Small volar fragment in the lunate fossa leads to volar tilt loss after volar plate fixation for AO/OTA type-C distal radius fracture.

OBJECTIVES: The relationship between volar fragment size and postoperative volar tilt loss in complete articular distal radius fracture is not well known. In this study, we measured precise radiological parameters to help identify other factors that might contribute to volar tilt loss. MATERIAL AND METHODS: We retrospectively reviewed the radiological examinations and charts of 256 patients with distal radial fracture who underwent volar locking plate fixation between March 2014 and July 2022. Radiological parameters were measured based on preoperative CT and immediate postoperative radiographs. Univariate and multivariate linear regression analysis was performed to identify relevant factors associated with volar tilt loss following volar locking plate fixation. The receiver operating characteristic curve was used to identify the cutoff value of the independent parameters. RESULTS: On univariate analysis, 2 radiologic parameters on preoperative CT (volar fragment length at the lunate fossa, and teardrop angle) and 4 on immediate postoperative X-ray (radial inclination, radial length, capitate shift, and volar tilt) were significantly associated with postoperative volar tilt loss. On multivariate linear regression analysis, the risk of volar tilt loss increased as the capitate moved toward the back of the radial shaft. The cut-off for anteroposterior length in the lunate fossa was 6.5 mm. CONCLUSIONS: AO/OTA type-C distal radius fractures with <6.5 mm anteroposterior length in the lunate fossa had significantly higher rates of malunion with dorsal deformity. In addition, preoperative teardrop angle <37.2 ° and immediate postoperative volar tilt <3.7º are also predictors of postoperative volar tilt loss.

Relation between the dash score and radiographic evaluation of the wrist in patients with wrist fracture.

Traditionally, the assessment of distal radius fracture outcomes has been based on radiological measurements and self-evaluation scores. However, there is uncertainty regarding how accurately these measurements reflect the patient's perception of their outcome. In this study, we examined the correlation between radiological measurements and patient-perceived outcomes using the Disabilities of the Arm, Shoulder, and Hand outcome (DASH) score. 140 individuals who had recovered from a distal radius fracture. and had been treated with DVR, Kapandji, percutaneous pinning or closed reduction were included in the study. The retrospective assessment included 78 females and 62 males, with a mean DASH score of 3.54 points.Except for the ulnar variance, the study found little to no significant association between the DASH score and the final radiological measurement.In summary, the DASH score did not always indicate that a superior radiological result translated into a better patient-perceived outcome.

A comparison of 3-D CT and 2-D plain radiograph measurements of the wrist in extra-articular malunited fractures of the distal radius.

Two-dimensional (2-D) plain radiographs may be insufficient for the evaluation of distal radial malunion, as it is a three-dimensional (3-D) deformity. This study introduced a 3-D measuring method that outputs radial inclination, ulnar variance, palmar tilt and axial rotation. To this end, a standardized and clearly defined coordinate system was constructed that allowed 3-D measurements closely resembling the conventional 2-D method in 35 patients. Mean differences between 3-D and 2-D measurements in affected wrists were 1.8° for radial inclination, 0.8 mm for ulnar variance and 3.7° for palmar tilt. In addition, inter- and intra-observer reproducibility of all 3-D and 2-D measurements were good or excellent (intraclass correlation coefficient >0.75), with 3-D reproducibility always better than 2-D. Axial rotation was present in all patients with a mean of 7.9° (SD 6.9). Although the differences between 2-D and 3-D measurements were small, 3-D evaluation enables the assessment of axial rotation and brings us closer to a routine 3-D evaluation of malunion.Level of evidence: III.

A simple tool for volar tilt restoration during volar plate osteosynthesis of distal radius fracture: A technical note.

Anatomical restoration of volar tilt is a technical challenge in a displaced distal radius fracture with a dorsally angulated fracture pattern accompanied by dorsal metaphyseal comminution. We adopted a reduction technique using a mini-Hohmann retractor, to accomplish the desired volar tilt in a controlled fashion. We would like to present this technical note through a case example describing the technique specifics along with one-year postoperative outcomes.

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE: Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome. METHODS: The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°. RESULTS: A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups. CONCLUSION: According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

Mathematical model of distal radius orientation.

Distal radius orientation is important in evaluating Colles' fracture. In most cases, the wrist was protected by a bandage, splint, or cast. Therefore, it was difficult for the radiology technician to take perfect anteroposterior and lateral view radiographs. In this study, we build a mathematical model and calculate the pronation angle needed to produce dorsal tilt, which is a volar tilt in a perfect lateral view radiograph. The formulas are all incorporated into Excel to facilitate usage.

