Eur J Orthop Surg Traumatol (2014) 24:1151–1154 DOI 10.1007/s00590-013-1383-y
ORIGINAL ARTICLE
Radiographic assessment of ligamentous injuries in distal radius fractures after open reduction and internal fixation Sanjay Naran • Yaron Zaulan • Sameer Shakir Louis A. Gilula • Frederick W. Werner • Ronit Wollstein
•
Received: 28 October 2013 / Accepted: 22 November 2013 / Published online: 4 December 2013 Ó Springer-Verlag France 2013
Abstract Objectives Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity. Methods Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods. Results Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture
S. Naran S. Shakir R. Wollstein (&) Department of Plastic and Reconstructive Surgery, Department of Orthopedic Surgery, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA 15261, USA e-mail: [email protected] Y. Zaulan R. Wollstein Division of Hand and Upper Extremity Surgery, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel L. A. Gilula Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA F. W. Werner Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
characteristics, surgical difficulty, and technique were not associated with scaphoid position. Conclusions Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF. Keywords Distal radius fracture Ligament injury Measurement Radiographic Scaphoid translation
Introduction The treatment for distal radius fractures (DRF) includes a multitude of systems for internal fixation that continue to evolve and improve our proficiency in reducing and fixing these fractures. Our ability to evaluate and treat any associated radiocarpal ligamentous injury has remained limited despite the recognition that these injuries may adversely affect clinical outcome. Though it is clear that these injuries may occur concomitantly with the fracture, the rate of occurrence and the need for treatment beyond fracture reduction have not been well defined. Rosenthal et al. [1] found 7.4 % carpal instability in radiographs of 199 DRF. These were associated with age and radial styloid fractures. Mudgal and Jones [2] described a series of 10 cases in which an associated scapholunate (SL) gap was identified, and this was possibly associated with fracture comminution. The advent of arthroscopic-assisted reduction in DRF has enabled more precise assessment of the status of the ligaments. A higher incidence of injuries was found in 88 DRF: 21.6 % SL injuries, a hemorrhagic SL ligament in 4.5 % as well as lunotriquetral injuries [3]. Still
123
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Eur J Orthop Surg Traumatol (2014) 24:1151–1154
arthroscopy involves a more complicated surgery with increased surgery time, and repair of the ligaments has not been clearly shown to affect overall outcome [4–6]. A method for measuring scaphoid translation in the radioulnar plane in standard neutral, radial and ulnar deviation in normal posteroanterior (PA) radiographs has been described. In this study, the distance between the radial styloid and the scaphoid and corresponding scaphoid width was evaluated. The ratio of distance/width at the mid styloid level (0.35, imprecision SD 0.1) had the lowest random error and most precisely reflected true scaphoid translation [7]. The purpose of this study was to evaluate DRF after reduction to assess scaphoid translation and compare it to normal values. This measurement may allow noninvasive evaluation of the radiocarpal ligaments, specifically the radioscapholunate and radiolunate ligaments.
Patients and methods PA radiographs of 50 intraarticular fractures of the distal radius treated with open reduction and internal fixation in our institution were retrospectively evaluated by one masked observer. Measurements could not be performed on the normal/uninjured wrist since this was a retrospective study and radiographs of the normal hand were not available. All radiographs were taken approximately 3 months after fracture fixation. In all of the cases, bony alignment as measured on PA radiographs was restored (including radial inclination, volar tilt, radial height and intraarticular step off). Exclusion criteria included patients with incomplete pre- and postoperative radiographs, lack of true PA radiographs, patients treated with external fixation as an adjunct to internal fixation. Radiographs were measured for radioscaphoid distance and corresponding scaphoid width as well as SL gap. Demographic information was collected including age, gender, hand dominance and background disease. The use of bone graft supplementation was obtained from the operative report and was documented. Subjective degree of surgical difficulty was obtained from the operative reports and divided into three grades of subjective difficulty: easy, moderate and difficult. This measure was meant to add a characteristic of the fracture that is not always given to assessment by radiographic imaging. The radioscaphoid measurements Three scaphoid location measurements (d) were made between the ulnar volar border of the radial styloid and the radial volar border of the scaphoid (parallel cortical surfaces of the radial styloid and scaphoid) (Fig. 1). A point
123
Fig. 1 A diagram of the measurement of d2/w2 of scaphoid translation on neutral PA radiographs. This diagram has been previously published by Hand Surgery
half way in between the tip of the radial styloid and the proximal pole of the scaphoid was measured and defined as d2. The scaphoid location measurements made between the ulnar border of the radial styloid and the radial border of the scaphoid were normalized by the width (w) of the scaphoid at the level of the scaphoid location measurements. This was done to account for scaphoid shape as well as flexion/extension/rotation. The corresponding width to d2 was defined as w2 to correspond to d2 (Fig. 1). All of these parameters were measured in the coronal plane perpendicular to the long axis of the radius. The ratio of d2/w2 was calculated for each fracture before and after reduction. Scapholunate gap was considered enlarged if measured above 2 mm. The distance between the scaphoid and lunate was measured at midjoint of the SL joint from the ulnar cortex of the scaphoid to the radial cortex of the lunate [7]. Statistical analysis Statistical analysis was performed by using SPSS 18 software. Demographic variables were available only for our group of DRF and not for the ‘‘normal’’ measurement group. Therefore, the analysis of these variables could only include the distal radius fracture group. These were analyzed by univariate analysis to determine distribution of data. Continuous variables, like age, were analyzed with ANOVA F test and were presented by mean, median and standard deviation. Categorical variables such as diabetes, arthritis, previous surgeries were analyzed with Fishers exact test and were presented in percentages. Chi-square test was used to compare between the categorical variables.
