the most proximal plate hole. By using nonlocking screws the plate is effectively lagged onto the intact bone. Plate alignment along the longitudinal axis of the radius is guaranteed by securing the distal most and proximal most screw holes first. The remaining holes were secured with fully threaded 2.4-mm bicortical locking screws. A minimum of three screws at either end of the plate is used.
It has been our experience that as the plate passes along the radial diaphysis through the second compartment and comes to lay on the second metacarpal extra-articular alignment, radial inclination, volar tilt, and radial length is restored. Intraarticular reduction may be further adjusted by using periarticular incisions centered over Listers tubercle. These incisions allow direct manipulation of fragments, placement of subchondral bone grafts, repair of intercarpal ligament injuries, and augmentation of fracture fixation with K-wires and plates. Displaced volar medial fracture fragments that are not reduced with this technique require a separate volar incision and buttress support.
The stability of the distal radioulnar joint (DRUJ) is assessed after radius reconstruction. If stable, the limb is immobilized in a long arm splint with the forearm in supination for the first 10 to 14 days postoperatively. If the DRUJ is unstable, and there were no contraindications to prolonging the operation, then reconstruction of the triangular fibrocartilage complex is undertaken. If however, the patient's condition does not allow prolonging the operation, then the forearm is placed in neutral rotation, the ulna head reduced into the sigmoid notch, and the ulna secured to the radius with a minimum of two 1.6 mm K wires passed proximal to the DRUJ.
Digit range of motion (ROM) exercises start within 24 hours of surgery. Loadbearing through the forearm and elbow is allowed immediately, and a platform crutch is used when the patient is physiologically stable. One month postoperatively the platform is removed and weight is allowed through the hand grip of crutches. Lifting and carrying is restricted to approximately 4.5 kg until fracture healing.
Distal radioulnar joint stability and forearm motion is assessed 2 weeks after reduction. If the patient can supinate the forearm with little effort and the DRUJ is stable then splints are discontinued. Axial loading through the extremity was then allowed. If the patient has difficulty maintaining supination, or if the DRUJ was reconstructed acutely, then a removable long arm splint is fabricated. The splint holds the forearm in supination for another 3 weeks. This splint is removed when the patient bathes and does ROM exercises. If the DRUJ is transfixed with K-wires, then the wires were removed on the third week postoperatively and DRUJ stability was reassessed.
Supplemental K-wires are removed 6 weeks postoperatively. The plate and screws are removed when the fracture is healed. Plate and screw removal rarely occurs sooner than 12 weeks after injury. If a mandibular reconstruction plates is used, the screws are removed and the plate is twisted axially 720° to break the soft tissue adhesions and fracture callous that grow into the scalloped edges of the titanium plates. This maneuver is unnecessary when using the smooth edged stainless steel DBP. A removable short arm splint was worn for 2 to 3 days after plate removal. After plate removal hand therapy is directed at regaining strength and concomitant return of motion.
Fracture healing occurred in all 62 patients. In each case radial length was within 5 mm of ulnar neutral. Radial inclination was greater than 5°. Palmar tilt was at least neutral. There were no articular gaps or step offs greater than 2 mm and the distal radioulnar joint was stable (Table 1).
The plate was removed on average 112 days after placement (range, 30-203 days). One patient, a commercial fisherman, kept his plate in place for 19 months because he did not wish to miss out on work activities. The plate broke 16 months after implantation. He agreed to have the broken implant removed when the hardware became increasingly prominent and painful.
This same patient also sustained a ruptured extensor carpi radialis longus (ECRL) tendon that occurred while removing the proximal portion of the plate. Fracture callous had grown into the scalloped edges of the mandibular reconstruction plate leading to adhesion of the tendon and the plate. The proximal portion of the ECRL was tenodesed to the extensor carpi radialis brevis (ECRB) in the forearm. Two weeks after plate removal and tendon repair, this man returned to commercial fishing against our advice. He reports motion and strength to be equal in both upper extremities.
