Hand & Wrist

ABSTRACT

We evaluated postoperative pain control and narcotic usage after thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of the distal radius in patients given opiates with or without other non-opiate medication using a specific dosing regimen. A prospective, randomized study of 79 patients undergoing elective CMC arthroplasty or ORIF of the distal radius evaluated postoperative pain in the first 5 postoperative days. Patients were divided into 4 groups: Group 1, oxycodone and acetaminophen PRN; Group 2, oxycodone and acetaminophen with specific dosing; Group 3, oxycodone, acetaminophen, and OxyContin with specific dosing; and Group 4, oxycodone, acetaminophen, and ketorolac with specific dosing. During the first 5 postoperative days, we recorded pain levels according to a numeric pain scale, opioid usage, and complications. Although differences in our data did not reach statistical significance, overall pain scores, opioid usage, and complication rates were less prevalent in the oxycodone, acetaminophen, and ketorolac group. Postoperative pain following ambulatory hand and wrist surgery under regional anesthesia was more effectively controlled with fewer complications using a combination of oxycodone, acetaminophen, and ketorolac with a specific dosing regimen.

Continue to: Regional anesthesia...

Regional anesthesia is a safe and effective modality of perioperative pain control in patients undergoing ambulatory hand procedures.^1-10 Often, as the regional block wears off, patients experience a rebound pain effect that can be challenging to manage.

We sought to determine if an organized, multimodal approach in patients undergoing thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of distal radius fractures would provide better postoperative pain control. We hypothesized that this approach would significantly reduce postoperative pain and the need for narcotic pain medication compared with PRN dosing of oxycodone/acetaminophen alone.^11-14

MATERIALS AND METHODS

Our study was approved by our Institutional Review Board. Informed consent was obtained from each patient. Patients presenting for elective thumb CMC arthroplasty or ORIF of the distal radius were screened for inclusion in a prospective, randomized study. Inclusion criteria included patients aged 18 to 65 years who could provide informed consent. Patients with chronic pain syndromes, long-term narcotic usage, chronic medical conditions precluding the use of opiates or nonsteroidal anti-inflammatory drugs (NSAIDs), and those who did not have a complete sensory and motor block postoperatively were excluded.

Patients were randomly divided into 1 of 4 study arms. Randomization was performed via sealed envelopes, which were opened in the recovery area when postoperative prescriptions were written. The group distribution was as follows: Group 1, Percocet 5 mg/325 mg alone (control); Group 2, oxycodone 5 mg, acetaminophen 325 mg administered separately; Group 3, oxycodone 5 mg, acetaminophen 325 mg, and oxycodone SR (OxyContin) 10 mg; and Group 4, oxycodone 5 mg, acetaminophen 325 mg, and ketorolac (Toradol) 10 mg (Table 1). Patients in the control group were instructed to take 1 or 2 tablets every 4 to 6 hours as needed for pain. Patients in the 3 experimental groups were given detailed instructions regarding when and how to take their medications. All patients were instructed to take 650 mg of acetaminophen every 6 hours. Patients were provided a sliding scale to assist in dosing their opioid medications according to their numeric pain score (NPS) (Table 2). Group 2 patients were given oxycodone 10 mg in the postanesthesia care unit (PACU) and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Table 1. Patient Groups

Table 2. Sliding Scale for Pain Control in the Experimental Groups

Group 3 patients were given oxycodone 10 mg in the PACU and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours and OxyContin 10 mg every 12 hours on a scheduled basis until their block wore off, then dose themselves using NPS. Group 4 patients were given oxycodone 10 mg postoperatively and ketorolac 30 mg intravenously in the PACU and instructed to take oxycodone 10 mg, acetaminophen 650 mg, and ketorolac 10 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Patients were provided with a journal and asked to record their medication usage, NPS, and any adverse effects (nausea, vomiting, and uncontrolled pain were specifically mentioned) or complications for 5 days after their procedure. We also attempted to contact patients by telephone on each of the 5 days after their procedure to remind them to complete their logs. They were asked specifically if they were having difficulty with their medications. They were also asked specifically about nausea, vomiting, and over-sedation. If patients requested additional medication to help treat their pain, they were instructed to add an over-the-counter NSAID of their choice based on the label’s suggested dosing.

Continue to: All patients received a supraclavicular...

All patients received a supraclavicular brachial plexus block using 0.75% ropivacaine under the supervision of an attending anesthesiologist experienced in regional anesthesia. Patients underwent thumb CMC arthroplasty utilizing complete resection of the trapezium followed by abductor pollicis longus suspensionplasty under the supervision of 1 of 3 fellowship-trained hand surgeons. ORIF of the distal radius was completed utilizing a volar approach and distal radius locking plate under the supervision of 1 of 3 fellowship-trained hand surgeons.

Primary outcome measures were the total number of oxycodone tablets taken daily and the average daily NPS. Secondary outcomes measured included adverse effects as noted above and the need for a trip to the emergency department for unrelieved pain.

A power analysis was completed prior to the beginning of the study. To detect a difference of at least 1 on the NPS, we determined that 18 patients per group would provide 80% power. This was based on literature utilizing the visual analog scale (VAS), a 100-mm line on which patients can place a mark to describe the intensity of their pain. The standard deviation on the VAS is approximately 15 mm. To account for potential dropout, we elected to recruit 20 patients per group. Non-paired t tests were used to compare groups.

RESULTS

One hundred and eighteen patients enrolled in the study. Of those, 79 patients completed and returned their summary logs (by group: 18 control, 20 oxycodone, 17 OxyContin, and 24 ketorolac). The remaining patients were excluded from the final analysis because they did not return their summary logs. Only 1 patient was excluded from the analysis because he did not have adequate regional anesthesia. Demographic data were analyzed and showed no significant differences between groups at the P < .05 level of significance. Surgical procedures were completed by 3 fellowship-trained hand surgeons. Distal radius fractures were performed using a volar approach. CMC arthroplasty was performed using a procedure that was standardized across surgeons. There were no between-surgeon differences in outcomes.

Average daily NPS (Figure 1) and the total number of oxycodone tablets taken (Figure 2) over the 5-day study period were recorded. Patients in the ketorolac group used fewer oxycodone tablets (19.3) than patients in the other 3 groups (24.4), P =.11, but the difference was not statistically significant. The maximum number of oxycodone tablets used was 71 in the Percocet group, 57 in the oxycodone and ketorolac groups, and 73 in the OxyContin group. The average daily NPS was lower in the ketorolac group during the period of medication use. This value only reached statistical significance on postoperative day 0 when the ketorolac group was compared with the OxyContin group (P = .01) and on postoperative day 1 when the ketorolac group was compared with the oxycodone group (P = .04). Complications (Figure 3) were greater in the non-ketorolac groups. One patient each in the oxycodone and OxyContin groups required a trip to the emergency department for pain control after their block wore off. Nausea and vomiting were present in each of the 4 groups but to a much greater degree in the Percocet and OxyContin groups; however, these results did not reach statistical significance (P = .129). Eleven of the 18 patients in the Percocet group required an additional NSAID (naproxen) and still did not achieve pain control similar to the other groups. This may explain why the average daily pain score in the Percocet group was lower than that in the oxycodone group, in which only 4 of the 20 patients supplemented with naproxen. Patients did, however, require many more oxycodone tablets to achieve pain control in the Percocet group. Over-sedation was reported in 3 patients in the oxycodone group and in 1 patient in the OxyContin group. No patients were found to have bleeding, renal, or other systemic complications.

Continue to: Discussion...

DISCUSSION

In this prospective, randomized study, we sought to determine whether a more organized approach to treating postoperative pain using a specific dosing regimen or opiates in conjunction with non-opiate medications would lead to improved pain control and a decreased need for opiates. We found that adding ketorolac to the postoperative pain regimen and outlining a more detailed set of instructions could lower narcotic usage in the first 4 postoperative days. In addition, adding ketorolac decreased other complications commonly seen with narcotic usage and was shown to be safe in our patient population.

Ketorolac has been shown to decrease narcotic pain medication usage in several surgical settings and across different surgical specialties. It is hypothesized that ketorolac potentiates the effects of narcotics.¹¹ Ketorolac given alone has a potent analgesic effect by acting as a strong non-selective cyclooxygenase inhibitor. The major drawback to ketorolac use has been its well-known side-effect profile. Ketorolac is renally excreted, and as such, should not be used in patients with renal insufficiency. In addition, ketorolac has been shown to cause increased gastrointestinal bleeding when used for >5 days.¹⁵ Caution should be taken when combining ketorolac with thromboprophylactic medications, especially in older patients.

Many surgeons use NSAIDs along with narcotics as part of a postoperative pain regimen. While this is often adequate for some procedures, when the surgery involves manipulating fractures, internal fixation, or resection arthroplasty, the variation in individual patient pain may call for a more robust protocol. Additionally, as surgeons expand to more complex procedures performed in the outpatient setting, evaluating different combinations of analgesics taken in a more structured manner may provide for improved pain control.

A major component of patient satisfaction is postoperative pain control.^3-8,12,16,17 Regional anesthesia is an important tool that allows patients to undergo a surgical procedure with a greatly reduced amount of opioid pain medications. In addition, regional anesthesia can provide significant pain control after the patient has left the ambulatory surgery center, but this relief is short-lived because the medication is designed to lose effectiveness over time. As the effects of regional anesthesia wear off, patients can experience “rebound pain” with severe levels of pain that, on occasion, cannot be controlled with oral analgesics alone. The addition of ketorolac provided improved pain control when compared with the other regimens during this transition period when the regional anesthesia was becoming ineffective. In addition, because patients taking ketorolac used less narcotic medication, they experienced less nausea, vomiting, and over-sedation.

Additionally, patients were instructed to record their medication usage and pain scores on a prospective basis, with the hope of eliminating recall bias. A potential weakness is the inability to show significance for pain relief and reduced narcotic usage with the addition of ketorolac, although there was a trend toward significance. Many of the patients who enrolled in the trial did not return their medication logs. While these patients had to be excluded from data analysis, we continued enrollment until we obtained an adequate number of patients in each group. In addition, in the OxyContin group (Group 3), we could only recruit 17 participants, instead of the 18 needed based on our power study. Although this has a potential to alter the significance of our results, we do not feel this had a substantial impact on our results.

Many patients in the non-ketorolac groups supplemented their medication regimens with NSAIDs, which may have falsely lowered pain scores and narcotic usage. While this confounds our study results, we do not believe that it invalidates the conclusion that ketorolac can be an effective adjunct pain medication for use in patients undergoing ambulatory hand surgery.

The study examined postoperative pain control for only 2 procedures, thumb basal joint arthroplasty and distal radius fracture fixation, both commonly performed in the outpatient setting under regional anesthesia and both typically requiring narcotic pain medication. Perhaps the utilization of these medication regimens with different surgical procedures would have differing results.

We conclude that ketorolac potentially provides patients with improved pain control over the use of narcotic pain medications alone in the setting of ambulatory hand surgery.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

We evaluated postoperative pain control and narcotic usage after thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of the distal radius in patients given opiates with or without other non-opiate medication using a specific dosing regimen. A prospective, randomized study of 79 patients undergoing elective CMC arthroplasty or ORIF of the distal radius evaluated postoperative pain in the first 5 postoperative days. Patients were divided into 4 groups: Group 1, oxycodone and acetaminophen PRN; Group 2, oxycodone and acetaminophen with specific dosing; Group 3, oxycodone, acetaminophen, and OxyContin with specific dosing; and Group 4, oxycodone, acetaminophen, and ketorolac with specific dosing. During the first 5 postoperative days, we recorded pain levels according to a numeric pain scale, opioid usage, and complications. Although differences in our data did not reach statistical significance, overall pain scores, opioid usage, and complication rates were less prevalent in the oxycodone, acetaminophen, and ketorolac group. Postoperative pain following ambulatory hand and wrist surgery under regional anesthesia was more effectively controlled with fewer complications using a combination of oxycodone, acetaminophen, and ketorolac with a specific dosing regimen.

Continue to: Regional anesthesia...

Regional anesthesia is a safe and effective modality of perioperative pain control in patients undergoing ambulatory hand procedures.^1-10 Often, as the regional block wears off, patients experience a rebound pain effect that can be challenging to manage.

We sought to determine if an organized, multimodal approach in patients undergoing thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of distal radius fractures would provide better postoperative pain control. We hypothesized that this approach would significantly reduce postoperative pain and the need for narcotic pain medication compared with PRN dosing of oxycodone/acetaminophen alone.^11-14

MATERIALS AND METHODS

Our study was approved by our Institutional Review Board. Informed consent was obtained from each patient. Patients presenting for elective thumb CMC arthroplasty or ORIF of the distal radius were screened for inclusion in a prospective, randomized study. Inclusion criteria included patients aged 18 to 65 years who could provide informed consent. Patients with chronic pain syndromes, long-term narcotic usage, chronic medical conditions precluding the use of opiates or nonsteroidal anti-inflammatory drugs (NSAIDs), and those who did not have a complete sensory and motor block postoperatively were excluded.

Patients were randomly divided into 1 of 4 study arms. Randomization was performed via sealed envelopes, which were opened in the recovery area when postoperative prescriptions were written. The group distribution was as follows: Group 1, Percocet 5 mg/325 mg alone (control); Group 2, oxycodone 5 mg, acetaminophen 325 mg administered separately; Group 3, oxycodone 5 mg, acetaminophen 325 mg, and oxycodone SR (OxyContin) 10 mg; and Group 4, oxycodone 5 mg, acetaminophen 325 mg, and ketorolac (Toradol) 10 mg (Table 1). Patients in the control group were instructed to take 1 or 2 tablets every 4 to 6 hours as needed for pain. Patients in the 3 experimental groups were given detailed instructions regarding when and how to take their medications. All patients were instructed to take 650 mg of acetaminophen every 6 hours. Patients were provided a sliding scale to assist in dosing their opioid medications according to their numeric pain score (NPS) (Table 2). Group 2 patients were given oxycodone 10 mg in the postanesthesia care unit (PACU) and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Table 1. Patient Groups

Table 2. Sliding Scale for Pain Control in the Experimental Groups

Group 3 patients were given oxycodone 10 mg in the PACU and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours and OxyContin 10 mg every 12 hours on a scheduled basis until their block wore off, then dose themselves using NPS. Group 4 patients were given oxycodone 10 mg postoperatively and ketorolac 30 mg intravenously in the PACU and instructed to take oxycodone 10 mg, acetaminophen 650 mg, and ketorolac 10 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Patients were provided with a journal and asked to record their medication usage, NPS, and any adverse effects (nausea, vomiting, and uncontrolled pain were specifically mentioned) or complications for 5 days after their procedure. We also attempted to contact patients by telephone on each of the 5 days after their procedure to remind them to complete their logs. They were asked specifically if they were having difficulty with their medications. They were also asked specifically about nausea, vomiting, and over-sedation. If patients requested additional medication to help treat their pain, they were instructed to add an over-the-counter NSAID of their choice based on the label’s suggested dosing.

Continue to: All patients received a supraclavicular...

