Combined Approach for Intra-articular Distal Radius Fracture: A Case Series and Literature Review

As this study was retrospective in nature, informed consent was not obtained according to the guidelines of our Institutional Review Board. This retrospective, single-center, case series study was approved by the Institutional Review Board of our institution (IRB No. 1809-001-16202). From March 2012 to November 2016, a total of 758 patients were treated with open reduction and internal fixation for DRFs at our institution. Among them, 37 patients who underwent a combined approach for surgical management of a DRF were enrolled in the study. Patients were treated with this method of treatment if the fracture pattern was included in the following classification. The classification took account of the combined injuries associated with displacement volar fragments and/or loss of volar cortical buttresses. Type 1 injuries were defined by a free intra-articular fragment without connection to a metaphysis. Type 2 injuries were defined by distal migration of a dorsal fragment beyond the wrist joint. Type 3 injuries were defined by a centrally impacted articular fragment and displaced dorsal fragment, which was not reduced by an indirect method. A volar approach was necessary for reduction of displaced volar fragment and volar cortical buttress plating. When restoration of the articular surface with indirect method was insufficient, a dorsal approach was used to approach the dorsal fragment or visualize the radiocarpal joint. Of the 37 study patients, 4 had accompanying fractures of the scaphoid (2 patients), radial head (1 patient), and ulnar shaft (1 patient) on the ipsilateral side. One patient had a Gustilo and Anderson type 3 wound at the fracture site, which was initially treated with external fixation. The patient underwent a second operation after 3 weeks and a combined approach was used.7) These 5 patients were excluded from the study (Fig. 1).

Fig. 1
Flowchart and treatment algorithm used in the current study. ORIF: open reduction and internal fixation, DRF: distal radius fracture.

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All patients were evaluated using three-dimensional computed tomography (CT) preoperatively and operated on by a single surgeon (JSL) within 2 weeks of their initial evaluations. They were followed clinically and radiographically for a minimum of 1 year. Each patient’s medical records and radiographs were reviewed and the demographic, mechanism of injury, and operative findings data were collected.

The study group included 8 men and 24 women with an average age of 56 years (range, 22–77 years). The mean duration of follow-up was 32 months (range, 13–84 months). The mechanisms of injury were as follows: falls from standing height (9 patients), falls from great height (17 patients), motor-vehicle accidents (4 patients), and sports-related injuries (2 patients) (Table 1).

Table 1
Patient Demographics

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Surgical Technique

Under general anaesthesia or brachial plexus block, the patients were placed in the supine position, and the injured hand was placed on a radiolucent operating table. A skin incision measuring about 4 cm was made and the fracture was exposed using a volar Henry approach. Once the volar metaphyseal fracture site was visualised, the fracture was reduced by longitudinal traction or an intrafocal method and was temporarily fixed using Kirschner wires. Under image intensification, a volar locking plate (Synthes, Paoli, PA, USA or Biomet, Miami, Florida, USA) was placed, which served as a buttress for the distal fragment, and a proximal screw was inserted first. In type 1 or 2 fractures, distal locking screws that fixed more than 75% of the bone thickness were then inserted. In type 3 fractures, distal locking screws that fixed less than 50% of the bone thickness were inserted just to maintain the extra-articular alignment of the DRF. With the volar buttress plate in place, an additional dorsal approach was performed through the third and fourth extensor compartment to excise the fracture fragments in type 1 or 2 fractures and to achieve an accurate reduction of the joint surface in type 3 fractures. The extensor pollicis longus (EPL) was mobilised from the third dorsal compartment, and the exposed joint capsule was incised longitudinally. In type 1 or 2 fractures, intra-articular free fragments or distally migrated fragments could be removed through a dorsal approach (Figs. 2 and 3).