There were no cases of excessive postoperative finger stiffness or reflex sympathetic dystrophy.
Other than bridge plate removal, secondary procedures for fracture care were preformed in only one patient. In that case the patients care was transferred to treating physicians closer to her home. Her distal radius bridge plate was removed 4 weeks after injury and replaced with a nonspanning 3.5-mm compression plate. The fracture healed without incident and the ROM 1year after injury was 80% that of the uninjured wrist. Strength measurements were not available but this patient did return to all previous activities.
Forty-one of the 62 patients have returned to their previous levels of employment. Of the remaining 21 patients, eight were unemployed when injured and remain so. Thirteen patients sustained multiple injures requiring considerable changes in occupations. Only one of the 13 patients consider the wrist fracture to be the limiting factor in returning to work.
As detailed above there was one broken fixation plate and one ruptured ECRL tendon in one patient. There were no other complications.
A 46-year-old woman was a restrained passenger in a high-speed rollover motor vehicle accident. She sustained a closed head injury, a cervical spine fracture, an ipsilateral closed elbow dislocation, and distal radius fracture associated with an unstable distal radioulnar joint (Fig 3A). She also sustained a combined partial and full thickness burn to the distal volar forearm. On the day of injury she was taken to the operating room for stabilization of her spine, placement of an intracranial pressure (ICP) device, and treatment of her upper extremity injuries. Because of concerns regarding gradually increasing intracranial pressures, the upper extremity fractures were treated expeditiously, addressing the radius fracture with closed reduction, percutaneous pin fixation, and application of a 20-hole 2.4 mm locking titanium plate from the Mandibular Reconstruction Set (Synthes). The DRUJ became stable with reduction and fixation of the radius. The elbow was treated with a closed reduction (Fig 3B). Seven days after injury burn eschars were removed and local tissues were advanced where possible to procure closure. A split thickness skin graft was applied to the distal volar forearm where primary closure could not be obtained. The fixation wires were removed 4 weeks after injury, and the plate was removed 8 weeks after injury (Fig 3C). Four months after injury she lacked 25° wrist extension and 35° elbow extension, otherwise her ROM was equal bilaterally. She returned to her occupation as an intensive care nurse 6 months after injury (Fig 3D). This patient is an example of how bridge plating is used in a critically ill patient with limited available operative time and an expected prolonged admission to an intensive care unit.
Patient 2 (Courtesy Christopher H. Allan MD)
A 51-year-old man sustained multiple injuries including cardiac contusion, pneumothorax, a left below-knee amputation, right brachial plexopathy, and the severely comminuted left distal radius and ulna fractures shown in (Fig 4A). The radius fracture was reduced with traction and application of an 18-hole 2.4-mm locking titanium plate. The ulna was reduced and fixed with a 9-hole 2.4-mm locking plate (Fig 4B). The spanning plate was removed 9 months postoperatively (Fig 4C). One year after injury wrist extension was 35°, wrist flexion was 45°, radial deviation was 10°, and ulnar deviation was 30°. Forearm supination was 60° and pronation was 70°. This case serves as an example of how a severely comminuted radius fracture can be reduced, internally fixated, and still allow use of the extremity as a major load-bearing limb. The involved limb was used to assist with bed-to-chair transfers and later to assist with the crutch and cane walking required in the assimilation of this patient's below-knee prosthetic.
