Radiological parameters outcomes in open reduction and internal

fixation of distal radius fractures. A case series study.

Rodríguez, Estanislao M.D.1; Badia, Alejandro M.D.2
1 rd
Dr. Rodriguez, Estanislao M.D. from Argentina, actually in 3 year of Orthopedics and traumatology
residency, at ―Hospital Provincial Centenario‖, Rosario city, Argentina.
Scholar during IBRA 2019 scholarship program for clinical residential stay at Badia Hand to Shoulder Center,
Doral, FL, US.
2
Dr. Badia, Alejandro M.D, F.A.C.S. hand and upper limb surgeon. Creator and founder of Badia Hand to
Shoulder Center, Doral, FL, US.

Background: Distal radius fractures represent a frequent orthopedic injury, 20% of the
fractures seen in the emergency room. Regardless of the treatment choice, the basis for
enhanced outcomes are the restoration of wrist anatomy, stable fixation, bone fragments
vascularity preservation and promote early mobilization. The objective of this study is to
analyze the radiographic parameters achieved through volar plating in distal radius
fractures, in order to understand the reliability of this method in the restoration of normal
morphology.

Method: In this case series, preoperative and postoperative radiological parameters of 7

patients with distal radius fracture were measured, analyzed and compared. Radial
inclination, ulnar variance and radial tilt were considered. All patients underwent surgery
for open reduction and internal fixation with locking volar plates.

Results: 81% of the parameters were improved and reached the normal values after
surgery. 19% of the measurements were not restored to normal ranges due to significant
preoperative alterations and probably anatomic variation.

Conclusions: Till nowadays the treatment continues to evolution, with a wide range of
options for the fracture stabilization. Radial inclination, ulnar variance and radial tilt were
restored after open reduction and internal fixation with locking volar plates. This technique
warranties a safer option in the management and restoration of the distal radius anatomy.

1
I N T R O D U C T I O N

The fractures of the distal radius are one of the most frequent traumas, and represent a
20% of the fractures seen in the emergency room.

Due to multifactorial etiology, incidence appears to be raising in the lasts years in all ages1:
in young population it is mostly related to car accidents; while in the elderly people, some
of the principals responsible factors are longer life expectancy, activity increase and bone
mineral density changes 2.

These injuries have been studied for more than 200 years, even before of radiology
advent, since Claude Pouteau (1783), Abraham Colles (1814), Rhea Barton (1838),
Robert Smith (1847) and Dupuytren (1847) classical descriptions, where distal radius
fractures were expected to present acceptable outcomes, independently from the
treatment method 3,4. Till nowadays the treatment continues to evolution, with a wide range
of options for the fracture stabilization: Nonoperative treatment, K-Wires, external fixation,
open reduction and internal fixation and a broad range of implants 5,6,7,8.

From volar plate appearance onward and posterior volar angular stable
plate osteosynthesis and locking screws development, open reduction with internal fixation
has raised its popularity between surgeons as it allows early mobilization, reports low
complication rates and reaches better anatomic and functional outcomes 9,10,11.

Plates are intended for osteosynthesis of intra-articular and extra-articular fractures of the
distal radius on the volar side. The aim of osteosynthesis is the reconstruction of the
articular surface, stable fixation of fragments, and restoration of radial length and angle.

Regardless of the treatment choice, the bases for enhanced outcomes are the restoration
of wrist anatomy, stable fixation, bone fragments vascularity preservation and promote
early mobilization. It seems vital to avoid vicious consolidation with angular alterations and
shortening as it would result in multiple functional disorders 12.

Anatomy

The distal forearm may be thought of in terms of three columns, that supports the carpal
bones and the hand (Figure 1):
First, a radial column that comprise the lateral side of the bone, including the radial styloid
process and the scaphoid facet; Second, the intermediate column conformed by the ulnar
side of the radius, including lunate facet and sigmoid notch; Finally, the third column is the
ulnar column integrated by the ulnar head, the triangular fibrocartilage complex (TFCC)
and the ulnar aspect of the distal radioulnar joint 13.

Distally at the wrist joint, the radial column articulates with the scaphoid and the
intermediate column articulates with the lunate and axial loads are 80% distributed in the
radius and 20% in the ulnar side 14.