Total Wrist Arthroplasty Alignment and Its Potential Association with Clinical Outcomes.

Purpose There is a lack of quantitative research that describes the alignment and, more importantly, the effects of malalignment on total wrist arthroplasty (TWA). The main goal of this pilot study was to assess the alignment of TWA components in radiographic images and compare them with measures computed by three-dimensional analysis. Using these measures, we then determined if malalignment is associated with range of motion (ROM) or clinical outcomes (PRWHE, PROMIS, QuickDash, and grip strength). Methods Six osteoarthritic patients with a single type of TWA were recruited. Radiographic images, computed tomography images, and clinical outcomes of the wrists were recorded. Using posteroanterior and lateral radiographs, alignment measurements were defined for the radial and carpal components. Radiographic measurements were validated with models reconstructed from computed tomography images using Bland-Altman analysis. Biplanar videoradiography (<1mm and <1 degree accuracy) was used to capture and compute ROM of the TWA components. Linear regression assessed the associations between alignment and outcomes. Results Radiographic measures had a 95% limit-of-agreement (mean difference ± 1.96 × SD) of 3 degrees and 3mm with three-dimensional values, except for the measures of the carpal component in the lateral view. In our small cohort, wrist flexion-extension and radial-ulnar deviation were correlated with volar-dorsal tilt and volar-dorsal offset of the radial component and demonstrated a ROM increase of 3.7 and 1.6 degrees per degree increase in volar tilt, and 10.8 and 4.2 degrees per every millimeter increase in volar offset. The carpal component's higher volar tilt was also associated with improvements in patient-reported pain. Conclusions We determined metrics describing the alignment of TWA, and found the volar tilt and volar offset of the radial component could potentially influence the replaced wrist's ROM. Clinical Relevance TWA component alignment can be measured reliably in radiographs, and may be associated with clinical outcomes. Future studies must evaluate its role in a larger cohort.

Changes in the Rate of Postoperative Flexor Tendon Rupture in Patients with Distal Radius Fractures.

Background: Flexor tendon rupture is a major complication after volar locking plating for distal radius fracture (DRF). Few studies have investigated changes in the rate of postoperative flexor tendon rupture in patients with DRFs. The present study aimed to investigate the changes in the rate of postoperative flexor tendon rupture and to assess plate placement and reduction positions. Methods: We retrospectively reviewed patients in whom more than 24 months had passed since DRF surgery. The patients were interviewed by telephone. Forty-nine patients (50 fractures; 2007-2009) from institution A were included in group 1 and 81 patients (84 fractures; 2013-2016) from institution B were included in group 2. The DRF surgery method was similar between the two groups. The rate of flexor tendon rupture, Soong classification grade, and radiological index (i.e., volar tilt [VT], radial inclination [RI], and ulnar variance [UV]) were statistically investigated in both groups. Results: Patient epidemiology was not significantly different between the two groups. The flexor tendon rupture rates were 2% and 0% in groups 1 and 2, respectively, without a significant difference. With regard to the Soong grade, 44 fractures were grade 2 and 6 were grade 1 in group 1, whereas 18 were grade 2, 38 were grade 1, and 28 were grade 0 in group 2, with a significant difference (p < 0.05). With regard to the radiological index, the mean VT values were 5° and 11° in groups 1 and 2, respectively, with a significant difference (p < 0.05). However, RI and UV showed no significant difference. Conclusions: Plate placement and reduction positions, which are risk factors for flexor tendon ruptures after DRFs, have improved recently when compared with previous findings. With these changes, the rate of flexor tendon rupture is presumed to have decreased.

Radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients.