All patients received a supraclavicular brachial plexus block using 0.75% ropivacaine under the supervision of an attending anesthesiologist experienced in regional anesthesia. Patients underwent thumb CMC arthroplasty utilizing complete resection of the trapezium followed by abductor pollicis longus suspensionplasty under the supervision of 1 of 3 fellowship-trained hand surgeons. ORIF of the distal radius was completed utilizing a volar approach and distal radius locking plate under the supervision of 1 of 3 fellowship-trained hand surgeons.

Primary outcome measures were the total number of oxycodone tablets taken daily and the average daily NPS. Secondary outcomes measured included adverse effects as noted above and the need for a trip to the emergency department for unrelieved pain.

A power analysis was completed prior to the beginning of the study. To detect a difference of at least 1 on the NPS, we determined that 18 patients per group would provide 80% power. This was based on literature utilizing the visual analog scale (VAS), a 100-mm line on which patients can place a mark to describe the intensity of their pain. The standard deviation on the VAS is approximately 15 mm. To account for potential dropout, we elected to recruit 20 patients per group. Non-paired t tests were used to compare groups.

RESULTS

One hundred and eighteen patients enrolled in the study. Of those, 79 patients completed and returned their summary logs (by group: 18 control, 20 oxycodone, 17 OxyContin, and 24 ketorolac). The remaining patients were excluded from the final analysis because they did not return their summary logs. Only 1 patient was excluded from the analysis because he did not have adequate regional anesthesia. Demographic data were analyzed and showed no significant differences between groups at the P < .05 level of significance. Surgical procedures were completed by 3 fellowship-trained hand surgeons. Distal radius fractures were performed using a volar approach. CMC arthroplasty was performed using a procedure that was standardized across surgeons. There were no between-surgeon differences in outcomes.

Average daily NPS (Figure 1) and the total number of oxycodone tablets taken (Figure 2) over the 5-day study period were recorded. Patients in the ketorolac group used fewer oxycodone tablets (19.3) than patients in the other 3 groups (24.4), P =.11, but the difference was not statistically significant. The maximum number of oxycodone tablets used was 71 in the Percocet group, 57 in the oxycodone and ketorolac groups, and 73 in the OxyContin group. The average daily NPS was lower in the ketorolac group during the period of medication use. This value only reached statistical significance on postoperative day 0 when the ketorolac group was compared with the OxyContin group (P = .01) and on postoperative day 1 when the ketorolac group was compared with the oxycodone group (P = .04). Complications (Figure 3) were greater in the non-ketorolac groups. One patient each in the oxycodone and OxyContin groups required a trip to the emergency department for pain control after their block wore off. Nausea and vomiting were present in each of the 4 groups but to a much greater degree in the Percocet and OxyContin groups; however, these results did not reach statistical significance (P = .129). Eleven of the 18 patients in the Percocet group required an additional NSAID (naproxen) and still did not achieve pain control similar to the other groups. This may explain why the average daily pain score in the Percocet group was lower than that in the oxycodone group, in which only 4 of the 20 patients supplemented with naproxen. Patients did, however, require many more oxycodone tablets to achieve pain control in the Percocet group. Over-sedation was reported in 3 patients in the oxycodone group and in 1 patient in the OxyContin group. No patients were found to have bleeding, renal, or other systemic complications.

Continue to: Discussion...

DISCUSSION

In this prospective, randomized study, we sought to determine whether a more organized approach to treating postoperative pain using a specific dosing regimen or opiates in conjunction with non-opiate medications would lead to improved pain control and a decreased need for opiates. We found that adding ketorolac to the postoperative pain regimen and outlining a more detailed set of instructions could lower narcotic usage in the first 4 postoperative days. In addition, adding ketorolac decreased other complications commonly seen with narcotic usage and was shown to be safe in our patient population.

Ketorolac has been shown to decrease narcotic pain medication usage in several surgical settings and across different surgical specialties. It is hypothesized that ketorolac potentiates the effects of narcotics.¹¹ Ketorolac given alone has a potent analgesic effect by acting as a strong non-selective cyclooxygenase inhibitor. The major drawback to ketorolac use has been its well-known side-effect profile. Ketorolac is renally excreted, and as such, should not be used in patients with renal insufficiency. In addition, ketorolac has been shown to cause increased gastrointestinal bleeding when used for >5 days.¹⁵ Caution should be taken when combining ketorolac with thromboprophylactic medications, especially in older patients.

Many surgeons use NSAIDs along with narcotics as part of a postoperative pain regimen. While this is often adequate for some procedures, when the surgery involves manipulating fractures, internal fixation, or resection arthroplasty, the variation in individual patient pain may call for a more robust protocol. Additionally, as surgeons expand to more complex procedures performed in the outpatient setting, evaluating different combinations of analgesics taken in a more structured manner may provide for improved pain control.

A major component of patient satisfaction is postoperative pain control.^3-8,12,16,17 Regional anesthesia is an important tool that allows patients to undergo a surgical procedure with a greatly reduced amount of opioid pain medications. In addition, regional anesthesia can provide significant pain control after the patient has left the ambulatory surgery center, but this relief is short-lived because the medication is designed to lose effectiveness over time. As the effects of regional anesthesia wear off, patients can experience “rebound pain” with severe levels of pain that, on occasion, cannot be controlled with oral analgesics alone. The addition of ketorolac provided improved pain control when compared with the other regimens during this transition period when the regional anesthesia was becoming ineffective. In addition, because patients taking ketorolac used less narcotic medication, they experienced less nausea, vomiting, and over-sedation.

Additionally, patients were instructed to record their medication usage and pain scores on a prospective basis, with the hope of eliminating recall bias. A potential weakness is the inability to show significance for pain relief and reduced narcotic usage with the addition of ketorolac, although there was a trend toward significance. Many of the patients who enrolled in the trial did not return their medication logs. While these patients had to be excluded from data analysis, we continued enrollment until we obtained an adequate number of patients in each group. In addition, in the OxyContin group (Group 3), we could only recruit 17 participants, instead of the 18 needed based on our power study. Although this has a potential to alter the significance of our results, we do not feel this had a substantial impact on our results.

Many patients in the non-ketorolac groups supplemented their medication regimens with NSAIDs, which may have falsely lowered pain scores and narcotic usage. While this confounds our study results, we do not believe that it invalidates the conclusion that ketorolac can be an effective adjunct pain medication for use in patients undergoing ambulatory hand surgery.

The study examined postoperative pain control for only 2 procedures, thumb basal joint arthroplasty and distal radius fracture fixation, both commonly performed in the outpatient setting under regional anesthesia and both typically requiring narcotic pain medication. Perhaps the utilization of these medication regimens with different surgical procedures would have differing results.

We conclude that ketorolac potentially provides patients with improved pain control over the use of narcotic pain medications alone in the setting of ambulatory hand surgery.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

We evaluated postoperative pain control and narcotic usage after thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of the distal radius in patients given opiates with or without other non-opiate medication using a specific dosing regimen. A prospective, randomized study of 79 patients undergoing elective CMC arthroplasty or ORIF of the distal radius evaluated postoperative pain in the first 5 postoperative days. Patients were divided into 4 groups: Group 1, oxycodone and acetaminophen PRN; Group 2, oxycodone and acetaminophen with specific dosing; Group 3, oxycodone, acetaminophen, and OxyContin with specific dosing; and Group 4, oxycodone, acetaminophen, and ketorolac with specific dosing. During the first 5 postoperative days, we recorded pain levels according to a numeric pain scale, opioid usage, and complications. Although differences in our data did not reach statistical significance, overall pain scores, opioid usage, and complication rates were less prevalent in the oxycodone, acetaminophen, and ketorolac group. Postoperative pain following ambulatory hand and wrist surgery under regional anesthesia was more effectively controlled with fewer complications using a combination of oxycodone, acetaminophen, and ketorolac with a specific dosing regimen.

Continue to: Regional anesthesia...

Regional anesthesia is a safe and effective modality of perioperative pain control in patients undergoing ambulatory hand procedures.^1-10 Often, as the regional block wears off, patients experience a rebound pain effect that can be challenging to manage.

We sought to determine if an organized, multimodal approach in patients undergoing thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of distal radius fractures would provide better postoperative pain control. We hypothesized that this approach would significantly reduce postoperative pain and the need for narcotic pain medication compared with PRN dosing of oxycodone/acetaminophen alone.^11-14

MATERIALS AND METHODS

Our study was approved by our Institutional Review Board. Informed consent was obtained from each patient. Patients presenting for elective thumb CMC arthroplasty or ORIF of the distal radius were screened for inclusion in a prospective, randomized study. Inclusion criteria included patients aged 18 to 65 years who could provide informed consent. Patients with chronic pain syndromes, long-term narcotic usage, chronic medical conditions precluding the use of opiates or nonsteroidal anti-inflammatory drugs (NSAIDs), and those who did not have a complete sensory and motor block postoperatively were excluded.

Patients were randomly divided into 1 of 4 study arms. Randomization was performed via sealed envelopes, which were opened in the recovery area when postoperative prescriptions were written. The group distribution was as follows: Group 1, Percocet 5 mg/325 mg alone (control); Group 2, oxycodone 5 mg, acetaminophen 325 mg administered separately; Group 3, oxycodone 5 mg, acetaminophen 325 mg, and oxycodone SR (OxyContin) 10 mg; and Group 4, oxycodone 5 mg, acetaminophen 325 mg, and ketorolac (Toradol) 10 mg (Table 1). Patients in the control group were instructed to take 1 or 2 tablets every 4 to 6 hours as needed for pain. Patients in the 3 experimental groups were given detailed instructions regarding when and how to take their medications. All patients were instructed to take 650 mg of acetaminophen every 6 hours. Patients were provided a sliding scale to assist in dosing their opioid medications according to their numeric pain score (NPS) (Table 2). Group 2 patients were given oxycodone 10 mg in the postanesthesia care unit (PACU) and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Table 1. Patient Groups

Table 2. Sliding Scale for Pain Control in the Experimental Groups

Group 3 patients were given oxycodone 10 mg in the PACU and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours and OxyContin 10 mg every 12 hours on a scheduled basis until their block wore off, then dose themselves using NPS. Group 4 patients were given oxycodone 10 mg postoperatively and ketorolac 30 mg intravenously in the PACU and instructed to take oxycodone 10 mg, acetaminophen 650 mg, and ketorolac 10 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.

Patients were provided with a journal and asked to record their medication usage, NPS, and any adverse effects (nausea, vomiting, and uncontrolled pain were specifically mentioned) or complications for 5 days after their procedure. We also attempted to contact patients by telephone on each of the 5 days after their procedure to remind them to complete their logs. They were asked specifically if they were having difficulty with their medications. They were also asked specifically about nausea, vomiting, and over-sedation. If patients requested additional medication to help treat their pain, they were instructed to add an over-the-counter NSAID of their choice based on the label’s suggested dosing.

Continue to: All patients received a supraclavicular...

All patients received a supraclavicular brachial plexus block using 0.75% ropivacaine under the supervision of an attending anesthesiologist experienced in regional anesthesia. Patients underwent thumb CMC arthroplasty utilizing complete resection of the trapezium followed by abductor pollicis longus suspensionplasty under the supervision of 1 of 3 fellowship-trained hand surgeons. ORIF of the distal radius was completed utilizing a volar approach and distal radius locking plate under the supervision of 1 of 3 fellowship-trained hand surgeons.

Primary outcome measures were the total number of oxycodone tablets taken daily and the average daily NPS. Secondary outcomes measured included adverse effects as noted above and the need for a trip to the emergency department for unrelieved pain.

A power analysis was completed prior to the beginning of the study. To detect a difference of at least 1 on the NPS, we determined that 18 patients per group would provide 80% power. This was based on literature utilizing the visual analog scale (VAS), a 100-mm line on which patients can place a mark to describe the intensity of their pain. The standard deviation on the VAS is approximately 15 mm. To account for potential dropout, we elected to recruit 20 patients per group. Non-paired t tests were used to compare groups.

RESULTS

One hundred and eighteen patients enrolled in the study. Of those, 79 patients completed and returned their summary logs (by group: 18 control, 20 oxycodone, 17 OxyContin, and 24 ketorolac). The remaining patients were excluded from the final analysis because they did not return their summary logs. Only 1 patient was excluded from the analysis because he did not have adequate regional anesthesia. Demographic data were analyzed and showed no significant differences between groups at the P < .05 level of significance. Surgical procedures were completed by 3 fellowship-trained hand surgeons. Distal radius fractures were performed using a volar approach. CMC arthroplasty was performed using a procedure that was standardized across surgeons. There were no between-surgeon differences in outcomes.

Average daily NPS (Figure 1) and the total number of oxycodone tablets taken (Figure 2) over the 5-day study period were recorded. Patients in the ketorolac group used fewer oxycodone tablets (19.3) than patients in the other 3 groups (24.4), P =.11, but the difference was not statistically significant. The maximum number of oxycodone tablets used was 71 in the Percocet group, 57 in the oxycodone and ketorolac groups, and 73 in the OxyContin group. The average daily NPS was lower in the ketorolac group during the period of medication use. This value only reached statistical significance on postoperative day 0 when the ketorolac group was compared with the OxyContin group (P = .01) and on postoperative day 1 when the ketorolac group was compared with the oxycodone group (P = .04). Complications (Figure 3) were greater in the non-ketorolac groups. One patient each in the oxycodone and OxyContin groups required a trip to the emergency department for pain control after their block wore off. Nausea and vomiting were present in each of the 4 groups but to a much greater degree in the Percocet and OxyContin groups; however, these results did not reach statistical significance (P = .129). Eleven of the 18 patients in the Percocet group required an additional NSAID (naproxen) and still did not achieve pain control similar to the other groups. This may explain why the average daily pain score in the Percocet group was lower than that in the oxycodone group, in which only 4 of the 20 patients supplemented with naproxen. Patients did, however, require many more oxycodone tablets to achieve pain control in the Percocet group. Over-sedation was reported in 3 patients in the oxycodone group and in 1 patient in the OxyContin group. No patients were found to have bleeding, renal, or other systemic complications.

Continue to: Discussion...

DISCUSSION

In this prospective, randomized study, we sought to determine whether a more organized approach to treating postoperative pain using a specific dosing regimen or opiates in conjunction with non-opiate medications would lead to improved pain control and a decreased need for opiates. We found that adding ketorolac to the postoperative pain regimen and outlining a more detailed set of instructions could lower narcotic usage in the first 4 postoperative days. In addition, adding ketorolac decreased other complications commonly seen with narcotic usage and was shown to be safe in our patient population.

Ketorolac has been shown to decrease narcotic pain medication usage in several surgical settings and across different surgical specialties. It is hypothesized that ketorolac potentiates the effects of narcotics.¹¹ Ketorolac given alone has a potent analgesic effect by acting as a strong non-selective cyclooxygenase inhibitor. The major drawback to ketorolac use has been its well-known side-effect profile. Ketorolac is renally excreted, and as such, should not be used in patients with renal insufficiency. In addition, ketorolac has been shown to cause increased gastrointestinal bleeding when used for >5 days.¹⁵ Caution should be taken when combining ketorolac with thromboprophylactic medications, especially in older patients.