Eur J Orthop Surg Traumatol (2014) 24:1151–1154
Independent t test was used to compare between the continuous variables. One-way ANOVA was used to compare between the d/w ratio and the subjective difficulty level of the operation. Outcome analysis such as malunion, nonunion and infections was analyzed using multivariate logistic regression. Significance was assumed at a p \ 0.05.
Results Of the 50 radiographs evaluated in the study, 29 were males and 21 were females, with a mean age of 47.9 (17–87.1). Ten patients had background disease such as diabetes, and 10 were smokers. The dominant hand was the injured hand in 54 % of the cases. Sixty-eight percent (34 patients) were treated with bone graft supplementation for structural support. The fractures were intraarticular. Using the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification system, 5 fractures were classified as B1, 3 as B2, 6 as C1, 20 as C2 and 16 were classified as C3. In 48 patients, a degree of difficulty to reduce the fracture was noted in the operative report. Overall, nineteen cases were reported as easy, 14 moderate and 15 were reported as a difficult reduction. The measured d2/w2 was significantly different from the measurements on normal radiographs p \ 0.0001 to the d2/w2 ratio measured as\0.35 (74 %) in 37 cases, 12 cases were [0.35 (24 %) and only 1 case was measured with a normal value (2 %). No statistical difference was found in regard to the measured value d2/w2 and to bone graft application (p = 0.169). When examining the association between the degree of difficulty, as reported by the surgeon, and the ratio measured, no statistical significance was observed (p = 0.471). The quality of reduction using the accepted parameters of distal radius anatomy was reasonable. Postoperative radial tilt was 22.9 (5.7) degrees, volar tilt was 3.1 (12.3), intraarticular step off was less than 1 mm in all radiographs and radial height was 0.75 mm (1.13) of shortening. These measurements were not significantly associated with the measurement of d2/w2. Scapholunate gap was not enlarged in any of the radiographs postoperatively and was not correlated with the measurements of d2/w2.
