1. Patients

Among patients presenting with severe comminuted fractures of the metadiaphysis associated with intra-articular fractures, between March 2015 and March 2017 at Department of Orthopaedic Surgery in our hospital, a total of 12 underwent open reduction and plate fixation using volar locking compression plates and reduction plates using the anterior approaches. These patients were recruited for this study and were followed up for ≥1 year. The participants included 8 male and 4 female patients having a mean age of 55.4 years (range, 28–77 years). The injury causes included falls (6 patients), slips (3 patients), and crush injuries (3 patients); 7 presented with open fractures. The AO classification of fracture type and site revealed that 5 cases were C2 and 7 were C3. Ten cases required the use of 1.5-mm miniplates, 3 cases required 2.0-mm plates, and 1 case required both sizes of miniplates. The study design and data collection were approved by the institutional review board of the Human Experimental and Ethics Committee of Gachon University Gil Medical Center (IRB No: GCIRB2019-186). The patients and/or their families were informed that data from their case would be submitted for publication, and gave their consent.

2. Methods

The surgical plans were based on the initial simple radiographs that indicated whether fracture comminution was severe enough to require reduction plates, and on 3-dimensional computed tomography (CT) to verify the fracture pattern. While planning the surgery, each fragment was numbered; the reduction sequence, method, and volar locking and reduction plate locations were determined (Fig. 1). A modified anterior Henry approach was used with the patient under general anesthesia. The flexor carpi radialis was palpated, the skin over it was incised approximately 5 to 8 cm, and a vertical incision of the fascia was carefully created, inferior to the flexor carpi radialis, to prevent damage to the radial artery and the median nerve palmar branch. Traction of the flexor pollicis longus toward the ulna was performed, the pronator quadratus was longitudinally incised from the radial side, the fracture site was dissected according to the CT findings, and the reductions were completed (Fig. 1,2). In open fracture cases, the plate was not initially fixed and an external fixator was temporarily used after thorough debridement and irrigation. Plate fixation was attempted within 2 weeks after the injury, when the wound had healed without evidence of infection (Fig. 3,4).

Fig. 1
A 55-year-old male (patient No. 8) visited the emergency room with a distal radial fracture due to a 2-m fall. (A) Preoperative computed tomography allowed the numbering of each fragment. (B) Following the anterior Henry approach, (C) fragments 1 and 5 were reduced using 1.5-mm miniplates for radial height restoration, and (D) fragments 4 and 5 were reduced using 2.0-mm miniplates.

• Download Figure

Fig. 2
Intraoperative image obtained using an image intensifier. (A, B) Miniplate was used as a reduction plate. (C) Volar locking plate was used as a definitive fixation plate.

• Download Figure

Fig. 3
(A) Anteroposterior and (B) lateral radiographs, (C) clinical image, and (D) computed tomography image of the wrist of a 59-year-old male (patient No. 11) with a metadiaphyseal comminuted distal radial open fracture (Gustilo-Anderson classification IIIA) due to a crush injury. The associated injuries include metacarpal fractures 3, 4, and 5 and an ulnar styloid process fracture.

• Download Figure

Fig. 4
Meticulous debridement and irrigation were performed on the day of admission, and an external fixator was applied to the fracture site. (A) Two weeks later, definitive surgery was performed when the soft tissue was healed and infection is not evident. (B) Secure surgical fixation of the small metadiaphyseal comminuted fragments involves the use of a miniplate, (C) image intensifier confirmation, and (D) fixation using a definitive plate.

• Download Figure

Per the individual preoperative plan, the metadiaphysis was fixed using 1.5- or 2.0-mm miniplate reduction plates (DePuy Synthes, Paoli, PA, USA); pointed reduction forceps for fragments or K-wires were used after reduction. In cases involving very small fragments or the cortical bone only, direct reduction plate fixation was performed using a Hohmann retractor and manual traction to minimize soft tissue damage. Among the various fragments, those that were essential for radial length recovery were reduced first (Fig. 1C, fragments 1 and 5); the remaining fragments were reduced and fixed according to the surgical plan (Fig. 1D, fragments 4 and 5). During the reduction, as much of the periosteum as possible was left attached to the fragments; the overall reduction state was investigated, using an image intensifier, since a minimal incision was created to minimize soft tissue dissection (Fig. 2A, B). Following this provisional fixation, a volar locking plate was fixed to the appropriate location over the reduction plate (Fig. 2C). Allogenic bone grafts were used in 3 cases involving severe bony defects. Each fracture site was splinted using a short-arm cast for 2 weeks after the surgical treatment, and each patient wore an orthosis for 2 weeks and performed active joint motion 2 to 3 times daily, with a gradually increasing range of joint motion.

3. Treatment outcome evaluation

Radiographs, anteroposterior and lateral views, of the wrist joint were obtained before and after surgery and at the final follow-up. These were used to determine the radial length, radial inclination, volar tilt, and radial distal intraarticular step-off. To evaluate the clinical outcomes, pain, ability to return to work, range of joint motion, and muscular strength were measured; comprehensive evaluations were also performed using the modified Mayo wrist score (MMWS).

The Wilcoxon signed rank test was performed as a nonparametric test of the radiological results, preoperatively, postoperatively, and at the final follow-up; a p-value <0.05 was considered significant (IBM SPSS Statistics ver. 20.0; IBM Corp., Armonk, NY, USA).

1. Radiological outcomes

The average follow-up period was 14.9 months, with complication-free bone union being achieved in all 12 cases at a mean of 6.8 months. The average radial length, radial inclination, and volar tilt increased from their preoperative values to their postoperative values, then remained relatively constant over the duration of the follow-up. Similarly, the average radial distal intra-articular step-off improved from its preoperative value to its postoperative value, and also remained relatively constant throughout the follow-up period. The differences between the postoperative and final followup values for radial length, radial inclination, volar tilt, and radial distal intra-articular step-off were not statistically significant (Table 1).

Table 1
Radiological Data for Distal Radial Fractures Treated Using Volar Locking Plates and Reduction Plates

• Download Table

2. Clinical outcomes

At the last follow-up visit, the patients had an average MMWS of 81.8 points, with the majority of patients (7) having fair scores (Table 2). The 7 patients with fair scores included 3 for whom accurate reductions were difficult to achieve due to severe bony defects, 3 with severe invasions of the fractures on the articular facet, and 1 requiring long-term fixation due to an associated scaphoid fracture. Furthermore, 5 of those cases involved open fractures with associated poor soft tissue condition; 2 cases had lower scores due the injuries being crush injuries.

Table 2
Demographics, Injury Types, and Treatment Information of the 12 Patients

• Download Table

Symptoms of postoperative median nerve compression were observed in 2 patients. One of the patients experienced improvement of the complication over time whereas the other experienced spontaneous regression. Carpal pain was reported in 3 cases, and finger flexor tenosynovitis was present in 2 patients; nevertheless, all patients recovered. Flexor stimulation or rupture, malunion, nonunion, or screw loosening were not noted in any patient.