BACKGROUND: To determine the radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients, we compared the radiographic parameters of the wrists between carpal tunnel syndrome patients and non-symptomatic controls. METHODS: We evaluated radiographic parameters of 94 wrists of 62 idiopathic carpal tunnel syndrome patients and 94 asymptomatic wrists of 94 controls. Carpal tunnel syndrome was diagnosed by clinical findings and nerve conduction studies. The lack of symptoms was confirmed with the medical records and interviews for the controls. X-ray images of the postero-anterior and lateral views of the wrist were taken. Using the obtained X-ray images, the indices of radial inclination, volar tilt, ulnar variance, and transverse and antero-posterior diameters of the wrists were measured. Two raters independently performed the measurement. One rater measured without information of clinical symptoms. Inter-rater reliabilities for each parameter were evaluated by the intra-class correlation coefficients. The averages of the measurements of two raters were compared between the carpal tunnel syndrome patients and the controls. RESULTS: The intra-class correlation coefficients were 0.58 for radial inclination, 0.77 for ulnar variance, 0.99 for transverse diameter, 0.60 for volar tilt, and 0.91 for antero-posterior diameter. Statistically significant correlations were found for all parameters (P < 0.01). The ulnar variance was significantly larger in the carpal tunnel syndrome patients compared to the controls (1.7 +/- 1.8 mm and 0.8 +/- 1.5 mm for the patients and controls, respectively P < 0.01). There were no significant differences in the other parameters. CONCLUSIONS: Significant differences in the ulnar variance were observed between carpal tunnel syndrome patients and controls. This suggests that the imbalance of radioulnar bone length is one of the risk factors to develop carpal tunnel syndrome. The positive ulnar variance may be an index that needs attention to the development of carpal tunnel syndrome. LEVEL OF EVIDENCE: level III, a case control study.

Use of a Large Tenaculum Clamp as a Reduction Technique for Treatment of Distal Radius Fractures.

Distal radius fractures are common upper extremity injuries requiring surgical treatment. In the context of management with a volar locking plate (VLP), a number of described techniques assist with restoration of individual anatomical parameters such as radial length, volar tilt, and articular congruity. We present a surgical technique that utilizes a large tenaculum bone clamp to provide an efficacious reduction in several planes. With anteroposterior compression, the clamp enables volar translation of the distal fracture fragment. This compression also decreases the interval between the distal portion of the VLP and the fracture fragments. With a rotational force, the clamp can restore volar tilt of the articular surface. By positioning the tines of the clamp across the fracture in the coronal plane, a clamping force can correct medial or lateral translation of the distal fracture fragment. Proper reduction substantially minimizes complications such as abrasion or rupture of the flexor tendons along the VLP.

Radiologic Evaluation of the Distal Radius Indices in Early And Late Childhood.

The osseous anatomy of the distal radius is well documented in adults. Three commonly discussed variables are the volar tilt (also known as palmar tilt or palmar inclination), radial inclination, and radial height. These values are not well defined in the growing skeleton. We studied the radiographic measurements of normal distal radius osseous anatomy in children and identified how these values change with age. 372 patients (215 males and 157 females) between the ages of 8 and 16 were included in the study. Normal values of volar tilt, radial inclination, and radial epiphyseal height were defined for each age group. Regression analysis showed that volar tilt increased significantly by increase in age (P <0.001). Radial inclination and radial epiphyseal height both showed significant increase with increase in age (P<0.001). This is the first study to define these radiographic values in children and their change with age.

Radiographic analysis of anatomic risk factors for scaphoid fractures; A case-control study.

AIM: The purpose of this study was to investigate the role of anatomic variations in distal radius radiographic indices in patients with or without scaphoid fractures. MATERIALS AND METHODS: Radial inclination (RI), volar tilt (VT), radial height (RH) and ulnar variance (UV) were measured on wrist radiographs of 320 patients with (Group I, n = 167) or without (Group II, n = 153) scaphoid fracture, fall on outstretched hand (FOOSH). Receiver operating characteristics (ROC) curve analysis was used to assess the diagnostic performance for each variable. Sensitivity (Sn), specificity (Sp), cutoff value, and area under the ROC curve were analyzed. Odds ratio was calculated for defined cutoff values. RESULTS: The mean age of the groups was similar (29.3 ±â€¯10.2 vs 31.1 ±â€¯9.9 years, p = 0.060). RI (30.0 ±â€¯2.9 vs 26.8 ±â€¯2.3°) VT (11.4 ±â€¯2.4 vs 10.5 ±â€¯2.2°), RH (14.8 ±â€¯2.1 vs 13.2 ±â€¯1.9 mm), UV (-0.46 ±â€¯1.7 vs 0.00 ±â€¯1.5 mm) were higher in scaphoid fracture group (Gr I vs Gr II, p = 0.000, p = 0.000, p = 0.001, p = 0.012 respectively). Ulna minus variant was more prevalent in fracture group (p = 0.001). Optimal cutoff points for RI, VT, RH and UV in differentiating fractured and intact scaphoid were 28.6° (Sn = 81.0%, Sp = 26.3%), 12.2° (Sn = 80.4%, Sp = 67.1%), 14.85 mm (Sn = 80.4%, Sp = 52.1%) and 0 mm (Sn = 88.6%, Sp = 75.8%), respectively. Odds ratios for defined cutoff points for RI, VT, RH and UV were 10.4 (95% CI, 6.2-17.4), 1.8 (95% CI, 1.1-3.0), 3.7 (95% CI, 2.3-6.2) and 2.2 (95% CI, 1.3-3.7) respectively. CONCLUSION: Increased RI, VT, RH and negative UV were found to be predisposing anatomical risk factors for scaphoid fracture when FOOSH.