Discussion Patients presenting with DRF may have concomitant carpal instability as a manifestation of intracarpal and radiocarpal ligament injuries [8]. This study found an abnormal d2/w2 ratio compared to normal values in almost all of the operatively treated fractures despite a reasonable bony reduction. It is possible that these findings reflect a true
1153
ligamentous injury that occurred either concomitantly with the fracture or during surgical release to obtain reduction. By nature of the measurement, it is likely that we are measuring at least in part the radiocarpal ligaments (as opposed to the SL ligament). However, injury to the intracarpal ligaments does affect the pronation/rotation position of the scaphoid, thus possibly influencing the w2 measurement and therefore the ratio. The exact impact of associated SL or other dissociative injuries would have to be investigated. These measurements could represent an attenuation or rupture (or iatrogenic partial release) of the radiocarpal ligaments that would be expected to produce an increase from the normal ratio or fibrosis and scar formation of an injured ligament manifested as a decrease in the ratio mentioned, though the ligaments could potentially scar in an attenuated position as well (again leading to a higher than normal ratio). We believe the measurements performed at 3 months can reflect these injuries since this is time enough for the fracture to unite and for the ligaments to adhere and scar formation to occur. Another possible explanation for the abnormal d2/w2 ratio is that we did not achieve complete bony reduction and that the measurements reflect a malunion. More specifically, an abnormal scaphoid translation exists as a manifestation of unsatisfactory fracture reduction, despite normal radiographic measurements. Mignemi et al. [9] reviewed 185 DRF that underwent volar locked plating with a single plate design over a 5-year period and found that this type of fixation achieved articular step off less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination and ulnar variance in 50 % of fractures. Our established measurements of reduction (such as volar tilt and ulnar variance) were in the expected range following ORIF. Limitations of this study include that this was a retrospective study with the weaknesses that are inherent to this type of investigation. Furthermore, the effect of variables such as demographic variables and fracture complexity on our measurements could not be evaluated in the normal group for comparison. The functional significance of these findings is unknown. We believe that these findings reflect a true ligamentous injury; however, the clinical significance of these injuries needs to be proven in a clinical outcomes study. A substantial number of patients complain of residual wrist pain, most often in the radial wrist following surgery [10]. This pain may be due to associated ligamentous injury that is not identified and therefore not treated. In a recent cadaver study, arms sustaining a distal radius fracture had an associated ligament tear in up to 75 % (unpublished data). Though some studies show a trend toward a better clinical result with better reduction in
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1154
Eur J Orthop Surg Traumatol (2014) 24:1151–1154
the intraarticular surface, when reviewing the literature for the functional significance of well-established measurements such as ulnar variance and radial tilt, there is surprisingly little evidence regarding the clinical significance of these measurements [11–13]. MacDermid et al. [14] found that return to work after a distal radius fracture could not be predicted by clinical variables. Further study evaluating the relationship of the measurements with functional parameters is needed, especially in view of the rising number of surgically treated DRF. It is possible that we will be able to improve our outcomes following ORIF of DRF if we can recognize and address concomitant ligamentous injuries at the time of surgery. This may not only improve postoperative results but also possibly prevent the development of osteoarthritis. Conflict of interest
None.
References 1. Rosenthal DI, Schwartz M, Phillips WC, Jupiter J (1983) Fracture of the radius with instability of the wrist. AJR Am J Roentgenol 141(1):113–116 2. Mudgal CS, Jones WA (1990) Scapho-lunate diastasis: a component of fractures of the distal radius. J Hand Surg Br 15(4):503–505 3. Richards RS, Bennett JD, Roth JH, Milne K Jr (1997) Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am 22(5):772–776 4. Espinosa-Gutierrez A, Rivas-Montero JA, Elias-Escobedo A, Alisedo-Ochoa PG (2009) Wrist arthroscopy for fractures of the distal end of the radius. Acta Ortop Mex 23(6):358–365
123
5. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME, Bargiotas K, Malizos K (2008) Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg Br 90(6):778–785 6. Kwon BC, Baek GH (2008) Fluoroscopic diagnosis of scapholunate interosseous ligament injuries in distal radius fractures. Clin Orthop Relat Res 466(4):969–976 7. Wollstein R, Werner FW, Rubinstein R, Nacca CR et al (2013) Translation measurements in normal wrists. Hand Surg 18:179–187 8. Schimmerl-Metz SM, Metz VM, Totterman SM, Mann FA, Gilula LA (1999) Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology. J Hand Surg Am 24(6):1237–1244 9. Mignemi ME, Byram IR, Wolfe CC et al (2013) Radiographic outcomes of volar locked plating for distal radius fractures. J Hand Surg Am 38:40–48 10. Kurimoto S, Tatebe M, Shinohara T, Arai T, Hirata H (2012) Residual wrist pain after volar locking plate fixation of distal radius fractures. Acta Orthop Belg 78(5):603–610 11. Karnezis IA (2005) Correlation between wrist loads and the distal radius volar tilt angle. Clin Biomech (Bristol, Avon) 20(3):270–276 12. Werner FW, Short WH, Green JK, Evans PJ, Walker JA (2007) Severity of scapholunate instability is related to joint anatomy and congruency. J hand Surg Am 32(1):55–60 13. Glickel SZ, Catalano LW, Raia FJ, Barron OA, Grabow R, Chia B (2008) Long-term outcomes of closed reduction and percutaneous pinning for the treatment of distal radius fractures. J hand Surg Am 33(10):1700–1705 14. MacDermid JC, Roth JH, McMurtry R (2007) Predictors of time lost from work following a distal radius fracture. J Occup Rehabil 17(1):47–62
ORIGINAL ARTICLE
Radiographic assessment of ligamentous injuries in distal radius fractures after open reduction and internal fixation Sanjay Naran • Yaron Zaulan • Sameer Shakir Louis A. Gilula • Frederick W. Werner • Ronit Wollstein