Many surgeons use NSAIDs along with narcotics as part of a postoperative pain regimen. While this is often adequate for some procedures, when the surgery involves manipulating fractures, internal fixation, or resection arthroplasty, the variation in individual patient pain may call for a more robust protocol. Additionally, as surgeons expand to more complex procedures performed in the outpatient setting, evaluating different combinations of analgesics taken in a more structured manner may provide for improved pain control.

A major component of patient satisfaction is postoperative pain control.^3-8,12,16,17 Regional anesthesia is an important tool that allows patients to undergo a surgical procedure with a greatly reduced amount of opioid pain medications. In addition, regional anesthesia can provide significant pain control after the patient has left the ambulatory surgery center, but this relief is short-lived because the medication is designed to lose effectiveness over time. As the effects of regional anesthesia wear off, patients can experience “rebound pain” with severe levels of pain that, on occasion, cannot be controlled with oral analgesics alone. The addition of ketorolac provided improved pain control when compared with the other regimens during this transition period when the regional anesthesia was becoming ineffective. In addition, because patients taking ketorolac used less narcotic medication, they experienced less nausea, vomiting, and over-sedation.

Additionally, patients were instructed to record their medication usage and pain scores on a prospective basis, with the hope of eliminating recall bias. A potential weakness is the inability to show significance for pain relief and reduced narcotic usage with the addition of ketorolac, although there was a trend toward significance. Many of the patients who enrolled in the trial did not return their medication logs. While these patients had to be excluded from data analysis, we continued enrollment until we obtained an adequate number of patients in each group. In addition, in the OxyContin group (Group 3), we could only recruit 17 participants, instead of the 18 needed based on our power study. Although this has a potential to alter the significance of our results, we do not feel this had a substantial impact on our results.

Many patients in the non-ketorolac groups supplemented their medication regimens with NSAIDs, which may have falsely lowered pain scores and narcotic usage. While this confounds our study results, we do not believe that it invalidates the conclusion that ketorolac can be an effective adjunct pain medication for use in patients undergoing ambulatory hand surgery.

The study examined postoperative pain control for only 2 procedures, thumb basal joint arthroplasty and distal radius fracture fixation, both commonly performed in the outpatient setting under regional anesthesia and both typically requiring narcotic pain medication. Perhaps the utilization of these medication regimens with different surgical procedures would have differing results.

We conclude that ketorolac potentially provides patients with improved pain control over the use of narcotic pain medications alone in the setting of ambulatory hand surgery.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Soft tissue defects associated with exposed tendon pose difficult reconstructive problems because of tendon adhesions, poor range of motion, poor cosmetic appearance, and donor site morbidity. Dermal regeneration template is a skin substitute widely used in reconstructive surgery, including the occasional coverage of tendons. However, postoperative functionality of the tendons has not been well documented. We report a case of using dermal regeneration template for soft tissue reconstruction overlying tendons with loss of paratenon in a patient with Dupuytren’s contracture. Dermal regeneration template may offer an alternative option for immediate tendon coverage in the hand.

Soft tissue defects overlying exposed tendon with loss of paratenon often precipitate poor clinical outcomes because of the dichotomous demands of both closing the overlying soft-tissue defect and providing a gliding surface for the underlying tendons.¹ Although avoidance of adhesions and restoration of function are the primary goals of the procedure, satisfactory appearance is also desirable. Likewise, any form of coverage should ideally provide good vasculature required for complete healing and an early form of closure following débridement.² Simple skin grafts do not adequately meet these demands because they result in a high rate of tendon adhesions,³ and also are limited in patients with limited donor skin availability or questionable underlying wound bed viability, such as in scleroderma.

In order to reduce the frequency of tendon adhesions by creating a gliding surface, the use of interpositional materials, both artificial and biologic, has been employed with varying degrees of success, including cellophane, chitosan membrane, fibrin sealant, autogenous fascial flaps, and autogenous venous grafts.^4-7 Many of the autogenous flaps and grafts have been employed with good success.⁸ However, complications and donor site morbidity encourage alternative procedures, including the use of artificial substances.^2,8-10

We present our clinical experience with a patient who underwent successful placement of Integra (Integra LifeSciences) Dermal Regeneration Template (DRT) directly over exposed tendons with a subsequent full-thickness skin graft several weeks later. The procedures were performed per the manufacturer’s specifications, resulting in 2 stages of reconstruction. In our experience, DRT can offer immediate coverage unrestricted by wound size, and provides shorter operative time and decreased donor site and surgical morbidity compared with flap coverage, while demonstrating good cosmetic results. The patient provided written informed consent for print and electronic publication of this case report.

CASE

A 74-year-old right-handed man with Dupuytren’s contracture was evaluated for recurrent symptomatic contracture causing difficulty with daily activities. He reported palpable cords and contractures in the ring and small fingers of the right hand. He had 2 prior open surgical procedures, including palmar and digital fasciectomy of both hands. On the right hand, the ring and small fingers demonstrated 90° proximal interphalangeal (PIP) and 60° metacarpophalangeal (MCP) flexion contractures. Palpable central cords were present on the flexor surfaces of both the ring and small fingers. A well-healed surgical incision, performed 22 years earlier, was present over the palmar aspect of the ring finger.

Continue to: With consideration given...

With consideration given to the patient’s recurrent contracture after a prior surgical procedure, we discussed surgical excision of the diseased cords in order to eliminate the possibility of a second recurrence and maximize the gain of motion. Following discussion with the patient, we performed palmar and digital fasciectomy of the ring and small finger contractures. Postoperatively, the patient was followed closely for wound complications and vascular status. On his return to our clinic 11 days later, the patient was noted to have dehiscence of the digital wounds in the ring and small fingers (Figure 1). 

STAGE 1

During the first stage, completed 14 days following the index procedure, débridement of the wounds was performed, followed by provisional DRT coverage of the tendons, secured with 5-0 nylon sutures (Figure 2). 

STAGE 2

At approximately 2 weeks after application of the DRT, a full-thickness skin graft was applied. The thickness of the graft was chosen to allow for durable coverage of the palmar skin defects. Upon successful completion of the second stage, the patient was followed and evaluated for complete wound healing. On performing an examination 14 days after surgery, the ring and small fingers demonstrated only partially healed skin graft but significantly improved range of motion (ROM), with 40° to 90° arc of motion in the PIP joint and 25° to 90° arc of motion in the MCP joint (Figure 4). Owing to their limited size, the wounds were treated with dressing changes until successful healing (Figure 5).

Hand therapy was instituted to achieve maximum mobility for covered soft tissue and tendons and to maximize tendon gliding. At 1-year follow-up, the skin was fully healed and the patient’s active PIP motion was 30° to 90°, active MCP motion was 0° to 90°, and grip strength was 90 lb on both sides. The tendons glided under a well-vascularized tissue at the DRT placement site, and no secondary tenolysis procedure was deemed necessary.

DISCUSSION

Soft tissue defects with exposed tendons may offer a number of challenges for coverage. The primary concern is the creation of a gliding surface and the restoration of a functional tendon without adhesions.² However, surgeons must use their own clinical judgment when choosing the method of coverage so as to minimize the effects of donor site morbidity and maximize the overall functional and cosmetic outcomes. All options must be considered while selecting a material or flap that is likely to survive in the relatively avascular tendon plane.^2,8,11 When considering the reconstructive ladder, skin grafts may not represent a viable option in the presence of a nonvascularized wound bed, such as exposed tendon or bone, where paratenon or periosteum have been damaged. That leaves the surgeon with local flaps, regional flaps, free flaps, and skin substitutes.

Continue to : Before planning closure...

As Levin¹² noted in 1993, decisions regarding repair of any soft tissue defect may follow a well-delineated ladder beginning with the primary choice of split-thickness skin grafts and ending with free flaps. When treating tissue defects in the hand complex, flaps are an excellent option as they replace like with like, allow minimal scarring and early rehabilitation. ^13,14 Nevertheless, a few general disadvantages are inherent in flap procedure: increase in operating time, risk of flap loss, and in case of free flaps, knowledge, experience, and microsurgical ability.² In reference to complications, the rate of flap loss found by Khouri and colleagues¹⁵ was 4.1% with a 12.1% chance of incurring some measured complication, including wound dehiscence, arterial insufficiency, and flap necrosis.

Likewise, some of the conventional local and free flaps, including cutaneous and muscular flaps, prove ineffective in preventing tendon adhesions, create unsightly postoperative contours, or increase the area of trauma on the wounded hand, encouraging the use of free fascial flaps.¹¹ Among the wide array of potential free fascial flaps, the temporoparietal, scapular, lateral arm, radial forearm, and free serratus fascial flaps are some of the most popular for hand defects.^8,9 However, these procedures require an additional surgical site, meticulous dissection, microsurgical technique at times, and increased operating cost and time.^2,8-10 Furthermore, free fascial flaps have demonstrated occasional partial flap loss and a decreased survival of the overlying skin graft, leading some to advocate delayed skin graft placement.^10,16,17

On the basis of these complications, Bray and colleagues¹¹ noted that the utility of free flaps may be limited in smaller clinical settings. The primary disadvantage of using DRTs is the necessity for a second operative procedure to harvest and place the skin graft. Traditionally, this is performed 2 to 3 weeks after the initial DRT application. Nevertheless, a 1-stage procedure can be performed in an outpatient setup, minimizing the burden to the patient and the medical costs, followed by secondary intention healing.

In response to critics of the 2-stage technique, Sanger and colleagues¹⁸ described single-stage use of DRT with split-thickness skin grafts with placement of an overlying wound vacuum-assisted closure to help speed incorporation of the DRT and improve survival of the immediately grafted skin. Another viable alternative is the McCash open-palm technique.¹⁹ In the open-palm technique, a Brunner zigzag incision is made in the affected digit. A transverse incision is made in the palm. A partial fasciectomy is performed in the palm and digit. After release, the digital incision is closed, and the palmar incision is left open. Although this well-studied and well-reported technique is known to reduce the risk of flap necrosis due to tension and hematoma,²⁰ its main application is in the palm, as the name implies. Because in our patient the defect was palmar-digital with exposed “white structures,” we elected to use DRT.

Continue to: Although there is still...

ABSTRACT

Soft tissue defects associated with exposed tendon pose difficult reconstructive problems because of tendon adhesions, poor range of motion, poor cosmetic appearance, and donor site morbidity. Dermal regeneration template is a skin substitute widely used in reconstructive surgery, including the occasional coverage of tendons. However, postoperative functionality of the tendons has not been well documented. We report a case of using dermal regeneration template for soft tissue reconstruction overlying tendons with loss of paratenon in a patient with Dupuytren’s contracture. Dermal regeneration template may offer an alternative option for immediate tendon coverage in the hand.

Soft tissue defects overlying exposed tendon with loss of paratenon often precipitate poor clinical outcomes because of the dichotomous demands of both closing the overlying soft-tissue defect and providing a gliding surface for the underlying tendons.¹ Although avoidance of adhesions and restoration of function are the primary goals of the procedure, satisfactory appearance is also desirable. Likewise, any form of coverage should ideally provide good vasculature required for complete healing and an early form of closure following débridement.² Simple skin grafts do not adequately meet these demands because they result in a high rate of tendon adhesions,³ and also are limited in patients with limited donor skin availability or questionable underlying wound bed viability, such as in scleroderma.

In order to reduce the frequency of tendon adhesions by creating a gliding surface, the use of interpositional materials, both artificial and biologic, has been employed with varying degrees of success, including cellophane, chitosan membrane, fibrin sealant, autogenous fascial flaps, and autogenous venous grafts.^4-7 Many of the autogenous flaps and grafts have been employed with good success.⁸ However, complications and donor site morbidity encourage alternative procedures, including the use of artificial substances.^2,8-10

We present our clinical experience with a patient who underwent successful placement of Integra (Integra LifeSciences) Dermal Regeneration Template (DRT) directly over exposed tendons with a subsequent full-thickness skin graft several weeks later. The procedures were performed per the manufacturer’s specifications, resulting in 2 stages of reconstruction. In our experience, DRT can offer immediate coverage unrestricted by wound size, and provides shorter operative time and decreased donor site and surgical morbidity compared with flap coverage, while demonstrating good cosmetic results. The patient provided written informed consent for print and electronic publication of this case report.

CASE

A 74-year-old right-handed man with Dupuytren’s contracture was evaluated for recurrent symptomatic contracture causing difficulty with daily activities. He reported palpable cords and contractures in the ring and small fingers of the right hand. He had 2 prior open surgical procedures, including palmar and digital fasciectomy of both hands. On the right hand, the ring and small fingers demonstrated 90° proximal interphalangeal (PIP) and 60° metacarpophalangeal (MCP) flexion contractures. Palpable central cords were present on the flexor surfaces of both the ring and small fingers. A well-healed surgical incision, performed 22 years earlier, was present over the palmar aspect of the ring finger.

Continue to: With consideration given...

With consideration given to the patient’s recurrent contracture after a prior surgical procedure, we discussed surgical excision of the diseased cords in order to eliminate the possibility of a second recurrence and maximize the gain of motion. Following discussion with the patient, we performed palmar and digital fasciectomy of the ring and small finger contractures. Postoperatively, the patient was followed closely for wound complications and vascular status. On his return to our clinic 11 days later, the patient was noted to have dehiscence of the digital wounds in the ring and small fingers (Figure 1). 

STAGE 1

During the first stage, completed 14 days following the index procedure, débridement of the wounds was performed, followed by provisional DRT coverage of the tendons, secured with 5-0 nylon sutures (Figure 2). 

STAGE 2

At approximately 2 weeks after application of the DRT, a full-thickness skin graft was applied. The thickness of the graft was chosen to allow for durable coverage of the palmar skin defects. Upon successful completion of the second stage, the patient was followed and evaluated for complete wound healing. On performing an examination 14 days after surgery, the ring and small fingers demonstrated only partially healed skin graft but significantly improved range of motion (ROM), with 40° to 90° arc of motion in the PIP joint and 25° to 90° arc of motion in the MCP joint (Figure 4). Owing to their limited size, the wounds were treated with dressing changes until successful healing (Figure 5).

Hand therapy was instituted to achieve maximum mobility for covered soft tissue and tendons and to maximize tendon gliding. At 1-year follow-up, the skin was fully healed and the patient’s active PIP motion was 30° to 90°, active MCP motion was 0° to 90°, and grip strength was 90 lb on both sides. The tendons glided under a well-vascularized tissue at the DRT placement site, and no secondary tenolysis procedure was deemed necessary.

DISCUSSION

Soft tissue defects with exposed tendons may offer a number of challenges for coverage. The primary concern is the creation of a gliding surface and the restoration of a functional tendon without adhesions.² However, surgeons must use their own clinical judgment when choosing the method of coverage so as to minimize the effects of donor site morbidity and maximize the overall functional and cosmetic outcomes. All options must be considered while selecting a material or flap that is likely to survive in the relatively avascular tendon plane.^2,8,11 When considering the reconstructive ladder, skin grafts may not represent a viable option in the presence of a nonvascularized wound bed, such as exposed tendon or bone, where paratenon or periosteum have been damaged. That leaves the surgeon with local flaps, regional flaps, free flaps, and skin substitutes.

