Volar Rim Fractures of the Distal Radius: Can We Reduce the Complications and Need for Revision Surgery?

Over the last couple of years there has been an increasing focus on the importance of volar rim fractures, and a better understanding of the poor clinical outcomes, due to associated instabilities, failure of fixation, and the need for revision surgery.[1]

To better define the problem and review the treatment options we have put together a symposium of invited papers on volar rim fractures ([Fig. 1]).[1] [2] [3] [4] [5] [6] [7] [8]

Fig. 1 Common causes of failure to fixation including failure of capture (A) and contain (B) the fracture.[1]

Clarnette et al provided a paper on the mapping of the volar rim fractures and how they relate to the osteoligamentous units ([Fig. 2]).[2]

Fig. 2 Fracture mapping of volar rim fractures (A) all the fragments together, and (B) the lunate facet fragments only.[2]

Heifner and Orbay provided a review of the principles of the watershed line and the management of volar rim distal radius fractures.[3] This paper highlighted the value of the extended flexor carpi radialis approach, to exposure and reduce the fractures ([Fig. 3]).

Fig. 3 Fixation of distal radius fracture via the extended flexor carpi radialis (FCR) approach (A). The volar marginal fragment has been stabilized with a volar locking plate and hook plate extension which captures the fragment.[3]

Chiri et al highlighted the importance of the critical corner, which has the unenviable role of transmitting the load and stabilizing the radiocarpal and distal radioulnar joints.[4] This paper introduced the concept of the calcar of the distal radius, which extends from the volar ulnar metaphysis to the subchondral bone plate of the distal radius. Also, the principles of the osteoligamentous units of the intra-articular fractures of the distal radius ([Fig. 4A]). The causes of secondary failure including the concept of the “Sleeper lesions,” which are injuries to the restraining ligamentous structures, that are compromised with time or loading ([Fig. 4B]). These lesions explain some of the late failures that occur despite apparent adequate fixation.

Fig. 4 Osteoligamentous concept of distal radius fractures—(A) Volar ulnar corner fragment, SRLL, and lunate.[3] (B) “Sleeper Lesion” avulsion of the LRLL is often missed due to subtle radiological changes but can result in delayed carpal instability if not identified and addressed. (Image courtesy: Max Crespi and Greg Bain.) SRLL, short radiolunate ligament; LRLL, long radiolunate ligament.[4] Delayed instability after initial fixation (C, D).[4]

Imatani and Kondo provided an insight into the spectrum of these complex injuries, highlighting the importance of the size of the volar fragment in the coronal and sagittal planes.[5] These concepts are brought together with the Kondo–Imatani classification ([Fig. 5]).[5]

Fig. 5 The Kondo–Imatani (K-I) computed tomography (CT) classification is used to assess volar rim fractures within 7.5 mm of the volar cortex.[5]

Hintringer et al discussed the osteoligamentous principles defined with on computed tomography (CT), and how each can be managed^, with different fixation options ([Fig. 6]).[6]

Fig. 6 Volar key fragment. The volar fracture can be associated with a (A) volar or (B) dorsal dislocation. Fixation options include (C) small hook plate and (D) volar rim fracture plates. Image courtesy: Hintringer et al.[6]

Herzberg et al reviewed the role of wrist arthroscopy in defining the associated ligament injuries, and how to stabilize the fractures.[7] He described how the dual-window approach can be used to expose the distal radius while using traction for wrist arthroscopy ([Fig. 7]).

Fig. 7 Volar rim fracture and arthroscopy. (A) With the hand in vertical traction, the flexor tendon mass is retracted radially, creating the medial part of the dual-window approach to directly view the volar rim fragment. Dry arthroscopy (B) before and (C) after reduction.

Orbay and Orbay reported the natural history of failed fixation, developed a classification and treatment algorithm.[8]

Acute revisions (< 4 weeks) – Revise fixation ± Bridge plate.

Subacute (4 weeks to 4 months) – Restoration articular surface including open wedge osteotomy, + bridge plating ([Fig. 8]).

Fig. 8 Subacute failed fixation.[8] Articular reconstruction with volar opening wedge osteotomy and corticocancellous autograft. Fixation with extension hook plate to capture the volar marginal fragment. Neutralization with lunate Kirschner wires (K wires) and dorsal bridge plate.

Chronic (> 4 months) – Salvage.

The papers in this symposium highlight the complexities of these injuries, especially the associated ligamentous injuries and instabilities. It is clear, currently there is a high rate of fixation failures and need for revision surgery.[1] To avoid these poor outcomes, we need to accurately assess the CT scan to determine the osteoligamentous injuries and associated “Sleeper lesions.” Awareness of the complexities, careful planning, and an adequate surgical approach is required to enable anatomical reduction and stabilization necessary for a good clinical outcome. It is imperative that the first operation stabilizes the radius and the wrist, to avoid the need for complex revision surgery, prolonged rehabilitation, and inferior clinical outcomes. These complex cases should be identified and then referred to the appropriate surgeon for the first surgery. Get it right the first time! [9]

Publikationsverlauf

Artikel online veröffentlicht:
12. Juli 2022

• References

• 1 Eardley-Harris N. et al. Volar marginal rim fractures of the distal radius have a higher rate of associated carpal injuries—a comparative cohort study. J Wrist Surg 2022; 11 (03) 195-202
• 2 Clarnette J. et al. Volar lunate facet fractures of the distal radius: fracture mapping using 3D CT scans. J Wrist Surg 2022; (e-Pub ahead of print) DOI: 10.1055/s-0041-1742228.
• 3 Heifner JJ, Orbay JL. Assessment and management of acute volar rim fractures. J Wrist Surg 2022; 11 (03) 214-218
• 4 Chiri W, MacLean S, Clarnette J. et al. Anatomical and clinical concepts in distal radius volar ulnar corner fractures. J Wrist Surg 2022; 11 (03) 238-249
• 5 Imatani J, Kondo H. Volar lunate facet rim fractures: KI classification and technique. J Wrist Surg 2022; 11 (03) 230-237
• 6 Hintringer W, Rosenauer R, Quadlbauer S. Computed tomography and pathobiomechanical-based treatment of volar distal radius fractures. J Wrist Surg 2022; 11 (03) 203-213
• 7 Herzberg G, Burnier M, Ly L. Arthroscopically assisted treatment of volar rim fractures. J Wrist Surg 2022; 11 (03) 224-229
• 8 Orbay MC, Orbay JL. Classification and management of failed fixation of the volar marginal fragment in distal radius fractures. J Wrist Surg 2022; 11 (03) 219-223
• 9 Briggs T. . Getting it Right First Time: Improving the Quality of Orthopaedic Care within the National Health Service in England. London: British Orthopaedic Association; 2012