2
 Figure 1. Columns of the distal radius. (Extracted from https://www2.aofoundation.org/)

There are many reports in the literature on the relationship between radiographic variables
and their influence on the final outcome of distal radius fractures. Most authors report that
a good functional result depends on anatomical restoration of the articular surface and
extra-articular alignment. Radial length is considered as an important prognostic factor15,
16
because its shortening can cause painful range of motion limitation due to distal
radioulnar joint incongruence, TFCC impactation and ulnar head subdislocation, therefore,
increasing risk of ulnocarpal osteoarthritis17.

Radiological measurements

Radial tilt / palmar tilt (RT)

Radial tilt is measured on a lateral radiograph. The radial tilt represents the angle between
a line along the distal radial articular surface and the line perpendicular to the longitudinal
Axis of the radius at the joint margin. The normal palmar tilt averages 11-12 degrees and
has a range of 2-20 degrees (Figure 2).

Figure 2. Radial tilt. (Extracted from https://www2.aofoundation.org/

3
Radial inclination or angle (RI)

Radial inclination represents the angle between one line connecting the radial styloid tip
and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal
axis of the radius. The radial inclination averages between 21 and 25 degrees and has a
range of 15-35 degrees. Loss of radial inclination will increase the load across the lunate
(Figure 3).

Figure 3. Radial inclination, ulnar variance and radial height. (Extracted from https://www2.aofoundation.org/ ).

Radial length or height

Radial length is measured on the PA radiograph as the distance between one line
perpendicular to the long axis of the radius passing through the distal tip of the radial
styloid. A second line intersects distal articular surface of ulnar head.
This measurement averages 10-13 mm (Figure 3).

Ulnar variance (UV), also known as Hulten variance

Ulnar variance
Neutral 0 +/- 2mm (length difference < / = 2mm)
Positive (ulna projects distally) > 2mm
Negative (ulna projects proximally) < 2mm
Table 1. Ulnar variance values.

Ulnar variance refers to the relative lengths of the distal articular surfaces of the radius
and ulna (Figure 3). Variance is independent of the length of the ulnar styloid process. It
results from the distance between two perpendicular lines to the long axis of the radius. On
the radial side a perpendicular line to the long axis is drawn through the ulnar limit of the
radius. To do that, a middle point between the dorsal and palmar limit of the ulnar edge of

4
the radius is set. On the ulnar side, a perpendicular line to the radial long axis is drown at
the level of articular surface of the ulnar head 18, 19.

Malalignment determines range of motion limitation 20, loss of fist strength, changes in
loads distribution 21, midcarpal instability 22 and a major risk of radiocarpal post traumatic
osteoarthritis. Moreover, anatomical reduction and stabilization of intrarticular fractures are
essential because of the functional implications of the involvement of the distal radioulnar
joint.

Accordingly, it keeps continuing awaking interest to study the anatomy and the
effectiveness of the different treatment methods. As said, nowadays ORIF appears to be
the most trending option for the distal radius fracture management. Thus the aim of this
study is to analyze the radiographic parameters achieved through volar plating in distal
radius fractures.

M E T H O D

This case series is an observational, descriptive, cross-sectional, retrospective study

performed in the context of an observership, during a three month scholarship taken place
in an upper limbs center in Miami, FL, USA; from October 2019 to January 2020.

Radiographic outcomes of distal radius fractures treated with volar plates were measured
in this study. All distal radius fractures turned up in the time of the observership were
evaluated.

The following criterion was considered for the recruitment:

Inclusion criteria:

 Over 18 years old.

 Distal radius fractures.
 Intrarticular and extrarticular fractures.
 Patients who accomplished X-rays follow up.
 Patients treated with open reduction and internal fixation with a volar plate for distal
radius fracture.

Exclusion criteria:

 Under 18 years old.

 Open fractures.

5
Accordingly to this criterion, 7 patients were included, and following variables were taken
into account:

 Gender: Female / Male

 Age: over 18 years old.
 Etiology: mechanism described by the patient.
 Fracture type: AO / OTA classification was considered (Table 2) 23
 Preoperative (PRE) and postoperative (POP) X-ray measurements: A-P and lateral
incidences were performed before and after surgery in the same X-ray room,
located at the upper limbs center. Radial inclination, radial tilt and ulnar variance
were measured.
 Time interval between injury and surgery: measured in days. All surgeries were
performed by the same upper limbs surgery specialist in the same operating room
located at the same building as the clinic.