Fig. 2
Type 1 injury. Preoperative anteroposterior radiograph (A) and lateral radiograph (B). (C) Sagittal view of computed tomography scan showing a free intra-articular fragment (white arrow). (D) The intra-articular free fragment (black arrow) was removed through the additional dorsal approach. One-year postoperative anteroposterior radiograph (E) and lateral radiograph (F).

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Fig. 3
Type 2 injury. Preoperative anteroposterior radiograph (A) and lateral radiograph (B). (C) Sagittal view of computed tomography scan showing distally migrated dorsal fragments beyond the wrist joint (white arrow). (D) The distally migrated fragment (black arrow) was removed through the additional dorsal approach. One-year postoperative anteroposterior radiograph (E) and lateral radiograph (F).

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If a distally migrated dorsal fragment was relatively large and involved articular surface such as dorsal partial articular shearing fractures, it was repositioned and fixed using a dorsal locking plate (Synthes) (Fig. 4). In type 3 fractures, the impacted articular and dorsal fragment was reduced and bone grafting was performed. During periosteal dissection, disruption to the capsular attachments of dorsal fragment, which makes reduction of fragments difficult and results in devascularization, was avoided. The impacted articular fragments were reduced initially to the lunate facet fragment and then supported by the bone graft placed into the metaphyseal defect. While locking plates provide a great deal of support to the articular surface, we always used bone graft substitute to fill the metaphyseal defect in type 3. Once a satisfactory reduction was obtained, one or two fracture-specific dorsal locking plates (Synthes), typically a combination of a left and right-angled L shaped, were placed according to the location of dorsal fragments. The radial styloid can then be fixed from screws from the volar locking plate. Next, the distal locking screws of the volar plate were replaced with longer-sized screws to compress and hold the fracture fragments (Fig. 5).

Fig. 4
If a distally migrated dorsal fragment was relatively large in a type 2 injury, the dorsal fragment was repositioned and fixed with a dorsal locking plate. Preoperative anteroposterior radiograph (A) and lateral radiograph (B) showing distally migrated dorsal fragments. One-year postoperative anteroposterior radiograph (C) and lateral radiograph (D).

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Fig. 5
The illustration shows how to treat a type 3 injury with combined volar and dorsal locking plates. (A) The fracture was reduced through a volar approach and fixed with a volar plate. When the volar plate was placed, distal locking screws of the plate that fixed less than 50% of the bone thickness were inserted just to maintain the extra-articular alignment. (B) The impacted articular or dorsal fragment was reduced and fixed with a dorsal locking plate. Screws that lock to the plate are very useful for maintaining elevated joint articulation, particularly when there is poor-quality bone. (C) Once satisfactory reduction was obtained, distal locking screws of the volar plate were replaced with longer-sized screws to compress and hold the fracture fragments.

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Finally, intraoperative fluoroscopy was performed to obtain a 20° elevated tangential lateral view and confirm the absence of intra-articular screw penetration. The extensor retinaculum was then repaired, and if a dorsal locking plate was used, the EPL was placed out of its sheath to prevent an attenuated rupture. Immediately after surgery, all patients had short-arm splints applied for approximately 2 days, and they were encouraged to move the fingers and metacarpophalangeal joints. All patients wore removable splints for 4 weeks and were allowed early movement of their wrist and fingers as tolerated to avoid stiffness.

In our study, 7 of 32 patients were included in type 1 fractures, which were treated with volar locking plates and excision of the intra-articular fragments. Among all the patients, more than one intra-articular fragment was found on the CT scans obtained after a closed reduction. Fourteen patients who had distally migrated dorsal fragments beyond the wrist joint were included in type 2 fractures and 12 of those 14 patients were treated with volar locking plates and excision of the dorsal fragments. Two of the 14 patients had relatively large dorsal fragments, such as dorsal Barton fractures, and they were treated with combined volar and dorsal locking plates. The remaining 11 patients were included in type 3 fractures, all of whom were treated with combined volar and dorsal locking plates.

