Bibliography of the Distal Radius

This section of eRadius is a searchable database that is continually being updated and expanded. Use the search utility in the upper right hand corner to look for specific topics or papers, or scroll through to see what might interest you.

(If you would like to review papers, please contact Dr. Nelson via nelsondl followed by the "at" sign followed by pacbell.net)

Margaliot, Haas, et al A Meta-Analysis of Outcomes of External Fixation versus Plate Osteosynthesis for Unstable Distal Radius Fractures

Journal of Hand Surgery, Hand Surg [Am]. 2005 Nov;30(6):1185-99

A retrospective review was performed via MEDLINE and EMBASE for articles published between 1980 and 2004, yielding 46 articles covering 28 studies (916 patients) of external fixation and 18 studies (603 patients) with internal fixation. (Note: all the internal fixation studies were prior to 2004, so there were very few with volar plates, much less modern fixed-angle volar plates.) "Meta-analysis did not detect clinically or statistically significant differences in pooled grip strength, wrist range of motion, radiographic alignment, pain, and physician-rated outcomes between the 2 treatment arms. There were higher rates of infection, hardware failure, and neuritis with external fixation and higher rates of tendon complications and early hardware removal with internal fixation. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis." The authors concluded that "The current literature offers no evidence to support the use of internal fixation over external fixation for unstable distal radius fractures. Comparative trials using appropriately sensitive and validated outcome measurements are needed to guide treatment decisions."

Comment It is important that we recognize the limits of literature support for many of the choices that we make, and a negative study like this one is quite valuable. To know that we don't know is powerful knowledge. We need to perform Level I studies, if at all possible, if we are to make progress in the science and art of distal radius fracture management.

It is also important to recognize the limits of the present study: the papers reviewed are substantially out of date. That is, given the rapid change in distal radius fracture management, studies that are only a few years old probably don't tell us much about current treatment outcomes. "Internal fixation" until recently meant dorsal plates, with their high complication rates and long operative times. Volar plating, while not perfect, is quite a different treatment. We are still learning about its complications (intraarticular screw placement, long screw placement). However, not much will be learned by a study that lumps volar plating with dorsal plating. In addition, as the authors point out (page 1195), their finding of lack of diffence may be due to a true lack of differnce between the two methods, or a lack of sensitivity of their method of measurement. This is a good study, one that should be read, but it may not help us much when faced with a patient in the ER with a displaced distal radius fracture and we need to decide what treatment we should recommend.

Knirk, JL and Jupiter, J Intra-articular fractures of the distal end of the radius in young adults.

Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnar styloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.

Comment This paper is probably the most widely cited modern paper on distal radius fractures. What is disconcerting about this is the fact that Dr. Jupiter has repeatedly stated that the paper overstates the case between arthritis and intraarticular stepoff. Specifically, he has stated that the close correlation between stepoff as seen on plain radiographs and the development of arthritis as stated in the paper is incorrect. The paper has a number of limitations, including:

(1) The four-step classification of stepoff (Grade 1: 0-1 mm, Grade 2: 1-2 mm, ...) contains an error. Where do you place a 1 mm stepoff? Grade 1 or 2?

(2) Plain radiographs have been shown to poorly differentiate stepoffs on the order of 1 mm

(3) It was a retrospective, radiographic study. They did not have any information on the ligamentous injuries of these patients, which injuries may be more important than simple stepoff measurements.

Dr. Jupiter has stated that if there was only one paper he could un-write, it would be this one.

I think, however, that it is important to recognize the importance of the paper, notwithstanding its limitations. If you examine the history of distal radius fractures, Dr. Jupiter showed both intellectual courage and scientific insight when he broke with the consensus of history and first brought to our attention the need to accurately reduce these fractures. While there may not be a close association between any particular amount of stepoff and the development of post-traumatic arthritis, it is the general consensus of all researchers in this area that accurate articular restoration is an important factor, if not "the most critical factor", in achieving a successful result. (reviewed by David Nelson, MD)

Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report.

Orbay JL, Fernandez DL.
Miami Hand Center, Miami, FL 33176, USA.

J Hand Surg [Am] 2002 Mar;27(2):205-15

Using a volar approach to avoid the soft tissue problems associated with dorsal plating, we treated a consecutive series of 29 patients with 31 dorsally displaced, unstable distal radial fractures with a new fixed-angle internal fixation device. At a minimal follow-up time of 12 months the fractures had healed with highly satisfactory radiographic and functional results. The final volar tilt averaged 5
degrees; radial inclination, 21 degrees; radial shortening, 1 mm; and articular incongruity, 0 mm. Wrist motion at final follow-up examination averaged 59 degrees extension, 57 degrees flexion, 27 degrees ulnar deviation, 17 degrees radial deviation, 80 degrees pronation, and 78 degrees supination. Grip strength was 79% of the contralateral side. The overall outcome according to the Gartland
and Werley scales showed 19 excellent and 12 good results. Our experience indicates that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. The combination of stable internal fixation with the preservation of the dorsal soft tissues resulted in rapid fracture healing, reduced need for bone grafting, and low incidence of tendon problems in our study.