•
Received: 28 October 2013 / Accepted: 22 November 2013 / Published online: 4 December 2013 Ó Springer-Verlag France 2013
Abstract Objectives Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity. Methods Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods. Results Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture
S. Naran S. Shakir R. Wollstein (&) Department of Plastic and Reconstructive Surgery, Department of Orthopedic Surgery, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA 15261, USA e-mail: [email protected] Y. Zaulan R. Wollstein Division of Hand and Upper Extremity Surgery, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel L. A. Gilula Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA F. W. Werner Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
characteristics, surgical difficulty, and technique were not associated with scaphoid position. Conclusions Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF. Keywords Distal radius fracture Ligament injury Measurement Radiographic Scaphoid translation
Introduction The treatment for distal radius fractures (DRF) includes a multitude of systems for internal fixation that continue to evolve and improve our proficiency in reducing and fixing these fractures. Our ability to evaluate and treat any associated radiocarpal ligamentous injury has remained limited despite the recognition that these injuries may adversely affect clinical outcome. Though it is clear that these injuries may occur concomitantly with the fracture, the rate of occurrence and the need for treatment beyond fracture reduction have not been well defined. Rosenthal et al. [1] found 7.4 % carpal instability in radiographs of 199 DRF. These were associated with age and radial styloid fractures. Mudgal and Jones [2] described a series of 10 cases in which an associated scapholunate (SL) gap was identified, and this was possibly associated with fracture comminution. The advent of arthroscopic-assisted reduction in DRF has enabled more precise assessment of the status of the ligaments. A higher incidence of injuries was found in 88 DRF: 21.6 % SL injuries, a hemorrhagic SL ligament in 4.5 % as well as lunotriquetral injuries [3]. Still
123
1152
Eur J Orthop Surg Traumatol (2014) 24:1151–1154
arthroscopy involves a more complicated surgery with increased surgery time, and repair of the ligaments has not been clearly shown to affect overall outcome [4–6]. A method for measuring scaphoid translation in the radioulnar plane in standard neutral, radial and ulnar deviation in normal posteroanterior (PA) radiographs has been described. In this study, the distance between the radial styloid and the scaphoid and corresponding scaphoid width was evaluated. The ratio of distance/width at the mid styloid level (0.35, imprecision SD 0.1) had the lowest random error and most precisely reflected true scaphoid translation [7]. The purpose of this study was to evaluate DRF after reduction to assess scaphoid translation and compare it to normal values. This measurement may allow noninvasive evaluation of the radiocarpal ligaments, specifically the radioscapholunate and radiolunate ligaments.
Patients and methods PA radiographs of 50 intraarticular fractures of the distal radius treated with open reduction and internal fixation in our institution were retrospectively evaluated by one masked observer. Measurements could not be performed on the normal/uninjured wrist since this was a retrospective study and radiographs of the normal hand were not available. All radiographs were taken approximately 3 months after fracture fixation. In all of the cases, bony alignment as measured on PA radiographs was restored (including radial inclination, volar tilt, radial height and intraarticular step off). Exclusion criteria included patients with incomplete pre- and postoperative radiographs, lack of true PA radiographs, patients treated with external fixation as an adjunct to internal fixation. Radiographs were measured for radioscaphoid distance and corresponding scaphoid width as well as SL gap. Demographic information was collected including age, gender, hand dominance and background disease. The use of bone graft supplementation was obtained from the operative report and was documented. Subjective degree of surgical difficulty was obtained from the operative reports and divided into three grades of subjective difficulty: easy, moderate and difficult. This measure was meant to add a characteristic of the fracture that is not always given to assessment by radiographic imaging. The radioscaphoid measurements Three scaphoid location measurements (d) were made between the ulnar volar border of the radial styloid and the radial volar border of the scaphoid (parallel cortical surfaces of the radial styloid and scaphoid) (Fig. 1). A point
123
Fig. 1 A diagram of the measurement of d2/w2 of scaphoid translation on neutral PA radiographs. This diagram has been previously published by Hand Surgery
half way in between the tip of the radial styloid and the proximal pole of the scaphoid was measured and defined as d2. The scaphoid location measurements made between the ulnar border of the radial styloid and the radial border of the scaphoid were normalized by the width (w) of the scaphoid at the level of the scaphoid location measurements. This was done to account for scaphoid shape as well as flexion/extension/rotation. The corresponding width to d2 was defined as w2 to correspond to d2 (Fig. 1). All of these parameters were measured in the coronal plane perpendicular to the long axis of the radius. The ratio of d2/w2 was calculated for each fracture before and after reduction. Scapholunate gap was considered enlarged if measured above 2 mm. The distance between the scaphoid and lunate was measured at midjoint of the SL joint from the ulnar cortex of the scaphoid to the radial cortex of the lunate [7]. Statistical analysis Statistical analysis was performed by using SPSS 18 software. Demographic variables were available only for our group of DRF and not for the ‘‘normal’’ measurement group. Therefore, the analysis of these variables could only include the distal radius fracture group. These were analyzed by univariate analysis to determine distribution of data. Continuous variables, like age, were analyzed with ANOVA F test and were presented by mean, median and standard deviation. Categorical variables such as diabetes, arthritis, previous surgeries were analyzed with Fishers exact test and were presented in percentages. Chi-square test was used to compare between the categorical variables.