At the latest follow-up, radiographs revealed an average of 16.9° of radial inclination (range, 6.5°–24°), an average of 4.2° of volar tilt (range, −2.2° to 8.9°), and an average of 7.5 mm of radial height (range, 3.2–12.81 mm). According to the scale of Knirk and Jupiter, 3 patients had grade 1 and 2 patients had grade 2 arthritic changes identified during the follow-up period. There were no signs of devitalization of the fracture fragments on the follow-up radiologic examinations in any of the patients. We also measured grip strength in the injured and uninjured wrists and compared the measurements. The average grip strength was 80.1% compared to the uninjured wrist. We have demonstrated the radiologic parameters and grip strength according to the types in Table 2.

Table 2
Postoperative Radiographic Parameters and Grip Strength of the Injured Compared with the Uninjured Wrist at Final Follow-up

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The average Quick DASH score was 18.3 (range, 6.8–34.1) and the average Garland and Werley score was 5.8 (range, 1–11). According to the Garland and Werley scores, the functional results were excellent in 3 patients, good in 25, and fair in 4. The final wrist range of motion assessed using a goniometer showed an average 63.9° of wrist extension (range, 58°–80°), 59.8° of wrist flexion (range, 50°–72°), 87.4° of pronation (range, 70°–90°) and 87.4° of supination (range, 70°–90°). The range of motion according to the types is presented in Table 3.

Table 3
Range of Motion Compared with the Contralateral Side at Final Follow-up

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Ten patients (2 type 1, 4 type 2, and 4 type 3) underwent plate removal within the follow-up period because of pain (2 type 3) or by patient request (2 type 1, 4 type 2, and 2 type 3). The postoperative complication rate was relatively low with no cases of nonunion, no deep infections, no tendon injuries, and no major nerve or vessel injuries. Three complications occurred in this study. One patient had a mild wound infection after a combined volar and dorsal locking plate placement. The patient was treated with drainage under local anaesthesia and intravenous antibiotics. The other two patients complained of chronic wrist pain, which was improved after implant removal. No patients complained of stiffness of the fingers or suffered from complex regional pain syndrome.

In the present study, after fixation of the volar locking plate in DRFs, an additional dorsal approach was performed to remove intra-articular fragments or distally migrated dorsal fragments and restore articular congruency. Certain fracture patterns including dorsal shear fractures (dorsal Barton) or “die-punch” fractures could be stabilised with dorsal plate fixation alone; thus, these types of fractures were not included in our cohort. The combined approach for DRFs allowed our patients to gain satisfactory radiographic and clinical outcomes. There were no cases of tendinitis, tendon rupture, or deep infection in this cohort, despite these being known as possible complications.3, 5) Based on the Garland and Werley scoring system, 88% of patients had either good or excellent functional outcomes, which were similar to the results of Iselin et al.,4) who reported that postoperative median grip strength was 107% of the contralateral side, and the median DASH score and patient-rated wrist evaluation (PRWE) were 2.3 and 6, respectively, at 10 years of follow-up. These results support the safety of this surgical approach with minimal adverse effect. However, there are a number of limitations obviating the ability to directly compare our outcomes to those of other studies because of differences in the inclusion criteria. For instance, most of the type 1 or type 2 fractures based on our classification system were less severe injuries than the complex DRFs providing the main indications for a combined approach in many previous studies.

The combined volar and dorsal plate approach is known to be a useful method for patients with severely comminuted or displaced intra-articular fractures. Ring et al.6) reported that combined volar and dorsal plate fixation could achieve a stable but mobile wrist in patients that have very complex DRFs with extensive metaphyseal comminution. Day et al.3) introduced the “sandwich” plating technique, which refers to a combined volar and dorsal plating that was an effective method for intra-articular fractures with volar and dorsal comminution. Medlock et al.5) also reported that combined volar and dorsal plating can provide a functioning wrist in patients with multifragmentary intra-articular DRFs. A review of the literature involving smaller studies demonstrated that most of the combined approach techniques were performed in complex DRFs and this technique focused on the reduction and fixation of displaced articular fractures.3, 5, 6, 11) In our investigation, the combined approach was a useful method in cases other than complex DRFs (Table 4).