Lift-Off Screw Results in Accurate Sagittal Tilt Correction in a Distal Radius Fracture Model.

PURPOSE: To determine the accuracy of a distal-first open reduction internal plate fixation technique in achieving correction of volar tilt in dorsally angulated distal radius fractures. METHODS: Twenty foam radius models were divided evenly into groups N (normal) and O (osteoporotic). Dorsally angulated extra-articular distal radius fractures were then created. Group O underwent further modification to simulate an osteoporotic model. After static pinning in various degrees of dorsal angulation, opaque fiducial markers were placed and fluoroscopy was used to measure prereduction volar tilt. A variation of the distal-first plate application technique was used where a lift-off screw (LOS) was placed in the proximal most locking hole and propped the proximal aspect of the plate by the screw's length. The LOS length corresponded to the volar tilt correction needed. After fracture reduction using this technique, we measured the volar tilt again. We then compared the actual volar tilt correction with what was predicted based on the LOS length used. We also compared the tilt correction accuracy in the normal and osteoporotic models. RESULTS: Prereduction tilt ranged from 3° to 52° of dorsal tilt from normal (10° volar tilt). Corresponding LOSs ranged from 5 to 42 mm in length. Tilt correction correlated with screw length in a linear fashion (R = 0.9). The mean difference between actual and predicted tilt correction for a given screw length was 0.5° ± 3.0°, and the mean absolute difference was 2.4° ± 1.7° for all specimens. There was no difference between normal and osteoporotic models. CONCLUSIONS: Prereduction dorsal tilt can be accurately corrected within a few degrees of the goal by using the distal-first technique with an LOS. The LOS length can be calculated, and this technique can potentially be used with any distal radius periarticular locking plate with locking options in the shaft. CLINICAL RELEVANCE: A technique that provides accurate tilt correction would be of benefit to surgeons treating distal radius fractures with volar plates.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation.

PURPOSE: To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model. METHODS: We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique. RESULTS: Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation. CONCLUSIONS: A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction. CLINICAL RELEVANCE: External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Trigonometry-Integrated 'Lift' Technique (TILT) for Restoring Volar Tilt in Distal Radius Fractures: Description of Technique and Preliminary Results.

BACKGROUND: Restoration of extra-articular and intra-articular parameters are important considerations during operative fixation of distal radius fractures. Restoration of volar tilt by using visual estimation and the 'lift' technique has previously been described. The aim of our study was to describe a mathematical technique for accurately restoring the volar tilt of the distal radius to acceptable anatomic values. METHODS: A retrospective review of cases performed using the trigonometry-integrated ' lift' technique (TILT) was performed. This technique uses the pre-operative volar tilt angle as well as the dimensions of the implant to calculate the 'lift' required to restore volar tilt. Intra-operative angles were measured using a marked transparency overlay on fluoroscopic images. Pre-operative and post-operative volar tilt were measured and analysed. RESULTS: Twenty-seven fractures were included in the study, with 20 being classified as Arbeitsgemeinschaft für Osteosynthesefragen (AO) C-type. Pre-'lift' volar tilt ranged from 0° to -20°. Post-'lift' volar tilt ranged from 2° to 16°, with all but three cases ranging from 5° to 15°. The mean volar tilt achieved was 10.2°. CONCLUSIONS: The trigonometry-integrated 'lift' technique resulted in reliable intra-operative restoration of anatomic volar tilt in distal radius fractures.

Anatomic Variation in Volar Tilt of the Scaphoid and Lunate Facet of the Distal Radius.