This 52-year-old man was struck by a car, launched from his motorcycle, and rolled approximately 100 feet down an embankment. He sustained multiple rib fractures, a tension pneumothorax, a contralateral hip fracture, and a wrist fracture (Fig 5A). He underwent fracture fixation on the second day after injury. After closed reduction, the intraarticular and extraarticular alignment appeared satisfactory. A 2.4-mm stainless steel DRB plate (Synthes) was applied. Oblique radiographs taken after reduction revealed a 3-mm articular step off involving the volar medial corner of the radius (Fig 5B). The displaced fracture was exposed through a longitudinal incision that started at the distal wrist crease just proximal and radial to Guyon's canal and extended proximally. The interval between ulnar neurovascular bundle and the finger flexor tendons was developed, the pronator quadratus was divided, and the volar fracture was reduced. A 2.4-mm stainless steel plate (Synthes) secured fixation (Fig 5C). The upper extremity was used for load bearing immediately postoperatively. The patient remained in an intensive care unit for 2 weeks for the treatment of pulmonary injuries. When stable, his care was transferred to his HMO. His fractures healed and the plate was removed 14 weeks postoperatively. His ROM 4 months after injury was near average. He lacked 15° palmar flexion compared with the uninjured wrist. This patient is an example of adhering to the principles outlined for adequate reduction of distal radius fractures. If a fracture cannot be reduced by indirect methods, then open reduction is essential even if the extraarticular parameters have been restored with spanning devices such as external fixators or plates.
Recent advances in the biologic and biomechanical understanding of wrist factures has prompted an aggressive approach to the fixation of distal radius fractures. The predictable benefit of near anatomic reduction has been argued in all of the studies referenced in this article. To achieve these reductions, implants have been designed to address distal radius and ulna fractures specifically, and the initial cohort studies using these newer methods have been uniformly promising. However, there remain two challenging groups of patients that have not been address by these innovations. These are patients with highly comminuted metadiaphyseal fractures of the distal radius and patients whose multiple injuries require weightbearing with an upper extremity that has an associated wrist fracture. In the first group, patients with metadiaphyseal comminution, there are were no implants that could effectively bridge the fracture at the time these patients were treated. There currently are plates being developed with longer diaphyseal limbs. These may circumvent the need for bridge plates in the future. In the second group, patients with multiple injuries, weightbearing through the injured extremity places excessive stress on the fracture reduction and the implants securing the fracture. Even with newer and longer implants, the articular fractures can not bear weight without anticipated proximal migration of the fracture fragments. In our 10-year experience at a Level 1 trauma center, these two groups of patients represent 13% (62 of 466) of distal radius factures requiring some method of operative fixation. In the study presented here we reviewed treatment of these patients using a fixation plate that bridges the wrist fracture from the radial diaphysis to the second metacarpal.
This study has the easily recognizable limitations of a retrospective cohort study. Although each of the patients in this cohort was followed up on until radiographic evidence of healing and bridge plate removal, 10 of 62 patients have limited followup data. Well-documented strength, ROM, and specific followup points were not uniform. Data from outcome measures such as the Disability of the Arm, Shoulder and Hand (DASH) or result scores such as the Gartland and Werley demerit system, although complimentary to our presentation, were not gathered in a manner that would allow prudent interpretation. Despite these limitations, this cohort reinforces the findings of Burke and Singer,5 who introduced the technique of bridge plating distal radius fractures and Ruch et al,19 who published a prospective cohort of patients treated with a distraction plate bridging severely comminuted meta- diaphyseal radius factures.
Authors of the studies we evaluated propose that distraction plating allows facture reduction and fixation over a broad metadiaphyseal area while effectively diverting compression forces away from the facture sight. Before the introduction of this technique, treatment of these injuries was limited to cast immobilization or external fixation with or without K-wire augmentation. Both of these methods are associated with an unacceptably high complication rate. Lafontaine et al12 has shown that the end results of comminuted distal radius fractures treated by closed methods resembles the prereduction radiographs more than any other radiograph during treatment, even when the reduction successfully restored wrist anatomy. Szabo and Weber20 reported a greater than 50% complication rate when using external fixation alone. The most frequent complications being pin tract infections. This latter complication is a particularly frequent occurrence in the patients confined to intensive care units.
The biomechanical stability of spanning plates is predictable. Behrens et al,4 studying the rigidity of external fixator configurations, demonstrated that rigidity is directly proportional to how close the longitudinal fixator bar is to the bone and the fracture. A bridge plate, resting directly against the radius proximally and metacarpals distally, is therefore the strongest possible fixator construct. Furthermore, Wolfe et al21 showed in an experimental model the benefit of K-wire in augmenting fracture stability when combined with external fixation. Along with those of Behrens et al,4 these findings are clinically applicable and help explain why reductions were maintained in the cases presented by Burke and Singer,5 Ruch et al,19 and the cases presented here.