Table 4
Summary of Studies on the Combined Approach for Distal Radius Fractures

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According to our classification system, type 3 fractures refer to complex DRFs that, in many previous reports, have presented good indications for the combined approach. Dorsoulnar fragments that are part of the lunate fossa were usually reduced by the indirect method, and even for intra-articular fractures, an indirect reduction by a volar approach is possible with an accurate reduction of the metaphysis.12) However, when this fragment was comminuted, impacted into the joint, or was significantly distally displaced, it was difficult to reduce by an indirect method. In these cases, an additional dorsal approach is necessary.13) Displaced dorsal rim fractures that affect the posterior articular surface of the distal radius were sometimes observed after volar locking fixation. One study reported that a displaced dorsal rim fracture does not adversely affect the outcomes after volar plate fixation.14) Therefore, unstable DRFs combined with displaced dorsal rim fragments were not classified as type 3 fractures in our study.

To our knowledge, there were few studies that have investigated the effects of intra-articular free fragments or distal migration of dorsal fragments on clinical outcomes. If an intra-articular free fragment is not removed from the joint, it could become a loose body and induce pain or locking symptoms.15, 16, 17) One case series reported that the majority of loose bodies were caused by traumatic events and could be removed via arthroscopy.16) In our study, the additional dorsal approach with a capsular incision was used to excise intra-articular fragments. Distal migration of dorsal fragments was often seen in DRFs, especially in those with a comminuted dorsal cortex. We treated 4 patients who had unstable DRFs and distal migration of dorsal fragments using volar locking fixation alone. Although a comparative study could not be performed due to the small sample size, all patients had persistent dorsal side pain especially in the dorsiflexion position.

Type 1, 2, and 3 are all situations in which an arthroscopic approach can be considered instead of a dorsal approach after the volar approach. Wrist arthroscopy is recognized as an important adjunctive procedure in the management of DRF because arthroscopically assisted reduction provides excellent visualization of the articular condition.18, 19, 20, 21) However, performing wrist arthroscopy during volar plating seems to be troublesome. Thus, plate presetting arthroscopic reduction technique has been recently introduced.18, 22) A volar locking plate is preset by inserting subchondral wires and a screw at the dynamic hole. After the volar locking plate is preset, wrist arthroscopy is performed in vertical traction. After achieving reduction of the fragment, volar locking plate is subsequently and securely fixed to the distal radius. Although arthroscopically assisted reduction achieved satisfactory outcome in many previous studies, we thought dorsal plating is necessary to maintain reduction and firm fixation of the dorsal fragment especially in type 3. Hence, we used the combined approach in the present study.

Some limitations of this study require consideration. The main limitation is that there was no control group for treatment outcomes between the classification types or treatment methods. Furthermore, reliability testing was not performed in the current study. Thus, comparison with other treatment methods could not be performed. After a volar approach, wrist arthroscopy can be used instead of a dorsal approach. Future research will be necessary to compare the combined approach and volar plating with an arthroscopic approach.

Despite these limitations, our study has some strength. First, to the best of our knowledge, this is the first report to suggest and classify the indications for a combined approach in the treatment of DRFs. Second, we reported the outcomes for excision of intra-articular fragments and distally migrated dorsal fragments after fixation of the volar locking plate. Even though this was a case series and a retrospective study, our study demonstrated the indication for an additional dorsal approach based on the location of the fracture fragments and comminution of intra-articular fractures.

In conclusion, the classification system described in this article identified the situations when an additional dorsal approach is needed in unstable DRFs and may establish useful guidelines for appropriate surgical decisionmaking in the future.