PURPOSE: The aim of distal radial fracture treatment is to achieve optimal function through the restoration of normal anatomy, including volar tilt. The accuracy of assessing volar tilt on standard lateral radiographs compared with anatomic tilt lateral (ATL) radiographs is uncertain. This study aimed to investigate the anatomy of the articular surface of the distal radius, in particular measuring the angle between the dorsal and volar rims at several points from radial to ulnar, to ascertain whether volar tilt is uniform between the scaphoid and lunate facet and to explore consistency between standard lateral and ATL views. METHODS: We studied 38 dry cadaveric specimens of radii. The distal articular surface of each specimen was marked at 5 intervals and placed in a customized jig. A 1.5-mm stylus was placed at each marker to represent the articular surface angle, and was photographed in standard lateral and ATL projections. An on-screen protractor was used to measure each angle from the digital photographs. RESULTS: The volar tilt measurements at the lunate facet demonstrated a significantly shallower angle than those at the scaphoid facet. The measurements between the standard lateral and ATL were found to have no significant difference. CONCLUSIONS: Adjusting the projection angle between a simulated standard lateral and ATL view did not significantly change the volar tilt measurements in this anatomic study. The lunate facet was found to have a significantly shallower volar tilt than the scaphoid facet. Variance in radiographic volar tilt may relate to different anatomic sagittal planes, reflecting the anatomic variation between the scaphoid and lunate facets. CLINICAL RELEVANCE: A detailed understanding of distal radius anatomy is required by the surgeon for accurate radiologic interpretation and anatomic fracture reduction and fixation.

Optimal Positioning for Volar Plate Fixation of a Distal Radius Fracture: Determining the Distal Dorsal Cortical Distance.

Distal radius fractures are currently among the most common fractures of the musculoskeletal system. With a population that is living longer, being more active, and the increasing incidence of osteoporosis, these injuries will continue to become increasingly prevalent. When operative fixation is indicated, the volar locking plate has recently become the treatment of choice. However, despite its success, suboptimal position of the volar locking plate can still result in radiographic loss of reduction. The distal dorsal cortical distance is being introduced as an intraoperative radiographic tool to help optimize plate position and minimize late loss of fracture reduction.

Intra-operative correction of volar tilt of distal radius fractures using volar locking plate as reduction tool: review of 24 cases.

In surgical fixation of distal radius fractures with metaphyseal comminution, volar tilt can be restored using an anatomical volar locking plate as a reduction tool. The purpose of our study is to assess the degree of over or under correction of volar tilt that can result with our 'lift' technique and to determine the ratio between theoretical and actual angular correction. We retrospectively reviewed 24 patients who underwent distal radius fracture fixation using this technique and assessed intra-operative radiographs for parameters including pre-'lift' and post-'lift' volar tilt and pre-'lift' plate-shaft angles. The ratio between actual angular correction and theoretical angular correction was calculated. The 'lift' technique is found to be reliable in restoring volar tilt in most fractures. Over- or under-correction does occur due to errors in visual estimation and actual angular correction is generally less than the theoretical angular correction.

Factors Predicting Late Collapse of Distal Radius Fractures

Background: Although fractures of the distal radius are a common clinical presentation, many factors affect instability of these injuries. The aim of this study was to assess the influence of age, sex, distal radial ulnar joint injury (DRUJ), ulnar styloid fracture, and dorsal displacement in late collapse of distal radius fractures. Methods: Three hundred twenty-nine patient fractures were measured for dorsal tilt, radial inclination and ulnar variance after reduction and 2 months later. Reduction loss was analysed statistically against variables like DRUJ involvement, ulnar styloid fractures, age, sex, and AO classification. Results: After two months there was loss of reduction in 171(51.9%) cases. Loss of reduction was related to age, AO classification, involvement of DRUJ, ulnar styloid fractures and initial displacement. Conclusions: Factors such as age, associated DRUJ injury, ulnar styloid fracture are predictive of loss of reduction. Knowing these predictor factors, can aid in decision regarding treatment methods.

A Radiological Study of Normal Wrist in Korean People / 대한정형외과학회잡지

The carpal injury is difficult to diagnose due to anatomical complexity and the like. So, in order to get radiological knowledge of normal wrist, the authors measured the values which will be described on the wrist PA and lateral roengenogram obtained from 440 normal wrists(male : 188 cases, female : 252 cases) in randomly selected patients. The following results were obtained. l. Ulnar variance(mm±standard deviation): Total 1.1±1.2 : negative variance : 9.3%, positive variance : 56.1%, 2. Scapholunate Gap(mm±standard deviation): Total 0.4±0.7, 3. Ulnar Tilt(degrees±standard deviation): Total 23.6±5.3, 4. Volar Tilt, 5. Carpal height rstio : Total 0.52±0.05 male 0.53±0.04 female 0.51±0.05 : Total 13.1±5.9, 6. Carpal ulnsr distance ratio Total 0.05±0.05, 7. Scapholunate Angle : Total 49.9'±10.1', 8. Capitatolunate Angle Total 17.5'±10.0', 9. Radiolunate Angle Total 8.8'±6.7', 10. Carpal width ratio Total 0.72±0.08 11. Carpal thickness ratio Total 0.49±0.07.