Continue to : Before planning closure...

As Levin¹² noted in 1993, decisions regarding repair of any soft tissue defect may follow a well-delineated ladder beginning with the primary choice of split-thickness skin grafts and ending with free flaps. When treating tissue defects in the hand complex, flaps are an excellent option as they replace like with like, allow minimal scarring and early rehabilitation. ^13,14 Nevertheless, a few general disadvantages are inherent in flap procedure: increase in operating time, risk of flap loss, and in case of free flaps, knowledge, experience, and microsurgical ability.² In reference to complications, the rate of flap loss found by Khouri and colleagues¹⁵ was 4.1% with a 12.1% chance of incurring some measured complication, including wound dehiscence, arterial insufficiency, and flap necrosis.

Likewise, some of the conventional local and free flaps, including cutaneous and muscular flaps, prove ineffective in preventing tendon adhesions, create unsightly postoperative contours, or increase the area of trauma on the wounded hand, encouraging the use of free fascial flaps.¹¹ Among the wide array of potential free fascial flaps, the temporoparietal, scapular, lateral arm, radial forearm, and free serratus fascial flaps are some of the most popular for hand defects.^8,9 However, these procedures require an additional surgical site, meticulous dissection, microsurgical technique at times, and increased operating cost and time.^2,8-10 Furthermore, free fascial flaps have demonstrated occasional partial flap loss and a decreased survival of the overlying skin graft, leading some to advocate delayed skin graft placement.^10,16,17

On the basis of these complications, Bray and colleagues¹¹ noted that the utility of free flaps may be limited in smaller clinical settings. The primary disadvantage of using DRTs is the necessity for a second operative procedure to harvest and place the skin graft. Traditionally, this is performed 2 to 3 weeks after the initial DRT application. Nevertheless, a 1-stage procedure can be performed in an outpatient setup, minimizing the burden to the patient and the medical costs, followed by secondary intention healing.

In response to critics of the 2-stage technique, Sanger and colleagues¹⁸ described single-stage use of DRT with split-thickness skin grafts with placement of an overlying wound vacuum-assisted closure to help speed incorporation of the DRT and improve survival of the immediately grafted skin. Another viable alternative is the McCash open-palm technique.¹⁹ In the open-palm technique, a Brunner zigzag incision is made in the affected digit. A transverse incision is made in the palm. A partial fasciectomy is performed in the palm and digit. After release, the digital incision is closed, and the palmar incision is left open. Although this well-studied and well-reported technique is known to reduce the risk of flap necrosis due to tension and hematoma,²⁰ its main application is in the palm, as the name implies. Because in our patient the defect was palmar-digital with exposed “white structures,” we elected to use DRT.

Continue to: Although there is still...

ABSTRACT

Soft tissue defects associated with exposed tendon pose difficult reconstructive problems because of tendon adhesions, poor range of motion, poor cosmetic appearance, and donor site morbidity. Dermal regeneration template is a skin substitute widely used in reconstructive surgery, including the occasional coverage of tendons. However, postoperative functionality of the tendons has not been well documented. We report a case of using dermal regeneration template for soft tissue reconstruction overlying tendons with loss of paratenon in a patient with Dupuytren’s contracture. Dermal regeneration template may offer an alternative option for immediate tendon coverage in the hand.

Soft tissue defects overlying exposed tendon with loss of paratenon often precipitate poor clinical outcomes because of the dichotomous demands of both closing the overlying soft-tissue defect and providing a gliding surface for the underlying tendons.¹ Although avoidance of adhesions and restoration of function are the primary goals of the procedure, satisfactory appearance is also desirable. Likewise, any form of coverage should ideally provide good vasculature required for complete healing and an early form of closure following débridement.² Simple skin grafts do not adequately meet these demands because they result in a high rate of tendon adhesions,³ and also are limited in patients with limited donor skin availability or questionable underlying wound bed viability, such as in scleroderma.

In order to reduce the frequency of tendon adhesions by creating a gliding surface, the use of interpositional materials, both artificial and biologic, has been employed with varying degrees of success, including cellophane, chitosan membrane, fibrin sealant, autogenous fascial flaps, and autogenous venous grafts.^4-7 Many of the autogenous flaps and grafts have been employed with good success.⁸ However, complications and donor site morbidity encourage alternative procedures, including the use of artificial substances.^2,8-10

We present our clinical experience with a patient who underwent successful placement of Integra (Integra LifeSciences) Dermal Regeneration Template (DRT) directly over exposed tendons with a subsequent full-thickness skin graft several weeks later. The procedures were performed per the manufacturer’s specifications, resulting in 2 stages of reconstruction. In our experience, DRT can offer immediate coverage unrestricted by wound size, and provides shorter operative time and decreased donor site and surgical morbidity compared with flap coverage, while demonstrating good cosmetic results. The patient provided written informed consent for print and electronic publication of this case report.

CASE

A 74-year-old right-handed man with Dupuytren’s contracture was evaluated for recurrent symptomatic contracture causing difficulty with daily activities. He reported palpable cords and contractures in the ring and small fingers of the right hand. He had 2 prior open surgical procedures, including palmar and digital fasciectomy of both hands. On the right hand, the ring and small fingers demonstrated 90° proximal interphalangeal (PIP) and 60° metacarpophalangeal (MCP) flexion contractures. Palpable central cords were present on the flexor surfaces of both the ring and small fingers. A well-healed surgical incision, performed 22 years earlier, was present over the palmar aspect of the ring finger.

Continue to: With consideration given...

With consideration given to the patient’s recurrent contracture after a prior surgical procedure, we discussed surgical excision of the diseased cords in order to eliminate the possibility of a second recurrence and maximize the gain of motion. Following discussion with the patient, we performed palmar and digital fasciectomy of the ring and small finger contractures. Postoperatively, the patient was followed closely for wound complications and vascular status. On his return to our clinic 11 days later, the patient was noted to have dehiscence of the digital wounds in the ring and small fingers (Figure 1). 

STAGE 1

During the first stage, completed 14 days following the index procedure, débridement of the wounds was performed, followed by provisional DRT coverage of the tendons, secured with 5-0 nylon sutures (Figure 2). 

STAGE 2

At approximately 2 weeks after application of the DRT, a full-thickness skin graft was applied. The thickness of the graft was chosen to allow for durable coverage of the palmar skin defects. Upon successful completion of the second stage, the patient was followed and evaluated for complete wound healing. On performing an examination 14 days after surgery, the ring and small fingers demonstrated only partially healed skin graft but significantly improved range of motion (ROM), with 40° to 90° arc of motion in the PIP joint and 25° to 90° arc of motion in the MCP joint (Figure 4). Owing to their limited size, the wounds were treated with dressing changes until successful healing (Figure 5).

Hand therapy was instituted to achieve maximum mobility for covered soft tissue and tendons and to maximize tendon gliding. At 1-year follow-up, the skin was fully healed and the patient’s active PIP motion was 30° to 90°, active MCP motion was 0° to 90°, and grip strength was 90 lb on both sides. The tendons glided under a well-vascularized tissue at the DRT placement site, and no secondary tenolysis procedure was deemed necessary.

DISCUSSION

Soft tissue defects with exposed tendons may offer a number of challenges for coverage. The primary concern is the creation of a gliding surface and the restoration of a functional tendon without adhesions.² However, surgeons must use their own clinical judgment when choosing the method of coverage so as to minimize the effects of donor site morbidity and maximize the overall functional and cosmetic outcomes. All options must be considered while selecting a material or flap that is likely to survive in the relatively avascular tendon plane.^2,8,11 When considering the reconstructive ladder, skin grafts may not represent a viable option in the presence of a nonvascularized wound bed, such as exposed tendon or bone, where paratenon or periosteum have been damaged. That leaves the surgeon with local flaps, regional flaps, free flaps, and skin substitutes.

Continue to : Before planning closure...

As Levin¹² noted in 1993, decisions regarding repair of any soft tissue defect may follow a well-delineated ladder beginning with the primary choice of split-thickness skin grafts and ending with free flaps. When treating tissue defects in the hand complex, flaps are an excellent option as they replace like with like, allow minimal scarring and early rehabilitation. ^13,14 Nevertheless, a few general disadvantages are inherent in flap procedure: increase in operating time, risk of flap loss, and in case of free flaps, knowledge, experience, and microsurgical ability.² In reference to complications, the rate of flap loss found by Khouri and colleagues¹⁵ was 4.1% with a 12.1% chance of incurring some measured complication, including wound dehiscence, arterial insufficiency, and flap necrosis.

Likewise, some of the conventional local and free flaps, including cutaneous and muscular flaps, prove ineffective in preventing tendon adhesions, create unsightly postoperative contours, or increase the area of trauma on the wounded hand, encouraging the use of free fascial flaps.¹¹ Among the wide array of potential free fascial flaps, the temporoparietal, scapular, lateral arm, radial forearm, and free serratus fascial flaps are some of the most popular for hand defects.^8,9 However, these procedures require an additional surgical site, meticulous dissection, microsurgical technique at times, and increased operating cost and time.^2,8-10 Furthermore, free fascial flaps have demonstrated occasional partial flap loss and a decreased survival of the overlying skin graft, leading some to advocate delayed skin graft placement.^10,16,17

On the basis of these complications, Bray and colleagues¹¹ noted that the utility of free flaps may be limited in smaller clinical settings. The primary disadvantage of using DRTs is the necessity for a second operative procedure to harvest and place the skin graft. Traditionally, this is performed 2 to 3 weeks after the initial DRT application. Nevertheless, a 1-stage procedure can be performed in an outpatient setup, minimizing the burden to the patient and the medical costs, followed by secondary intention healing.

In response to critics of the 2-stage technique, Sanger and colleagues¹⁸ described single-stage use of DRT with split-thickness skin grafts with placement of an overlying wound vacuum-assisted closure to help speed incorporation of the DRT and improve survival of the immediately grafted skin. Another viable alternative is the McCash open-palm technique.¹⁹ In the open-palm technique, a Brunner zigzag incision is made in the affected digit. A transverse incision is made in the palm. A partial fasciectomy is performed in the palm and digit. After release, the digital incision is closed, and the palmar incision is left open. Although this well-studied and well-reported technique is known to reduce the risk of flap necrosis due to tension and hematoma,²⁰ its main application is in the palm, as the name implies. Because in our patient the defect was palmar-digital with exposed “white structures,” we elected to use DRT.

Continue to: Although there is still...

ABSTRACT

The avulsion of the flexor digitorum profundus from its insertion, or “jersey finger,” is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

The avulsion-type injury of the flexor digitorum profundus (FDP) from its insertion on the distal phalanx is relatively common. FDP avulsions are seen in athletes and nonathletes, and are the result of the sudden hyperextension of the distal interphalangeal joint during active flexion. These injuries usually occur while grasping the jersey of an opposing player and are thus commonly referred to as “jersey finger.” Initially described in 1977 by Leddy and Packer¹, FDP avulsions are classified on the basis of the proximal extent of the retraction of the FDP and the presence or absence of a bony avulsion fracture fragment. Type I injuries are defined by tendon retraction to the level of the palm, where it is tethered by the lumbricals. At this level, the vinculum longus profundus (VLP) and vinculum brevis profundus (VBP) are ruptured, resulting in the substantial loss of intrinsic and extrinsic vascular supply to the tendon. In type II injuries, which are the most common type of FDP avulsions, the FDP tendon retracts to the level of the proximal interphalangeal (PIP) joint. Although the VBP is disrupted in this scenario, the VLP remains preserved because it arises at the level of the volar plate of the PIP joint.  Type III lesions involve tendon avulsions with an associated bony fragment that is typically sufficiently large to not pass through the flexor sheath, thus limiting retraction to the level of the A4 pulley. Both vincula remain intact, given that the VBP originates at the distal portion of the middle phalanx. The Leddy and Packer classification was later expanded to include type IV and V injury patterns, which are less common than other injury patterns. Similar to type III injuries, type IV injuries involve a bony avulsion; however, the FDP subsequently ruptures from this fragment and the tendon subsequently retracts into the finger or palm.^2,3 Type V injuries are more complex than other injury types because they involve a concomitant distal phalanx fracture with the FDP avulsion.⁴ Al-Qattan⁵ subclassified type V injuries into extra-articular (type Va) and intra-articular (type Vb) distal phalanx fractures on the basis of the distinct management of these 2 entities.

Numerous techniques have been proposed and described for the repair of FDP avulsion injuries. The pullout suture-dorsal button combination is the most widely described technique and was initially described by Bunnell.⁶ Unfortunately, this technique is accompanied by numerous potential postoperative complications.⁶ Nail plate deformity is the most commonly described complication. Other complications include local wound irritation, pain, button snagging, and repair failure. Additionally, the presence of external sutures creates a potential route of ingress for bacterial infection.

Continue to: Bone suture anchor techniques...

SURGICAL TECHNIQUE

TYPES I, II, AND III

A Bruner incision is performed on the volar aspect of the affected finger, and full thickness flaps are elevated off the flexor sheath (Figures 1A-1C). 

TYPES IV AND V

In cases of type IV or V injury (Figure 4A), a screw or plate construct is first used to allow for the successful reduction and fixation of the fracture (Figure 4B). 

DISCUSSION

The avulsion of the FDP tendon from its insertion (zone I) on the distal phalanx is commonly called “jersey finger” and is a well-described injury that occurs most commonly in the ring finger.¹⁰ These injuries can be difficult to treat and are associated with a complication rate of as high as 60%.^11,12 Bunnell’s initial description of a suture passed through the fingernail and then tied over a polypropylene button has been associated with multiple complications. Kang and colleagues¹³ reported abnormal nail growth, nail fold necrosis, fingertip deformity, stiffness, infection, and amputation, 43% of all complications were directly related to the button. As an alternative to the button, sutures may be tied directly over the nail plate itself via 2 separate holes.¹⁴ While this technique eliminates the complications directly associated with the button, the potential for infection remains. Additionally, increased direct pressure is placed on the nail plate and nail bed, thus potentially increasing the risk of nail deformity.

In 1994, Hallock⁷ initially described the use of bone anchors as an “internal fixation” alternative and cited the “expense of the apparatus” as the major drawback of this technique. McCallister and colleagues¹⁵ compared the clinical outcome of suture anchor fixation with that of the button-over-nail technique. Although they ultimately demonstrated that the clinical outcomes of the 2 techniques are not significantly different, they noted that suture anchor fixation is associated with decreased infection rate (7% vs 0%) and time to return to work. Poor bone mineral density and low cortical thickness are correlated with anchor pull-out, thus limiting its universal use.¹⁶ Furthermore, the universal use of many commonly available anchors is limited given that they are too large to be accommodated within many phalanges, particularly in women and in the small and ring fingers.¹⁷  The use of microanchors rather than mini anchors not only decreases this risk but also decreases construct strength, thus necessitating the use of 2 anchors to restore adequate fixation strength. Anchor use is associated with specific risks, including the dorsal migration of the anchor, the osteolysis of the surrounding bone, as well as the perforation of the dorsal cortex and the possible extrusion of the anchor through the phalanx and into the nail bed.^18,19 Additionally, in the wake of a changing healthcare system, the cost of suture anchors, as initially noted by Hallock,⁷ must be considered. This consideration is particularly relevant to the use of a 2 microanchor construct, which has been advocated given its biomechanical advantage.^20,21

Continue to: Transosseous tendon repair...