Eur J Orthop Surg Traumatol (2014) 24:1151–1154
Independent t test was used to compare between the continuous variables. One-way ANOVA was used to compare between the d/w ratio and the subjective difficulty level of the operation. Outcome analysis such as malunion, nonunion and infections was analyzed using multivariate logistic regression. Significance was assumed at a p \ 0.05.
Results Of the 50 radiographs evaluated in the study, 29 were males and 21 were females, with a mean age of 47.9 (17–87.1). Ten patients had background disease such as diabetes, and 10 were smokers. The dominant hand was the injured hand in 54 % of the cases. Sixty-eight percent (34 patients) were treated with bone graft supplementation for structural support. The fractures were intraarticular. Using the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification system, 5 fractures were classified as B1, 3 as B2, 6 as C1, 20 as C2 and 16 were classified as C3. In 48 patients, a degree of difficulty to reduce the fracture was noted in the operative report. Overall, nineteen cases were reported as easy, 14 moderate and 15 were reported as a difficult reduction. The measured d2/w2 was significantly different from the measurements on normal radiographs p \ 0.0001 to the d2/w2 ratio measured as\0.35 (74 %) in 37 cases, 12 cases were [0.35 (24 %) and only 1 case was measured with a normal value (2 %). No statistical difference was found in regard to the measured value d2/w2 and to bone graft application (p = 0.169). When examining the association between the degree of difficulty, as reported by the surgeon, and the ratio measured, no statistical significance was observed (p = 0.471). The quality of reduction using the accepted parameters of distal radius anatomy was reasonable. Postoperative radial tilt was 22.9 (5.7) degrees, volar tilt was 3.1 (12.3), intraarticular step off was less than 1 mm in all radiographs and radial height was 0.75 mm (1.13) of shortening. These measurements were not significantly associated with the measurement of d2/w2. Scapholunate gap was not enlarged in any of the radiographs postoperatively and was not correlated with the measurements of d2/w2.