Table 2. AO distal radius classification (Extracted from https://www2.aofoundation.org/ ).

6
Technique Open reduction and internal fixation (ORIF)

With the patient in supine position under regional block, a non sterile pneumatic tourniquet
is used, with the forearm extended in the hand table. Complete imaging assistance with
fluoroscopy was carried on during the surgery.

Following the modified Henry approach the fracture was exposed. Surgical gestures for
soft tissues and technique pearls are not described for the actual article. Reduction was
performed under direct vision and assisted with fluoroscopy. Then, the locking volar plate
is positioned suitably 2mm proximal to de watershed line, and secured to the proximal
fragment while distal is reduced to it with traction and direct manipulation. This maneuver
facilitates obtaining the correct volar tilt 24. A different strategy is to attach the plate to the
distal fragment first and then lever the distal fragment into correction relying on the
variable angle fixation. Plate size, placement, screw length and subcondral positioning is
checked under fluoroscopy.

Figure 4. Modifyed Henry approach Figure 5. Lateral view control with fluoroscopy

Once intraoperative assessment is satisfactory, washing and wound closure is followed to

finish the procedure.

Post operative cares, immobilization and rehabilitation is not taken into account in this
study, as it is focused in the early anatomy restoration after ORIF.

7
 The implant options run from volar locking plate with
variable angle or fixed angle. Decision lays down on
surgeon preference and it is made depending on
fracture morphology and technical issues.

Figure 6. Distal Radius Volar Plate (Extracted from

https://www.medartis.com/)

R E S U L T S

Of 7 patients, 2 were male (29%) and 5 female (71%). The average age found was 64
years old (from 54 to 79).

Regarding etiology, 4 (58%) were due to fall from own height, 2 (28%) from one step
height and 1 (14%) for fall from bicycle. All of those were interpreted as low to mid energy
mechanism according to how the patients described the moment of injury.

According to AO fracture classification, 5 patients (71%) presented type ―A‖ extra articular
fractures and 2 patients (29%) presented ―C‖ complete articular fractures (Table 3).

As expected, both complex and complete articular fractures correspond to higher energy
trauma, one falling from the first step of a stair and the other falling from a bicycle.

Days waited AO
Patient Gender Age Etiology
for surgery Classification

1 F 79 Own height 5 2R3 A2,1

2 M 66 Own height 4 2R3 A3,3
3 F 73 Own height 1 2R3 A2,3
4 F 63 Fall from 1st stair step 1 2R3 A2,1
5 F 64 Own height 2 2R3 A2,1
6 F 54 Fall from bicycle 5 2R3 C1,2
7 M 55 Fall from 1st stair step 1 2R3 C1,2

Table 3. Fractures classification and epidemiology.

8
The average interval between trauma and surgery was 2,7 days (range from 5 to 1 day).

Radiographic outcomes

Preoperative and postoperative radiographic measurements were accomplished in all

patients and are shown in the Table 4, which permitted to analyze the average values.

Patient RI PRE RI POP UV PRE UV POP RT PRE RT POP

1 16 26 -3,3 -2 9 6
2 9 16 3,2 0 -25 11
3 4 18 4 2 1 1
4 21 25 1,5 1 3 11
5 20 20 1,2 0 4 1
6 14 17 -3 -2,9 -15 3
7 28 25 -3 -2,7 -7 1

Table 4. Preoperative (PRE) and postoperative (POP) radiographic measurements. (Radial inclination, RI; Ulnar
variance, UV; Radial tilt, RT)

The average magnitude of the correction for RI was of 5° where the biggest correction in
this topic was of 10°. UV average was improved in 1,2 mm. Two patients with significant
UV alteration did not reach normal ranges, remaining 0,9mm and 0,7mm extra variance.
The best correction scored 3,2 mm. Finally, average correction of the RT was 9°, with its
biggest correction in patient n°2 who was improved from -25° to 11° (Table 5).

Normal
Average measurements Preoperative (PRE) Postoperative (POP) Correction
values
Radial inclination (RI) 23 16 21 5
Ulnar variance (UV) 0 2,74 1,5 1,24
Radial tilt (RT) 11 -4,2 4,8 9

Table 5.Outcomes: Average measurements.