All internal fixation techniques have been described previously by Sood and Elliot⁸ and, later, by Schultz and colleagues.⁹ In contrast to Sood and Elliott’s⁸ technique, which requires the creation of transverse tunnels, a volar-to-dorsal tunnel is technically easy to create and creates a direct repair to tendon insertion. Our technique is similar to that of Schultz and colleagues'⁹ but has the following differences and potential improvements:

1. Keith needles are passed in a volar-to-dorsal fashion, thus allowing for the direct visualization of the transosseous tunnel origin, minimizing the size of the transosseous tunnels, and allowing for the anatomic reduction of the tendon.
2. Fluoroscopy is used to confirm wire placement prior to skin incision, thus enabling precise placement and potentially allowing the needles to be placed so as to avoid physeal injury in pediatric jersey fingers.
3. By using Keith needles, sutures can be passed with the same instrument that created the tunnel, thus simplifying surgical technique.
4. A Krakow suture technique is used. This technique results in less gapping and higher load-to-failure than other suturing techniques.²²
5. A 2-0 braided suture is used, therefore strengthening repair.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

The avulsion of the flexor digitorum profundus from its insertion, or “jersey finger,” is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

The avulsion-type injury of the flexor digitorum profundus (FDP) from its insertion on the distal phalanx is relatively common. FDP avulsions are seen in athletes and nonathletes, and are the result of the sudden hyperextension of the distal interphalangeal joint during active flexion. These injuries usually occur while grasping the jersey of an opposing player and are thus commonly referred to as “jersey finger.” Initially described in 1977 by Leddy and Packer¹, FDP avulsions are classified on the basis of the proximal extent of the retraction of the FDP and the presence or absence of a bony avulsion fracture fragment. Type I injuries are defined by tendon retraction to the level of the palm, where it is tethered by the lumbricals. At this level, the vinculum longus profundus (VLP) and vinculum brevis profundus (VBP) are ruptured, resulting in the substantial loss of intrinsic and extrinsic vascular supply to the tendon. In type II injuries, which are the most common type of FDP avulsions, the FDP tendon retracts to the level of the proximal interphalangeal (PIP) joint. Although the VBP is disrupted in this scenario, the VLP remains preserved because it arises at the level of the volar plate of the PIP joint.  Type III lesions involve tendon avulsions with an associated bony fragment that is typically sufficiently large to not pass through the flexor sheath, thus limiting retraction to the level of the A4 pulley. Both vincula remain intact, given that the VBP originates at the distal portion of the middle phalanx. The Leddy and Packer classification was later expanded to include type IV and V injury patterns, which are less common than other injury patterns. Similar to type III injuries, type IV injuries involve a bony avulsion; however, the FDP subsequently ruptures from this fragment and the tendon subsequently retracts into the finger or palm.^2,3 Type V injuries are more complex than other injury types because they involve a concomitant distal phalanx fracture with the FDP avulsion.⁴ Al-Qattan⁵ subclassified type V injuries into extra-articular (type Va) and intra-articular (type Vb) distal phalanx fractures on the basis of the distinct management of these 2 entities.

Numerous techniques have been proposed and described for the repair of FDP avulsion injuries. The pullout suture-dorsal button combination is the most widely described technique and was initially described by Bunnell.⁶ Unfortunately, this technique is accompanied by numerous potential postoperative complications.⁶ Nail plate deformity is the most commonly described complication. Other complications include local wound irritation, pain, button snagging, and repair failure. Additionally, the presence of external sutures creates a potential route of ingress for bacterial infection.

Continue to: Bone suture anchor techniques...

SURGICAL TECHNIQUE

TYPES I, II, AND III

A Bruner incision is performed on the volar aspect of the affected finger, and full thickness flaps are elevated off the flexor sheath (Figures 1A-1C). 

TYPES IV AND V

In cases of type IV or V injury (Figure 4A), a screw or plate construct is first used to allow for the successful reduction and fixation of the fracture (Figure 4B). 

DISCUSSION

The avulsion of the FDP tendon from its insertion (zone I) on the distal phalanx is commonly called “jersey finger” and is a well-described injury that occurs most commonly in the ring finger.¹⁰ These injuries can be difficult to treat and are associated with a complication rate of as high as 60%.^11,12 Bunnell’s initial description of a suture passed through the fingernail and then tied over a polypropylene button has been associated with multiple complications. Kang and colleagues¹³ reported abnormal nail growth, nail fold necrosis, fingertip deformity, stiffness, infection, and amputation, 43% of all complications were directly related to the button. As an alternative to the button, sutures may be tied directly over the nail plate itself via 2 separate holes.¹⁴ While this technique eliminates the complications directly associated with the button, the potential for infection remains. Additionally, increased direct pressure is placed on the nail plate and nail bed, thus potentially increasing the risk of nail deformity.

In 1994, Hallock⁷ initially described the use of bone anchors as an “internal fixation” alternative and cited the “expense of the apparatus” as the major drawback of this technique. McCallister and colleagues¹⁵ compared the clinical outcome of suture anchor fixation with that of the button-over-nail technique. Although they ultimately demonstrated that the clinical outcomes of the 2 techniques are not significantly different, they noted that suture anchor fixation is associated with decreased infection rate (7% vs 0%) and time to return to work. Poor bone mineral density and low cortical thickness are correlated with anchor pull-out, thus limiting its universal use.¹⁶ Furthermore, the universal use of many commonly available anchors is limited given that they are too large to be accommodated within many phalanges, particularly in women and in the small and ring fingers.¹⁷  The use of microanchors rather than mini anchors not only decreases this risk but also decreases construct strength, thus necessitating the use of 2 anchors to restore adequate fixation strength. Anchor use is associated with specific risks, including the dorsal migration of the anchor, the osteolysis of the surrounding bone, as well as the perforation of the dorsal cortex and the possible extrusion of the anchor through the phalanx and into the nail bed.^18,19 Additionally, in the wake of a changing healthcare system, the cost of suture anchors, as initially noted by Hallock,⁷ must be considered. This consideration is particularly relevant to the use of a 2 microanchor construct, which has been advocated given its biomechanical advantage.^20,21

Continue to: Transosseous tendon repair...

All internal fixation techniques have been described previously by Sood and Elliot⁸ and, later, by Schultz and colleagues.⁹ In contrast to Sood and Elliott’s⁸ technique, which requires the creation of transverse tunnels, a volar-to-dorsal tunnel is technically easy to create and creates a direct repair to tendon insertion. Our technique is similar to that of Schultz and colleagues'⁹ but has the following differences and potential improvements:

1. Keith needles are passed in a volar-to-dorsal fashion, thus allowing for the direct visualization of the transosseous tunnel origin, minimizing the size of the transosseous tunnels, and allowing for the anatomic reduction of the tendon.
2. Fluoroscopy is used to confirm wire placement prior to skin incision, thus enabling precise placement and potentially allowing the needles to be placed so as to avoid physeal injury in pediatric jersey fingers.
3. By using Keith needles, sutures can be passed with the same instrument that created the tunnel, thus simplifying surgical technique.
4. A Krakow suture technique is used. This technique results in less gapping and higher load-to-failure than other suturing techniques.²²
5. A 2-0 braided suture is used, therefore strengthening repair.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

The avulsion of the flexor digitorum profundus from its insertion, or “jersey finger,” is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

The avulsion-type injury of the flexor digitorum profundus (FDP) from its insertion on the distal phalanx is relatively common. FDP avulsions are seen in athletes and nonathletes, and are the result of the sudden hyperextension of the distal interphalangeal joint during active flexion. These injuries usually occur while grasping the jersey of an opposing player and are thus commonly referred to as “jersey finger.” Initially described in 1977 by Leddy and Packer¹, FDP avulsions are classified on the basis of the proximal extent of the retraction of the FDP and the presence or absence of a bony avulsion fracture fragment. Type I injuries are defined by tendon retraction to the level of the palm, where it is tethered by the lumbricals. At this level, the vinculum longus profundus (VLP) and vinculum brevis profundus (VBP) are ruptured, resulting in the substantial loss of intrinsic and extrinsic vascular supply to the tendon. In type II injuries, which are the most common type of FDP avulsions, the FDP tendon retracts to the level of the proximal interphalangeal (PIP) joint. Although the VBP is disrupted in this scenario, the VLP remains preserved because it arises at the level of the volar plate of the PIP joint.  Type III lesions involve tendon avulsions with an associated bony fragment that is typically sufficiently large to not pass through the flexor sheath, thus limiting retraction to the level of the A4 pulley. Both vincula remain intact, given that the VBP originates at the distal portion of the middle phalanx. The Leddy and Packer classification was later expanded to include type IV and V injury patterns, which are less common than other injury patterns. Similar to type III injuries, type IV injuries involve a bony avulsion; however, the FDP subsequently ruptures from this fragment and the tendon subsequently retracts into the finger or palm.^2,3 Type V injuries are more complex than other injury types because they involve a concomitant distal phalanx fracture with the FDP avulsion.⁴ Al-Qattan⁵ subclassified type V injuries into extra-articular (type Va) and intra-articular (type Vb) distal phalanx fractures on the basis of the distinct management of these 2 entities.

Numerous techniques have been proposed and described for the repair of FDP avulsion injuries. The pullout suture-dorsal button combination is the most widely described technique and was initially described by Bunnell.⁶ Unfortunately, this technique is accompanied by numerous potential postoperative complications.⁶ Nail plate deformity is the most commonly described complication. Other complications include local wound irritation, pain, button snagging, and repair failure. Additionally, the presence of external sutures creates a potential route of ingress for bacterial infection.

Continue to: Bone suture anchor techniques...

SURGICAL TECHNIQUE

TYPES I, II, AND III

A Bruner incision is performed on the volar aspect of the affected finger, and full thickness flaps are elevated off the flexor sheath (Figures 1A-1C). 

TYPES IV AND V

In cases of type IV or V injury (Figure 4A), a screw or plate construct is first used to allow for the successful reduction and fixation of the fracture (Figure 4B). 

DISCUSSION

The avulsion of the FDP tendon from its insertion (zone I) on the distal phalanx is commonly called “jersey finger” and is a well-described injury that occurs most commonly in the ring finger.¹⁰ These injuries can be difficult to treat and are associated with a complication rate of as high as 60%.^11,12 Bunnell’s initial description of a suture passed through the fingernail and then tied over a polypropylene button has been associated with multiple complications. Kang and colleagues¹³ reported abnormal nail growth, nail fold necrosis, fingertip deformity, stiffness, infection, and amputation, 43% of all complications were directly related to the button. As an alternative to the button, sutures may be tied directly over the nail plate itself via 2 separate holes.¹⁴ While this technique eliminates the complications directly associated with the button, the potential for infection remains. Additionally, increased direct pressure is placed on the nail plate and nail bed, thus potentially increasing the risk of nail deformity.

In 1994, Hallock⁷ initially described the use of bone anchors as an “internal fixation” alternative and cited the “expense of the apparatus” as the major drawback of this technique. McCallister and colleagues¹⁵ compared the clinical outcome of suture anchor fixation with that of the button-over-nail technique. Although they ultimately demonstrated that the clinical outcomes of the 2 techniques are not significantly different, they noted that suture anchor fixation is associated with decreased infection rate (7% vs 0%) and time to return to work. Poor bone mineral density and low cortical thickness are correlated with anchor pull-out, thus limiting its universal use.¹⁶ Furthermore, the universal use of many commonly available anchors is limited given that they are too large to be accommodated within many phalanges, particularly in women and in the small and ring fingers.¹⁷  The use of microanchors rather than mini anchors not only decreases this risk but also decreases construct strength, thus necessitating the use of 2 anchors to restore adequate fixation strength. Anchor use is associated with specific risks, including the dorsal migration of the anchor, the osteolysis of the surrounding bone, as well as the perforation of the dorsal cortex and the possible extrusion of the anchor through the phalanx and into the nail bed.^18,19 Additionally, in the wake of a changing healthcare system, the cost of suture anchors, as initially noted by Hallock,⁷ must be considered. This consideration is particularly relevant to the use of a 2 microanchor construct, which has been advocated given its biomechanical advantage.^20,21

Continue to: Transosseous tendon repair...

All internal fixation techniques have been described previously by Sood and Elliot⁸ and, later, by Schultz and colleagues.⁹ In contrast to Sood and Elliott’s⁸ technique, which requires the creation of transverse tunnels, a volar-to-dorsal tunnel is technically easy to create and creates a direct repair to tendon insertion. Our technique is similar to that of Schultz and colleagues'⁹ but has the following differences and potential improvements:

1. Keith needles are passed in a volar-to-dorsal fashion, thus allowing for the direct visualization of the transosseous tunnel origin, minimizing the size of the transosseous tunnels, and allowing for the anatomic reduction of the tendon.
2. Fluoroscopy is used to confirm wire placement prior to skin incision, thus enabling precise placement and potentially allowing the needles to be placed so as to avoid physeal injury in pediatric jersey fingers.
3. By using Keith needles, sutures can be passed with the same instrument that created the tunnel, thus simplifying surgical technique.
4. A Krakow suture technique is used. This technique results in less gapping and higher load-to-failure than other suturing techniques.²²
5. A 2-0 braided suture is used, therefore strengthening repair.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

SAN DIEGO – Between 1980 and 2016, women with RA had a higher rate of small-joint orthopedic surgery procedures than did men, but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.

Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.

dbrunk@frontlinemedcom.com

SAN DIEGO – Between 1980 and 2016, women with RA had a higher rate of small-joint orthopedic surgery procedures than did men, but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.

Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.

dbrunk@frontlinemedcom.com

SAN DIEGO – Between 1980 and 2016, women with RA had a higher rate of small-joint orthopedic surgery procedures than did men, but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.

Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.

dbrunk@frontlinemedcom.com

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

DALLAS – Older patients with carpal tunnel syndrome that requires release surgery appear to have a relatively high prevalence of amyloidosis that, in some, involves their heart, suggesting that routine screening for amyloidosis is warranted in elderly patients undergoing the surgery.

Routine Congo red staining of a tenosynovial biopsy taken at the time of carpal tunnel release surgery in a single-center experience with 96 patients showed that 10 (10%) were positive for amyloidosis, Mazen Hanna, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

DALLAS – Older patients with carpal tunnel syndrome that requires release surgery appear to have a relatively high prevalence of amyloidosis that, in some, involves their heart, suggesting that routine screening for amyloidosis is warranted in elderly patients undergoing the surgery.