With prolonged immobilization and distraction, there may be concerns that wrist stiffness will result and fracture nonunion will occur. These complications were not encountered. There were no nonunions and a functional ROM returned within a year of plate removal.
Other than bridge plate removal, secondary procedures for fracture care were preformed in only one patient. In that case the patient's care was transferred to physicians closer to her home. Her distal radius bridge plate was removed 4 weeks after injury and replaced with a non-spanning 3.5-mm compression plate. The fracture healed without incident and the ROM 1 year after injury was 80% that of the uninjured wrist. Strength measurements were not available, but this patient did return to all previous activities.
The technique used in our cases varies from that described by Burke and Singer.5 The bridge plate we used was smaller, using 2.4-mm screws instead of 3.5-mm screws and was converted to a fixed-angle device by using locking screws. We placed the fixation plate in the second dorsal compartment rather than the fourth and secured the plate to the second metacarpal rather than the third metacarpal. This is not a new concept. Becton et al3 first suggested this position while presenting a fixation plate specific to the task. We did not use the implant he suggested because it was too short for most of the fractures we encountered and could not be converted to a fixed angle device. Similar to Becton et al, we did note that the dorsal radial aspect of the radial diaphysis, the floor of the second compartment, and the dorsal radial aspect of the second metacarpal are collinear.3 Passing a fixation plate along these surfaces through the intact retinaculum of the second dorsal compartment while applying longitudinal traction effectively restored radial length, radial inclination, and volar tilt of the radial styloid and scaphoid. Depression fractures of the lunate facet and volar shearing factures, especially those involving the critical volar ulnar corner of the radius, may require separate manipulation and fixation. Burke and Singer5 cite this possibility as the major advantage to a fourth dorsal compartment approach to these injuries.5 We used indirect reduction techniques, percutaneous wires, limited dorsal incisions, and open reduction of volar shearing fractures as needed to complete and maintain reductions.
Limitations not withstanding, our results were comparable with those reported in the current literature. All fractures healed without loss of reduction and plates were removed on average 112 days after placement. This is similar to the 110 days reported by Ruch et al19 and reflects the general impression that fracture healing was assessed 12, 16, and 20 weeks after injury, with the average fracture healing sometime after 12 weeks and plate removal being scheduled 16 weeks after injury. There was no difference in the timing of plate removal in the 23 patients with associated lower extremity injuries.
Complications with this technique are infrequent. Burke and Singer5 reported none. Ruch et al19 reported long finger extensor lag of 10° to 15° in three patients. They had no hardware failures. We had two complications. Both occurred in the same patient: a broken plate and a ruptured wrist extensor tendon. The implant failure occurred well after the fracture had healed. The patient stated that as a commercial fisherman, he could not find the time to have the plate removed until it broke. A larger implant in a different position as described by Burke and Singer5 may not have broke, but considering the circumstances of this complication, we do not think that the implants need to be more sturdy or the that the position of the plate needs to be changed. We do think that using a stainless steel implant specifically designed for this application can circumvent additional tendon ruptures because of the smooth edges and tapered tips of this type of implant. The distal radius bridge plate (DRB plate) (Synthes) is easier to apply and remove.
We think using bridge plates in the treatment of distal radius fractures avoids the complications of external fixation, especially pin tract irritation. A bridge plate can remain implanted for extended periods of time, without deleterious affect on functional outcome. Just as noted by Burke and Singer5 and Ruch et al,19 our patients all went on to heal with acceptable metadiaphyseal and intraarticular alignment. In patients with multiple traumatic injuries, bridge plating allowed earlier postoperative load bearing across the affected wrist. This enabled independent transfers and the use of ambulatory aids. Application of bridge plates is simple and surgical time is comparable with the application of an external fixator.
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