81% of parameters were found between acceptable ranges after surgery, from which 72%
were enhanced from major alterations and 9% were maintained in the same acceptable
values presented before surgery, not requiring further alignment. Not restored parameters

9
Figure 7. Preoperative X-Rays

Figure 8. Post operative X-Rays

10
represent a 19%, and it includes 2 UV and 2 RT with significant improvements, but still not
reaching the normal range due to excessive preoperative alteration and maybe to
anatomical variances as well. RI parameter was within the normal range in 100% of
postoperative measurements (Table 6).

Average
Restoration RI UV RT TOTAL
restoration
Yes 6 5 4 15 72%
No changes 1 0 1 2 9%
Insufficient 0 2 0 2 9%
No 0 0 2 2 9%

Acceptable 100% 72% 72% 17 81%

Not acceptable 0% 28% 28% 4 19%

Table 6. Shows the numer of X-ray parameters that were changed in surgery. YES: When restoration to normal
values was made; NO CHANGES: When the was no changes on the parameter but was within the normal ranges;
INSSUFFICIENT: Values were improved but still under acceptable ranges. NO: the parameter was not improved.
ACCEPTABLE: Measurements withing the normal range (YES + NO CHANGES) NOT ACCEPTABLE: Measurements
outside normal range (INSSUFFICIENT + NO)

D I S C U S S I O N

There is currently no definitive consensus about which is the best treatment for each type
of distal radius type25. However, there was a paradigm shift since volar plates introduction
and its progressive evolution 26.

K-wire fixation is a classic option that continues to offer accessible and quick solutions for
wrist fractures, with the advantage of fast widespread availability of the material for early
solution. Additionally, K-wires means a cheap alternative as it is considered a low cost
material. Ambulatory surgery and no need to reoperate the patient to retire the wire would
help to determine it as a cheap treatment option.

However this traditional method carries its own complications like 21% risk of K-wire
infection reported by Lakshmanan et. Al. 27 and 34% described by Hargreaves et. Al.28

11
One of the priorities of treatment, regardless the employed method, is to restore the distal
radius anatomy. Brady et. Al. 29 analyzes the radiologic behavior and demonstrated
significant recurrence of dorsal angulations and radial shortening in fractures treated with
K-wires. Geatting and Bishop also have reported deformity recurrence after pin removal 30.

A methaanalysis showed that Patients treated with volar locking plates had slightly better
function than did patients treated with K-wires as measured by their DASH scores at 3
months, but did not found notorious differences in radiographic outcomes as many other
studies 31, 32, 33 In this case series all measurements were took back into normal values for
anatomic restoration.

Another benefit of ORIF is early mobilization that could lead to better functional outcomes
and suppose less days of inactivity and earlier reincorporation.

Results of a retrospective study report the persistence of articular step-off in 35.3% of

patients, normal radial inclination restored in 74.5% of patients; normal radial height
restored in 66.6% of patients; normal volar tilt was achieved in 90.2% of patients; and
normal ulnar variance restored in 86.3% of patients. This study suggests that ulnar
variance and volar tilt are the most important radiographic parameters to be restored to
obtain good functional outcome in distal radius fracture 34.

C O N C L U S I O N S

Distal radius fractures represent a frequent orthopedic injury, more common in females
and easily found in old patients, related with low energy trauma.

Radial inclination, ulnar variance and radial tilt were restored after open reduction and
internal fixation with locking volar plates. This technique warranties a safer option in the
management and restoration of the distal radius anatomy.

The actual tendency between surgeons, in accordance with the bibliography, continues to
be treating wrist fractures with volar plate, in view of enhancing the outcomes and prevent
further complications.

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A C K N O W L E D G E M E N T S

I am most thankful for the International Bone Research Association that has provided
support for this paper. Being included in the Scholarship program for clinical residence,
allowed me, as intern resident, to achieve one of most fruitful experiences of my
professional training.

This paper and the research behind it would not have been possible without the
exceptional support of my supervisor, Alejandro Badia, M.D. His hospitality, enthusiasm,
knowledge and exacting attention to detail have been an inspiration and kept my work on
track from the beginning.

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