Routine Congo red staining of a tenosynovial biopsy taken at the time of carpal tunnel release surgery in a single-center experience with 96 patients showed that 10 (10%) were positive for amyloidosis, Mazen Hanna, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

DALLAS – Older patients with carpal tunnel syndrome that requires release surgery appear to have a relatively high prevalence of amyloidosis that, in some, involves their heart, suggesting that routine screening for amyloidosis is warranted in elderly patients undergoing the surgery.

Routine Congo red staining of a tenosynovial biopsy taken at the time of carpal tunnel release surgery in a single-center experience with 96 patients showed that 10 (10%) were positive for amyloidosis, Mazen Hanna, MD, said at the annual scientific meeting of the Heart Failure Society of America.

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

Take-Home Points

• Analysis of patients in the Medicare database showed that each successive ESI decreased the risk of an osteoporotic spine fracture by 2%, and that each successive LJSI decreases it by 4%.

• Although statistically significant, this may not be clinically relevant.

• Successive ESI did not influence the risk of developing an osteoporotic hip or wrist fracture, but that each additional LJSI reduced the risk.

• Prolonged steroid exposure was found to increase the risk of spine fracture for ESI and LJSI patients.

• Acute exposure to exogenous steroids via the epidural space, transforaminal space, or large joints does not seem to increase the risk of an osteoporotic fracture of the spine, hip, or wrist.

Epidural steroid injections (ESIs) are widely used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. The treatment rationale is that locally injected anti-inflammatory drugs, such as steroids, reduce inflammation by inhibiting formation and release of inflammatory cytokines, leading to pain reduction.^1,2 According to 4 systematic reviews, the best available evidence of the efficacy of ESIs is less than robust.^3-6 These reviews were limited by the heterogeneity of patient selection, delivery mode, type and dose of steroid used, number and frequency of ESIs, and outcome measures.

The association of chronic oral steroid use and the development of osteoporosis was previously established.^7,8 One concern is that acute exposure to steroids in the form of lumbar ESIs may also lead to osteoporosis and then a pathologic fracture of the vertebra. Several studies have found no association between bone mineral density and cumulative steroid dose,^9,10 mean number of ESIs, or duration of ESIs,¹⁰ though other studies have found lower bone mineral density in postmenopausal women treated with ESIs.^11-13

In a study of 3000 ESI patients propensity-matched to a non-ESI cohort, Mandel and colleagues¹⁴ found that each successive ESI increased the risk of osteoporotic spine fracture by 21%. This clinically relevant 21% increased risk might lead physicians to stop prescribing or using this intervention. However, the association between osteoporotic fractures and other types of steroid injections remains poorly understood and underinvestigated. 

To further evaluate the relationship between steroid injections and osteoporotic fracture risk, we analyzed Medicare administrative claims data on both large-joint steroid injections (LJSIs) into knee and hip and transforaminal steroid injections (TSIs), as well as osteoporotic hip and wrist fractures. Our hypothesis was that a systemic effect of steroid injections would increase fracture risk in all skeletal locations regardless of injection site, whereas a local effect would produce a disproportionate increased risk of spine fracture with spine injection.

Materials and Methods

Medicare is a publicly funded US health insurance program for people 65 years old or older, people under age 65 years with certain disabilities, and people (any age) with end-stage renal disease or amyotrophic lateral sclerosis. The 5% Medicare Part B (physician, carrier) dataset contains individual claims records for a random sample of Medicare beneficiaries (~2.4 million enrollees). Patients who received steroid injections were identified from 5% Medicare claims made between January 1, 2004 and December 31, 2011. LJSIs were identified by Current Procedural Terminology (CPT) code 20610 and any of 16 other CPT codes: J0702, J1020, J1030, J1040, J1094, J1100, J1700, J1710, J1720, J2650, J2920, J2930, J3300, J3301, J3302, and J3303. ESIs were identified by CPT code 62310, 62311, 62318, or 62319, and TSIs by CPT code 64479, 64480, 64483, or 64484. Patients were followed in their initial injection cohort. For example, a patient who received an ESI initially and later received an LJSI remained in the ESI cohort.

Several groups of patients were excluded from the study: those who received Medicare coverage because of their age (under 65 years) and disabilities; those who received Medicare health benefits through health maintenance organizations (healthcare expenses were not submitted to the Centers for Medicare & Medicaid Services for payment, and therefore claims were not in the database or were incomplete); those with a prior claim history of <12 months (incomplete comorbidity history); and those who received a diagnosis of osteoporotic fracture (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 733.1x) before the initial steroid injection.

We determined the incidence of osteoporotic wrist, hip, and spine fractures within 1, 2, and 8 years after LJSI, ESI, and TSI. Wrist, hip, and spine fractures were identified by ICD-9-CM diagnosis codes 733.12, 733.13, and 733.14, respectively. We also determined the number of steroid injections given before wrist, hip, or spine fracture or, if no fracture occurred, before death or the end of the data period.

Statistical Analysis

Multivariate Cox regression analysis was performed to evaluate the risk factors for wrist, spine, and hip fractures. The covariates in this model included age, sex, race, census region, Medicare buy-in status, Charlson Comorbidity Index (CCI),¹⁵ year, and number of steroid injections before fracture, death, or end of data period. Medicare buy-in status, which indicates whether the beneficiary received financial assistance in paying insurance premiums, was used as a proxy for socioeconomic status. CCI is used as a composite score of a patient’s general health status in terms of comorbidities.^15,16 Four previously established categories¹⁷ were used to group CCIs in this study: 0 (none), 1 to 2 (low), 3 to 4 (moderate), and 5 or more (high). In addition, several diagnoses made within the 12 months before initial steroid injection were considered: osteoporosis (ICD-9-CM codes 733.0x, V82.81), Cushing syndrome (ICD-9-CM code 255.0), long-term (current) use of bisphosphonates (ICD-9-CM code V58.68), asymptomatic postmenopausal status (ICD-9-CM code V49.81), postmenopausal hormone replacement therapy (ICD-9-CM code V07.4), and long-term (current) use of steroids (ICD-9-CM code V58.65). The comparison of relative risk between any groups was reported as the adjusted hazard ratio (AHR), which is the ratio of the hazard rates of that particular outcome, taking into account inherent patient characteristics such as age, sex, and race as covariates. AHR of 1 corresponds to equivalent risk, AHR of >1 to elevated risk, and AHR of <1 to reduced risk.

Results

Using the 5% Medicare data for 2004 to 2011, we identified 275,999 Medicare beneficiaries who underwent LJSI, 93,943 who underwent ESI, and 32,311 who underwent TSI. During this period, TSI use increased, ESI use decreased, and LJSI use was relatively stable (Figure).

The risk for osteoporotic spine fracture 1, 2, and 8 years after ESI, TSI, or LJSI was affected by age, race, sex, and CCI (P < .001 for all; Tables 2-4).

The risk for osteoporotic hip fracture after 1 and 2 years was affected by age and number of LJSIs and TSIs but not by number of ESIs. Sex and CCI were also risk factors for hip fracture at 1 and 2 years for ESI and LJSI patients, as was race for LJSI patients. Risk for osteoporotic wrist fracture at 1 and 2 years was affected by sex and race for ESI and LJSI patients; age, race, CCI, and long-term steroid use were risk factors for TSI patients at all time points. Higher number of LJSIs, but not ESIs or TSIs, was associated with lower wrist fracture risk.

Discussion

ESIs continue to be used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. Although the present study found ESI use increased in the Medicare population between 1994 and 2001,¹⁸ the trend is reversing, decreasing by 25%, with rates of 264 per 10,000 Medicare enrollees in 2004 and 194 per 10,000 enrollees in 2011. ESI use may have changed after systematic reviews revealed there was no clear evidence of the efficacy of ESIs in managing low back pain and radicular leg pain^3,5,6 or spinal stenosis.⁴

Nevertheless, ESIs are widely used because of the perceived benefit balanced against the perceived rarity of adverse events.⁶ Even if patients recognize a low likelihood of significant benefit, they may accept ESI as preferable to surgery. In addition, most private payers require extensive nonoperative treatment before they will approve surgery as a treatment option.

In a study by Mandel and colleagues,¹⁴ ESI increased the risk of vertebral compression fractures by 21%, which in turn increased the risk of death.¹⁹ If accurate, these findings obviously would challenge the perception that ESI is a low-risk intervention. In contrast to the Mandel study,¹⁴ the present analysis of the Medicare population revealed no clinically relevant change in risk of osteoporotic spine fracture with each successive ESI after the initial injection. After the initial injection, each successive ESI decreased the relative risk of osteoporotic spine fracture by 2%, and each successive LJSI decreased it by 4%. Although statistically significant, the small change in relative risk may not be clinically relevant. However, taken cumulatively over a number of successive injections, these effects may be clinically relevant.

The data also showed that, after the initial injection, each successive ESI had no effect on risk of osteoporotic hip or wrist fracture, and each successive LJSI reduced the risk. Similar to earlier findings,^20,21 long-term steroid use increased the risk of spine fracture in ESI and LJSI patients. Prolonged exposure to steroids may be necessary to reduce bone formation and increase bone breakdown.¹²

Although the study by Mandel and colleagues¹⁴ and our study both used administrative databases and survival analysis methods, conclusions differed. First, Mandel and colleagues¹⁴ used a study inclusion criterion of spine-related steroid injections, whereas we used a criterion of any steroid injection. Second, they used 50 years as the lower age for study inclusion, and we used 65 years. Third, to control for patients who had osteoporosis before study entry, they excluded those who had a fracture in an adjacent vertebra after kyphoplasty and vertebroplasty. It is unclear if patients who had osteoporotic fractures at other sites were excluded as well. Thus, the 2 cohorts may not be directly comparable.

Whereas Mandel and colleagues¹⁴ based their definition of osteoporotic spine fracture on a keyword search of a radiology database, we used a specific reportable ICD-9-CM diagnosis code. As a result, they may have overreported osteoporotic spine fractures, and we may have underreported. Finally, our sample was much larger than theirs. Given the relative rarity of osteoporotic fractures, a study with a larger sample may have more power to detect differences. In addition, unlike Mandel and colleagues,¹⁴ we focused on an injection cohort. We did not include or make comparisons with a no-injection cohort because our study hypothesis involved the potential systemic effects of steroid injections based on injection site. Although chronic steroid use was found to have a significant effect in our study, it is unclear to what extent the diagnosis code was used, during the comorbidity assessment or only in the event of steroid-related complications.

Our study also found that, after the initial injection, each successive LJSI decreased the risk of osteoporotic wrist fracture by 10%, and each successive TSI decreased the risk of osteoporotic hip fracture by 5%. It is plausible these injections allowed improved mobility, mitigating the effects of osteoporosis induced by inactivity and lack of resistance training. It is also possible that improved mobility limited falls.

In summary, this analysis of the Medicare claims database revealed that ESI, TSI, and LJSI decreased osteoporotic spine fracture risk. However, the effect was small and may not be clinically meaningful. After the initial injection, successive ESIs had no effect on the risk of osteoporotic hip or wrist fracture, and successive LJSIs reduced the risk of osteoporotic wrist fracture, perhaps because of improved mobility. Prolonged oral steroid use increased spine fracture risk in ESI and LJSI patients. More studies are needed to evaluate the risk-benefit profile of steroid injections.

Take-Home Points

• Analysis of patients in the Medicare database showed that each successive ESI decreased the risk of an osteoporotic spine fracture by 2%, and that each successive LJSI decreases it by 4%.

• Although statistically significant, this may not be clinically relevant.

• Successive ESI did not influence the risk of developing an osteoporotic hip or wrist fracture, but that each additional LJSI reduced the risk.

• Prolonged steroid exposure was found to increase the risk of spine fracture for ESI and LJSI patients.

• Acute exposure to exogenous steroids via the epidural space, transforaminal space, or large joints does not seem to increase the risk of an osteoporotic fracture of the spine, hip, or wrist.

Epidural steroid injections (ESIs) are widely used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. The treatment rationale is that locally injected anti-inflammatory drugs, such as steroids, reduce inflammation by inhibiting formation and release of inflammatory cytokines, leading to pain reduction.^1,2 According to 4 systematic reviews, the best available evidence of the efficacy of ESIs is less than robust.^3-6 These reviews were limited by the heterogeneity of patient selection, delivery mode, type and dose of steroid used, number and frequency of ESIs, and outcome measures.

The association of chronic oral steroid use and the development of osteoporosis was previously established.^7,8 One concern is that acute exposure to steroids in the form of lumbar ESIs may also lead to osteoporosis and then a pathologic fracture of the vertebra. Several studies have found no association between bone mineral density and cumulative steroid dose,^9,10 mean number of ESIs, or duration of ESIs,¹⁰ though other studies have found lower bone mineral density in postmenopausal women treated with ESIs.^11-13

In a study of 3000 ESI patients propensity-matched to a non-ESI cohort, Mandel and colleagues¹⁴ found that each successive ESI increased the risk of osteoporotic spine fracture by 21%. This clinically relevant 21% increased risk might lead physicians to stop prescribing or using this intervention. However, the association between osteoporotic fractures and other types of steroid injections remains poorly understood and underinvestigated. 

To further evaluate the relationship between steroid injections and osteoporotic fracture risk, we analyzed Medicare administrative claims data on both large-joint steroid injections (LJSIs) into knee and hip and transforaminal steroid injections (TSIs), as well as osteoporotic hip and wrist fractures. Our hypothesis was that a systemic effect of steroid injections would increase fracture risk in all skeletal locations regardless of injection site, whereas a local effect would produce a disproportionate increased risk of spine fracture with spine injection.

Materials and Methods

Medicare is a publicly funded US health insurance program for people 65 years old or older, people under age 65 years with certain disabilities, and people (any age) with end-stage renal disease or amyotrophic lateral sclerosis. The 5% Medicare Part B (physician, carrier) dataset contains individual claims records for a random sample of Medicare beneficiaries (~2.4 million enrollees). Patients who received steroid injections were identified from 5% Medicare claims made between January 1, 2004 and December 31, 2011. LJSIs were identified by Current Procedural Terminology (CPT) code 20610 and any of 16 other CPT codes: J0702, J1020, J1030, J1040, J1094, J1100, J1700, J1710, J1720, J2650, J2920, J2930, J3300, J3301, J3302, and J3303. ESIs were identified by CPT code 62310, 62311, 62318, or 62319, and TSIs by CPT code 64479, 64480, 64483, or 64484. Patients were followed in their initial injection cohort. For example, a patient who received an ESI initially and later received an LJSI remained in the ESI cohort.

Several groups of patients were excluded from the study: those who received Medicare coverage because of their age (under 65 years) and disabilities; those who received Medicare health benefits through health maintenance organizations (healthcare expenses were not submitted to the Centers for Medicare & Medicaid Services for payment, and therefore claims were not in the database or were incomplete); those with a prior claim history of <12 months (incomplete comorbidity history); and those who received a diagnosis of osteoporotic fracture (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 733.1x) before the initial steroid injection.

We determined the incidence of osteoporotic wrist, hip, and spine fractures within 1, 2, and 8 years after LJSI, ESI, and TSI. Wrist, hip, and spine fractures were identified by ICD-9-CM diagnosis codes 733.12, 733.13, and 733.14, respectively. We also determined the number of steroid injections given before wrist, hip, or spine fracture or, if no fracture occurred, before death or the end of the data period.