Discussion Patients presenting with DRF may have concomitant carpal instability as a manifestation of intracarpal and radiocarpal ligament injuries [8]. This study found an abnormal d2/w2 ratio compared to normal values in almost all of the operatively treated fractures despite a reasonable bony reduction. It is possible that these findings reflect a true
1153
ligamentous injury that occurred either concomitantly with the fracture or during surgical release to obtain reduction. By nature of the measurement, it is likely that we are measuring at least in part the radiocarpal ligaments (as opposed to the SL ligament). However, injury to the intracarpal ligaments does affect the pronation/rotation position of the scaphoid, thus possibly influencing the w2 measurement and therefore the ratio. The exact impact of associated SL or other dissociative injuries would have to be investigated. These measurements could represent an attenuation or rupture (or iatrogenic partial release) of the radiocarpal ligaments that would be expected to produce an increase from the normal ratio or fibrosis and scar formation of an injured ligament manifested as a decrease in the ratio mentioned, though the ligaments could potentially scar in an attenuated position as well (again leading to a higher than normal ratio). We believe the measurements performed at 3 months can reflect these injuries since this is time enough for the fracture to unite and for the ligaments to adhere and scar formation to occur. Another possible explanation for the abnormal d2/w2 ratio is that we did not achieve complete bony reduction and that the measurements reflect a malunion. More specifically, an abnormal scaphoid translation exists as a manifestation of unsatisfactory fracture reduction, despite normal radiographic measurements. Mignemi et al. [9] reviewed 185 DRF that underwent volar locked plating with a single plate design over a 5-year period and found that this type of fixation achieved articular step off less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination and ulnar variance in 50 % of fractures. Our established measurements of reduction (such as volar tilt and ulnar variance) were in the expected range following ORIF. Limitations of this study include that this was a retrospective study with the weaknesses that are inherent to this type of investigation. Furthermore, the effect of variables such as demographic variables and fracture complexity on our measurements could not be evaluated in the normal group for comparison. The functional significance of these findings is unknown. We believe that these findings reflect a true ligamentous injury; however, the clinical significance of these injuries needs to be proven in a clinical outcomes study. A substantial number of patients complain of residual wrist pain, most often in the radial wrist following surgery [10]. This pain may be due to associated ligamentous injury that is not identified and therefore not treated. In a recent cadaver study, arms sustaining a distal radius fracture had an associated ligament tear in up to 75 % (unpublished data). Though some studies show a trend toward a better clinical result with better reduction in
123
1154
Eur J Orthop Surg Traumatol (2014) 24:1151–1154
the intraarticular surface, when reviewing the literature for the functional significance of well-established measurements such as ulnar variance and radial tilt, there is surprisingly little evidence regarding the clinical significance of these measurements [11–13]. MacDermid et al. [14] found that return to work after a distal radius fracture could not be predicted by clinical variables. Further study evaluating the relationship of the measurements with functional parameters is needed, especially in view of the rising number of surgically treated DRF. It is possible that we will be able to improve our outcomes following ORIF of DRF if we can recognize and address concomitant ligamentous injuries at the time of surgery. This may not only improve postoperative results but also possibly prevent the development of osteoarthritis. Conflict of interest
None.
References 1. Rosenthal DI, Schwartz M, Phillips WC, Jupiter J (1983) Fracture of the radius with instability of the wrist. AJR Am J Roentgenol 141(1):113–116 2. Mudgal CS, Jones WA (1990) Scapho-lunate diastasis: a component of fractures of the distal radius. J Hand Surg Br 15(4):503–505 3. Richards RS, Bennett JD, Roth JH, Milne K Jr (1997) Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am 22(5):772–776 4. Espinosa-Gutierrez A, Rivas-Montero JA, Elias-Escobedo A, Alisedo-Ochoa PG (2009) Wrist arthroscopy for fractures of the distal end of the radius. Acta Ortop Mex 23(6):358–365
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5. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME, Bargiotas K, Malizos K (2008) Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg Br 90(6):778–785 6. Kwon BC, Baek GH (2008) Fluoroscopic diagnosis of scapholunate interosseous ligament injuries in distal radius fractures. Clin Orthop Relat Res 466(4):969–976 7. Wollstein R, Werner FW, Rubinstein R, Nacca CR et al (2013) Translation measurements in normal wrists. Hand Surg 18:179–187 8. Schimmerl-Metz SM, Metz VM, Totterman SM, Mann FA, Gilula LA (1999) Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology. J Hand Surg Am 24(6):1237–1244 9. Mignemi ME, Byram IR, Wolfe CC et al (2013) Radiographic outcomes of volar locked plating for distal radius fractures. J Hand Surg Am 38:40–48 10. Kurimoto S, Tatebe M, Shinohara T, Arai T, Hirata H (2012) Residual wrist pain after volar locking plate fixation of distal radius fractures. Acta Orthop Belg 78(5):603–610 11. Karnezis IA (2005) Correlation between wrist loads and the distal radius volar tilt angle. Clin Biomech (Bristol, Avon) 20(3):270–276 12. Werner FW, Short WH, Green JK, Evans PJ, Walker JA (2007) Severity of scapholunate instability is related to joint anatomy and congruency. J hand Surg Am 32(1):55–60 13. Glickel SZ, Catalano LW, Raia FJ, Barron OA, Grabow R, Chia B (2008) Long-term outcomes of closed reduction and percutaneous pinning for the treatment of distal radius fractures. J hand Surg Am 33(10):1700–1705 14. MacDermid JC, Roth JH, McMurtry R (2007) Predictors of time lost from work following a distal radius fracture. J Occup Rehabil 17(1):47–62