Statistical Analysis

Multivariate Cox regression analysis was performed to evaluate the risk factors for wrist, spine, and hip fractures. The covariates in this model included age, sex, race, census region, Medicare buy-in status, Charlson Comorbidity Index (CCI),¹⁵ year, and number of steroid injections before fracture, death, or end of data period. Medicare buy-in status, which indicates whether the beneficiary received financial assistance in paying insurance premiums, was used as a proxy for socioeconomic status. CCI is used as a composite score of a patient’s general health status in terms of comorbidities.^15,16 Four previously established categories¹⁷ were used to group CCIs in this study: 0 (none), 1 to 2 (low), 3 to 4 (moderate), and 5 or more (high). In addition, several diagnoses made within the 12 months before initial steroid injection were considered: osteoporosis (ICD-9-CM codes 733.0x, V82.81), Cushing syndrome (ICD-9-CM code 255.0), long-term (current) use of bisphosphonates (ICD-9-CM code V58.68), asymptomatic postmenopausal status (ICD-9-CM code V49.81), postmenopausal hormone replacement therapy (ICD-9-CM code V07.4), and long-term (current) use of steroids (ICD-9-CM code V58.65). The comparison of relative risk between any groups was reported as the adjusted hazard ratio (AHR), which is the ratio of the hazard rates of that particular outcome, taking into account inherent patient characteristics such as age, sex, and race as covariates. AHR of 1 corresponds to equivalent risk, AHR of >1 to elevated risk, and AHR of <1 to reduced risk.

Results

Using the 5% Medicare data for 2004 to 2011, we identified 275,999 Medicare beneficiaries who underwent LJSI, 93,943 who underwent ESI, and 32,311 who underwent TSI. During this period, TSI use increased, ESI use decreased, and LJSI use was relatively stable (Figure).

The risk for osteoporotic spine fracture 1, 2, and 8 years after ESI, TSI, or LJSI was affected by age, race, sex, and CCI (P < .001 for all; Tables 2-4).

The risk for osteoporotic hip fracture after 1 and 2 years was affected by age and number of LJSIs and TSIs but not by number of ESIs. Sex and CCI were also risk factors for hip fracture at 1 and 2 years for ESI and LJSI patients, as was race for LJSI patients. Risk for osteoporotic wrist fracture at 1 and 2 years was affected by sex and race for ESI and LJSI patients; age, race, CCI, and long-term steroid use were risk factors for TSI patients at all time points. Higher number of LJSIs, but not ESIs or TSIs, was associated with lower wrist fracture risk.

Discussion

ESIs continue to be used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. Although the present study found ESI use increased in the Medicare population between 1994 and 2001,¹⁸ the trend is reversing, decreasing by 25%, with rates of 264 per 10,000 Medicare enrollees in 2004 and 194 per 10,000 enrollees in 2011. ESI use may have changed after systematic reviews revealed there was no clear evidence of the efficacy of ESIs in managing low back pain and radicular leg pain^3,5,6 or spinal stenosis.⁴

Nevertheless, ESIs are widely used because of the perceived benefit balanced against the perceived rarity of adverse events.⁶ Even if patients recognize a low likelihood of significant benefit, they may accept ESI as preferable to surgery. In addition, most private payers require extensive nonoperative treatment before they will approve surgery as a treatment option.

In a study by Mandel and colleagues,¹⁴ ESI increased the risk of vertebral compression fractures by 21%, which in turn increased the risk of death.¹⁹ If accurate, these findings obviously would challenge the perception that ESI is a low-risk intervention. In contrast to the Mandel study,¹⁴ the present analysis of the Medicare population revealed no clinically relevant change in risk of osteoporotic spine fracture with each successive ESI after the initial injection. After the initial injection, each successive ESI decreased the relative risk of osteoporotic spine fracture by 2%, and each successive LJSI decreased it by 4%. Although statistically significant, the small change in relative risk may not be clinically relevant. However, taken cumulatively over a number of successive injections, these effects may be clinically relevant.

The data also showed that, after the initial injection, each successive ESI had no effect on risk of osteoporotic hip or wrist fracture, and each successive LJSI reduced the risk. Similar to earlier findings,^20,21 long-term steroid use increased the risk of spine fracture in ESI and LJSI patients. Prolonged exposure to steroids may be necessary to reduce bone formation and increase bone breakdown.¹²

Although the study by Mandel and colleagues¹⁴ and our study both used administrative databases and survival analysis methods, conclusions differed. First, Mandel and colleagues¹⁴ used a study inclusion criterion of spine-related steroid injections, whereas we used a criterion of any steroid injection. Second, they used 50 years as the lower age for study inclusion, and we used 65 years. Third, to control for patients who had osteoporosis before study entry, they excluded those who had a fracture in an adjacent vertebra after kyphoplasty and vertebroplasty. It is unclear if patients who had osteoporotic fractures at other sites were excluded as well. Thus, the 2 cohorts may not be directly comparable.

Whereas Mandel and colleagues¹⁴ based their definition of osteoporotic spine fracture on a keyword search of a radiology database, we used a specific reportable ICD-9-CM diagnosis code. As a result, they may have overreported osteoporotic spine fractures, and we may have underreported. Finally, our sample was much larger than theirs. Given the relative rarity of osteoporotic fractures, a study with a larger sample may have more power to detect differences. In addition, unlike Mandel and colleagues,¹⁴ we focused on an injection cohort. We did not include or make comparisons with a no-injection cohort because our study hypothesis involved the potential systemic effects of steroid injections based on injection site. Although chronic steroid use was found to have a significant effect in our study, it is unclear to what extent the diagnosis code was used, during the comorbidity assessment or only in the event of steroid-related complications.

Our study also found that, after the initial injection, each successive LJSI decreased the risk of osteoporotic wrist fracture by 10%, and each successive TSI decreased the risk of osteoporotic hip fracture by 5%. It is plausible these injections allowed improved mobility, mitigating the effects of osteoporosis induced by inactivity and lack of resistance training. It is also possible that improved mobility limited falls.

In summary, this analysis of the Medicare claims database revealed that ESI, TSI, and LJSI decreased osteoporotic spine fracture risk. However, the effect was small and may not be clinically meaningful. After the initial injection, successive ESIs had no effect on the risk of osteoporotic hip or wrist fracture, and successive LJSIs reduced the risk of osteoporotic wrist fracture, perhaps because of improved mobility. Prolonged oral steroid use increased spine fracture risk in ESI and LJSI patients. More studies are needed to evaluate the risk-benefit profile of steroid injections.

Take-Home Points

• Analysis of patients in the Medicare database showed that each successive ESI decreased the risk of an osteoporotic spine fracture by 2%, and that each successive LJSI decreases it by 4%.

• Although statistically significant, this may not be clinically relevant.

• Successive ESI did not influence the risk of developing an osteoporotic hip or wrist fracture, but that each additional LJSI reduced the risk.

• Prolonged steroid exposure was found to increase the risk of spine fracture for ESI and LJSI patients.

• Acute exposure to exogenous steroids via the epidural space, transforaminal space, or large joints does not seem to increase the risk of an osteoporotic fracture of the spine, hip, or wrist.

Epidural steroid injections (ESIs) are widely used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. The treatment rationale is that locally injected anti-inflammatory drugs, such as steroids, reduce inflammation by inhibiting formation and release of inflammatory cytokines, leading to pain reduction.^1,2 According to 4 systematic reviews, the best available evidence of the efficacy of ESIs is less than robust.^3-6 These reviews were limited by the heterogeneity of patient selection, delivery mode, type and dose of steroid used, number and frequency of ESIs, and outcome measures.

The association of chronic oral steroid use and the development of osteoporosis was previously established.^7,8 One concern is that acute exposure to steroids in the form of lumbar ESIs may also lead to osteoporosis and then a pathologic fracture of the vertebra. Several studies have found no association between bone mineral density and cumulative steroid dose,^9,10 mean number of ESIs, or duration of ESIs,¹⁰ though other studies have found lower bone mineral density in postmenopausal women treated with ESIs.^11-13

In a study of 3000 ESI patients propensity-matched to a non-ESI cohort, Mandel and colleagues¹⁴ found that each successive ESI increased the risk of osteoporotic spine fracture by 21%. This clinically relevant 21% increased risk might lead physicians to stop prescribing or using this intervention. However, the association between osteoporotic fractures and other types of steroid injections remains poorly understood and underinvestigated. 

To further evaluate the relationship between steroid injections and osteoporotic fracture risk, we analyzed Medicare administrative claims data on both large-joint steroid injections (LJSIs) into knee and hip and transforaminal steroid injections (TSIs), as well as osteoporotic hip and wrist fractures. Our hypothesis was that a systemic effect of steroid injections would increase fracture risk in all skeletal locations regardless of injection site, whereas a local effect would produce a disproportionate increased risk of spine fracture with spine injection.

Materials and Methods

Medicare is a publicly funded US health insurance program for people 65 years old or older, people under age 65 years with certain disabilities, and people (any age) with end-stage renal disease or amyotrophic lateral sclerosis. The 5% Medicare Part B (physician, carrier) dataset contains individual claims records for a random sample of Medicare beneficiaries (~2.4 million enrollees). Patients who received steroid injections were identified from 5% Medicare claims made between January 1, 2004 and December 31, 2011. LJSIs were identified by Current Procedural Terminology (CPT) code 20610 and any of 16 other CPT codes: J0702, J1020, J1030, J1040, J1094, J1100, J1700, J1710, J1720, J2650, J2920, J2930, J3300, J3301, J3302, and J3303. ESIs were identified by CPT code 62310, 62311, 62318, or 62319, and TSIs by CPT code 64479, 64480, 64483, or 64484. Patients were followed in their initial injection cohort. For example, a patient who received an ESI initially and later received an LJSI remained in the ESI cohort.

Several groups of patients were excluded from the study: those who received Medicare coverage because of their age (under 65 years) and disabilities; those who received Medicare health benefits through health maintenance organizations (healthcare expenses were not submitted to the Centers for Medicare & Medicaid Services for payment, and therefore claims were not in the database or were incomplete); those with a prior claim history of <12 months (incomplete comorbidity history); and those who received a diagnosis of osteoporotic fracture (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 733.1x) before the initial steroid injection.

We determined the incidence of osteoporotic wrist, hip, and spine fractures within 1, 2, and 8 years after LJSI, ESI, and TSI. Wrist, hip, and spine fractures were identified by ICD-9-CM diagnosis codes 733.12, 733.13, and 733.14, respectively. We also determined the number of steroid injections given before wrist, hip, or spine fracture or, if no fracture occurred, before death or the end of the data period.

Statistical Analysis

Multivariate Cox regression analysis was performed to evaluate the risk factors for wrist, spine, and hip fractures. The covariates in this model included age, sex, race, census region, Medicare buy-in status, Charlson Comorbidity Index (CCI),¹⁵ year, and number of steroid injections before fracture, death, or end of data period. Medicare buy-in status, which indicates whether the beneficiary received financial assistance in paying insurance premiums, was used as a proxy for socioeconomic status. CCI is used as a composite score of a patient’s general health status in terms of comorbidities.^15,16 Four previously established categories¹⁷ were used to group CCIs in this study: 0 (none), 1 to 2 (low), 3 to 4 (moderate), and 5 or more (high). In addition, several diagnoses made within the 12 months before initial steroid injection were considered: osteoporosis (ICD-9-CM codes 733.0x, V82.81), Cushing syndrome (ICD-9-CM code 255.0), long-term (current) use of bisphosphonates (ICD-9-CM code V58.68), asymptomatic postmenopausal status (ICD-9-CM code V49.81), postmenopausal hormone replacement therapy (ICD-9-CM code V07.4), and long-term (current) use of steroids (ICD-9-CM code V58.65). The comparison of relative risk between any groups was reported as the adjusted hazard ratio (AHR), which is the ratio of the hazard rates of that particular outcome, taking into account inherent patient characteristics such as age, sex, and race as covariates. AHR of 1 corresponds to equivalent risk, AHR of >1 to elevated risk, and AHR of <1 to reduced risk.

Results

Using the 5% Medicare data for 2004 to 2011, we identified 275,999 Medicare beneficiaries who underwent LJSI, 93,943 who underwent ESI, and 32,311 who underwent TSI. During this period, TSI use increased, ESI use decreased, and LJSI use was relatively stable (Figure).

The risk for osteoporotic spine fracture 1, 2, and 8 years after ESI, TSI, or LJSI was affected by age, race, sex, and CCI (P < .001 for all; Tables 2-4).

The risk for osteoporotic hip fracture after 1 and 2 years was affected by age and number of LJSIs and TSIs but not by number of ESIs. Sex and CCI were also risk factors for hip fracture at 1 and 2 years for ESI and LJSI patients, as was race for LJSI patients. Risk for osteoporotic wrist fracture at 1 and 2 years was affected by sex and race for ESI and LJSI patients; age, race, CCI, and long-term steroid use were risk factors for TSI patients at all time points. Higher number of LJSIs, but not ESIs or TSIs, was associated with lower wrist fracture risk.

Discussion

ESIs continue to be used in the nonoperative treatment of low back pain, radicular leg pain, and spinal stenosis. Although the present study found ESI use increased in the Medicare population between 1994 and 2001,¹⁸ the trend is reversing, decreasing by 25%, with rates of 264 per 10,000 Medicare enrollees in 2004 and 194 per 10,000 enrollees in 2011. ESI use may have changed after systematic reviews revealed there was no clear evidence of the efficacy of ESIs in managing low back pain and radicular leg pain^3,5,6 or spinal stenosis.⁴

Nevertheless, ESIs are widely used because of the perceived benefit balanced against the perceived rarity of adverse events.⁶ Even if patients recognize a low likelihood of significant benefit, they may accept ESI as preferable to surgery. In addition, most private payers require extensive nonoperative treatment before they will approve surgery as a treatment option.

In a study by Mandel and colleagues,¹⁴ ESI increased the risk of vertebral compression fractures by 21%, which in turn increased the risk of death.¹⁹ If accurate, these findings obviously would challenge the perception that ESI is a low-risk intervention. In contrast to the Mandel study,¹⁴ the present analysis of the Medicare population revealed no clinically relevant change in risk of osteoporotic spine fracture with each successive ESI after the initial injection. After the initial injection, each successive ESI decreased the relative risk of osteoporotic spine fracture by 2%, and each successive LJSI decreased it by 4%. Although statistically significant, the small change in relative risk may not be clinically relevant. However, taken cumulatively over a number of successive injections, these effects may be clinically relevant.

The data also showed that, after the initial injection, each successive ESI had no effect on risk of osteoporotic hip or wrist fracture, and each successive LJSI reduced the risk. Similar to earlier findings,^20,21 long-term steroid use increased the risk of spine fracture in ESI and LJSI patients. Prolonged exposure to steroids may be necessary to reduce bone formation and increase bone breakdown.¹²

Although the study by Mandel and colleagues¹⁴ and our study both used administrative databases and survival analysis methods, conclusions differed. First, Mandel and colleagues¹⁴ used a study inclusion criterion of spine-related steroid injections, whereas we used a criterion of any steroid injection. Second, they used 50 years as the lower age for study inclusion, and we used 65 years. Third, to control for patients who had osteoporosis before study entry, they excluded those who had a fracture in an adjacent vertebra after kyphoplasty and vertebroplasty. It is unclear if patients who had osteoporotic fractures at other sites were excluded as well. Thus, the 2 cohorts may not be directly comparable.

Whereas Mandel and colleagues¹⁴ based their definition of osteoporotic spine fracture on a keyword search of a radiology database, we used a specific reportable ICD-9-CM diagnosis code. As a result, they may have overreported osteoporotic spine fractures, and we may have underreported. Finally, our sample was much larger than theirs. Given the relative rarity of osteoporotic fractures, a study with a larger sample may have more power to detect differences. In addition, unlike Mandel and colleagues,¹⁴ we focused on an injection cohort. We did not include or make comparisons with a no-injection cohort because our study hypothesis involved the potential systemic effects of steroid injections based on injection site. Although chronic steroid use was found to have a significant effect in our study, it is unclear to what extent the diagnosis code was used, during the comorbidity assessment or only in the event of steroid-related complications.

Our study also found that, after the initial injection, each successive LJSI decreased the risk of osteoporotic wrist fracture by 10%, and each successive TSI decreased the risk of osteoporotic hip fracture by 5%. It is plausible these injections allowed improved mobility, mitigating the effects of osteoporosis induced by inactivity and lack of resistance training. It is also possible that improved mobility limited falls.

In summary, this analysis of the Medicare claims database revealed that ESI, TSI, and LJSI decreased osteoporotic spine fracture risk. However, the effect was small and may not be clinically meaningful. After the initial injection, successive ESIs had no effect on the risk of osteoporotic hip or wrist fracture, and successive LJSIs reduced the risk of osteoporotic wrist fracture, perhaps because of improved mobility. Prolonged oral steroid use increased spine fracture risk in ESI and LJSI patients. More studies are needed to evaluate the risk-benefit profile of steroid injections.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.

Take-Home Points

• The author had a 90% success rate with no complications in treating almost 600 trigger digits.
• All digits can be safely treated, including multiple fingers on one hand, all in an office setting.
• Percutaneous trigger release appears to be a safe and reliable alternative to open surgery.
• Success rate, discomfort, and cost may make a percutaneous trigger release preferable to even a trial of corticosteroid injection.
• A failed percutaneous release can be successfully treated with an open release, if needed.

Trigger finger, or stenosing flexor tenosynovitis, is a condition characterized by clicking or locking during finger movement, sometimes resulting in the freezing of a digit in flexion or extension¹ (Figure 1). [[{"fid":"202300","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]Tendon inflammation is thought to cause constriction of the tendon sheath and bunching of the fibrous bundles of the first annular (A1) pulley, often creating a palpable nodule at the base of the digit.^2,3 Many patients experience intermittent joint pain and swelling, which may progress to triggering or complete locking of the digit.¹ One of the most common conditions treated by hand surgeons, trigger finger is most often reported in the dominant hand of women in their sixth decade of life and has been associated with several conditions, including diabetes and rheumatoid arthritis.^4-6 Other researchers have indicated the thumb and ring finger are most commonly affected, though all fingers can potentially trigger.^7,8

Initial treatment often involves injecting corticosteroid into the flexor tendon sheath, at or proximal to the annular pulley system, to reduce inflammation and the fibrous nodule.³ Another injection study found an initial success rate of 57% with a single injection, and 86% with a second injection, but patients were monitored for only 6 months, a period that may have been too short for symptom recurrence.⁷

On failure of steroid injections, patients typically are treated with open tendon sheath incision.⁹ This procedure, usually performed in a hospital or outpatient surgery setting, requires postoperative wound care, including dressing changes, suture removal, possible hand therapy, and follow-up physician visits. Operative treatment involves making a 1-cm to 2-cm incision, releasing the A1 pulley, and skin suturing.^7,8,10 The most common postoperative complaint is incisional tenderness, though long-term scar pain, infection, nerve injury, and disease recurrence have been reported.⁸ Overall, the procedure is very successful, providing up to 100% symptom relief.^7,8,10

Endoscopic release of trigger finger has also been described as an effective operative treatment. This technique involves passing a small cannula through a palmar incision—using an endoscope and retrograde knife within this 2.7-mm tunnel.¹⁰ With this treatment, reduced visibility may increase the risk of nerve injury.¹⁰ Although generally successful, endoscopic release requires anesthesia and expensive instruments and has a significant learning curve.^8,10

More recently, percutaneous release of trigger finger has been described as a definitive, in-office treatment.^5,6,11,12 Percutaneous release has the obvious advantages of no open incision, less scarring, less discomfort, and shorter recovery. Several studies have found comparable success rates for open and percutaneous procedures but consistently shorter recovery with the percutaneous technique.^7,8,12 Given its lower recurrence rate (vs steroid injections) and shorter recovery and lower cost (vs a surgical procedure), percutaneous treatment of stenosing tenosynovitis appears to be a safe, highly successful, and minimally invasive treatment method.⁸ This study represents a single surgeon’s experience with percutaneous tendon sheath incision over a 10-year period.

Methods

Patients presented with symptoms of stenosing flexor tenosynovitis with severity ranging from intermittent triggering to frank locking of the digit. Most patients underwent prior conservative treatment, including corticosteroid injections and hand therapy. With each patient, the senior author discussed the pathophysiology of trigger digit; treatment options, including observation, hand therapy, corticosteroid injection, percutaneous release, and open release; and potential risks and complications. The treatment path—initial corticosteroid injection, percutaneous release, or open release—was left up to the patient. The only exclusion criterion was prior surgery to the involved digit, and there was no discrimination by finger, symptomatic period, or severity. Each released digit was recorded independently. In no case was anticoagulant therapy discontinued.
A complete medical history was obtained for each patient.

Over a 10-year period (March 2003-December 2013), percutaneous release was performed on 596 trigger fingers in 429 patients, 18 years old or older. Of these patients, 279 were female. Mean age was 62 years (range, 26-97 years). Of the 531 releases with handedness recorded, 56.3% were performed on trigger digits on dominant hands (Table 1). [[{"fid":"202302","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Table 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Table 1.","field_file_image_credit[und][0][value]":""}}}]]Mean duration of symptoms before percutaneous release was 9.7 months (range, 0.5-132 months). Of the 596 digits, 69 were reported to have previously sustained trauma, and 161 had been unsuccessfully treated with one or more cortisone injections before undergoing release. Of the suspected comorbidities examined, carpal tunnel syndrome was previously diagnosed in 79 patients and diabetes in 56 patients.¹

Of the 429 patients, 313 had a single digit released and 116 had multiple digits released. Of the 116 patients in the multiple-release group, 80 had 2 fingers released, 24 had 3 released, 7 had 4 released, and 5 had 5 released. The 596 released trigger fingers consisted of 188 thumbs, 41 index fingers, 185 middle fingers, 140 ring fingers, and 42 small fingers.

Surgical Technique

In-office percutaneous trigger finger releases were performed with a local anesthetic. One milliliter of lidocaine 1% injection was used to anesthetize the skin, the subcutaneous tissues, and the flexor tendon sheath at the level of the A1 pulley. As described by Pandey and colleagues,⁶ the proper location of the pulley was confirmed using specific surface landmarks on each digit. After waiting several minutes to allow the anesthetic to take effect, the surgeon inserted an 18-gauge needle into the center of the pulley with the digit held in extension (Figure 2). [[{"fid":"202303","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]The needle was carefully moved longitudinally along the length of the pulley with the bevel of the needle parallel to the tendon. A grating sensation was felt as the fibers of the pulley were cut. Several needle passes were made until the pulley was felt to have been released. Complete release was determined by loss of the grating sensation, along with complete relief of any further symptoms of triggering. The puncture site was cleaned and covered with a light sterile dressing (watch the Video online). There was no postoperative immobilization, and patients were encouraged to immediately return to normal use of the digit. Hand therapy was not prescribed, and pain medications were not dispensed. A 1-week follow-up appointment was scheduled, and patients were advised to return for evaluation in the event of any recurring symptoms (eg, triggering, swelling, stiffness, pain).

Results

were successfully released with 1 percutaneous procedure (recurrence or failure rate, 9.9%). The thumb was the digit most reliably released (success rate, 94.7%) (Table 2). [[{"fid":"202306","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Table 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Table 2.","field_file_image_credit[und][0][value]":""}}}]]Patients with recurrent or unresolved symptoms were given the options of a second percutaneous release or an open surgical procedure. Of the 59 digits unsuccessfully released, as identified by persistent triggering or locking of the digit, 17 were treated with a second percutaneous release (15 were successful), and 40 underwent open tendon sheath incision as a second procedure (success rate, 100%); triggering persisted in the remaining 2 digits, and these were considered failures (the 2 patients did not pursue further treatment).

There were no complications: infection; nerve, artery, or tendon injury; or chronic pain. Some patients had mild stiffness, swelling, or pain for a few days after the procedure, and these effects typically resolved without treatment. In 29 digits, persistent pain or swelling without triggering was successfully treated with a corticosteroid injection.

Discussion

[[{"fid":"202307","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table 3.","field_file_image_credit[und][0][value]":""}}}]]Over a 10-year period, 596 percutaneous trigger finger releases were sequentially performed by a single surgeon. The 90% success rate compares favorably with rates found in other studies (Table 3).^5-9,12-14 The surgeon’s success rates for individual years vary and demonstrate no clear trend or learning curve with the procedure (Figure 3). There were no significant complications. Patient satisfaction with the procedure was high.[[{"fid":"202308","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"6"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"6":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]

There were no injuries to digital nerves, arteries, or flexor tendons, either early or late, and no reports of infections or long-term pain or loss of motion. Although it is quite probable that in some procedures the longitudinal passes of the 18-gauge needle may have also slightly cut into the flexor tendon after passing through the A1 pulley, the direction of the needle passes was in line with the direction of the collagen fibers of the tendon, and thus any inadvertent superficial abrasion would not have structurally weakened the tendon. Of the 40 digits that underwent open release after incomplete or failed percutaneous release, none showed significant longitudinal lacerations of the superficialis tendon. During these revision surgeries, the typical intraoperative finding was incomplete release of the A1 pulley, usually at the distal end. Although loss of the grating sensation or relief of further triggering symptoms was considered adequate evidence of a successful release in this study, small tendon attachments could remain and potentially could lead to recurrent triggering. Given the high success rate achieved with the large sample, however, these 2 factors are considered appropriate indicators of successful release.

It is unclear why there was a relatively consistent 10% failure rate and why it did not decrease over the 10-year study period. Although the technique used does not have a significant learning curve, it appears that digits are not actively triggering at time of procedure have a higher failure rate. When a patient’s digit is actively triggering, assessment of the success of the procedure is relatively straightforward, whereas when a digit intermittently triggers and locks and is not symptomatic in the office, success cannot be immediately determined.

No specific digit was significantly more prone to failed releases, though the small finger had the lowest success rate (85.7%). Given that only 56.4% of patients experienced triggering on the dominant hand, there is not enough evidence to suggest a significant relationship between likelihood of a trigger digit and a patient’s hand dominance. Similarly, there was no correlation between the duration of symptoms and the success of the percutaneous procedure.

Investigation of the relationship between the previously suggested comorbidities of carpal tunnel syndrome and diabetes was also inconclusive. Only 79 (18%) of 429 patients reported having carpal tunnel syndrome, and even fewer, 56 (13.0%), reported having diabetes. Only 69 of the 596 treated digits reportedly had sustained trauma before developing triggering symptoms, and only 12 of the 69 were unsuccessfully released. In addition, of the 161 digits in which one or more steroid injections failed to resolve triggering symptoms, 158 (87.3%) were successfully released with 1 percutaneous procedure. Collectively, these data show percutaneous release can effectively eliminate triggering symptoms in a digit that has sustained injury or that has been unsuccessfully treated with nonoperative methods. Failed percutaneous release subsequently can be reliably treated with an open procedure, and results are excellent.

This study had several limitations. It was retrospective, nonblinded, and did not compare outcomes of percutaneous release with those of an open procedure. Data are presented to support the efficacy and safety of percutaneous release as a treatment option. Another limitation is that pre-release treatment was not controlled. Patients had been treated with a variety of nonoperative methods, including use of anti-inflammatory medication, hand therapy, splinting, and one or more corticosteroid injections, both at our office and elsewhere.

Percutaneous release appears to have an advantage in terms of pain relief, but the study did not evaluate or control for procedure discomfort. However, patients who had been treated with a corticosteroid injection before percutaneous release consistently refused corticosteroid injections for subsequent trigger digits, citing the dramatic pain reduction achieved with release relative to injection. Similarly, all patients who had a trigger digit treated with open tendon sheath incision in the past indicated a strong preference for the percutaneous release.

Follow-up on this patient population was inconsistent and incomplete. Many patients did not return, presumably because they considered the procedure a success and thought follow-up was unnecessary. However, some patients may have had a recurrence or an incomplete release and gone elsewhere for treatment.

The results of this study, to date the largest study on percutaneous release of trigger finger, provide more evidence of the safety and efficacy of this procedure as a treatment option. The success rate of percutaneous release is high, surpasses that of nonoperative treatments such as steroid injections, and approaches that of open and endoscopic surgical alternatives. Some of the obvious advantages of percutaneous release are less visible scarring, fewer incision-related complications, and shorter rehabilitation.¹⁰ In addition, post-procedure pain is possibly reduced, symptom relief is comparable, operative time is significantly shorter,⁸ and percutaneous release is easily performed in the office setting.

Percutaneous release is a viable treatment option for stenosing flexor tenosynovitis, regardless of previously used nonoperative treatment methods, duration or severity of symptoms, or trigger digit treated.

Take-Home Points

• The author had a 90% success rate with no complications in treating almost 600 trigger digits.
• All digits can be safely treated, including multiple fingers on one hand, all in an office setting.
• Percutaneous trigger release appears to be a safe and reliable alternative to open surgery.
• Success rate, discomfort, and cost may make a percutaneous trigger release preferable to even a trial of corticosteroid injection.
• A failed percutaneous release can be successfully treated with an open release, if needed.

Trigger finger, or stenosing flexor tenosynovitis, is a condition characterized by clicking or locking during finger movement, sometimes resulting in the freezing of a digit in flexion or extension¹ (Figure 1). [[{"fid":"202300","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]Tendon inflammation is thought to cause constriction of the tendon sheath and bunching of the fibrous bundles of the first annular (A1) pulley, often creating a palpable nodule at the base of the digit.^2,3 Many patients experience intermittent joint pain and swelling, which may progress to triggering or complete locking of the digit.¹ One of the most common conditions treated by hand surgeons, trigger finger is most often reported in the dominant hand of women in their sixth decade of life and has been associated with several conditions, including diabetes and rheumatoid arthritis.^4-6 Other researchers have indicated the thumb and ring finger are most commonly affected, though all fingers can potentially trigger.^7,8