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DOI: 10.1055/s-0043-1771376
The Volar Cortical Hinge: An Independent Risk Factor for Distal Radius Fracture Displacement
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Abstract
Background Displaced distal radius fractures are prone to redisplacement after manipulation. This can result in the need for delayed surgery. Several criteria have been studied to predict the likelihood of redisplacement. We hypothesized that reduction in the volar cortex would be an additional predictive factor.
Purpose The aim of this study was to assess whether the quality of the volar cortex reduction predicts the subsequent need for further intervention (surgery or remanipulation). As a secondary outcome, we assessed whether the quality of the reduction predicts the rate of malunion.
Methods A retrospective review was performed of displaced adult distal radius fractures over a 2-year period that had undergone closed reduction at presentation. We identified 105 patients and a review of their electronic notes and radiographs was then performed. The volar cortex reduction was defined as “anatomical,” “opposed,” or “displaced.” We assessed the radial height, radial inclination, radial/ulnar translation, volar/dorsal angulation, teardrop angle, presence of dorsal comminution, quality of the cast (molding, cast index), and volar cortex reduction. These measurements were taken at five time points (prereduction, postreduction, 1 week, 2 weeks, and 6 weeks). All patients that subsequently required surgical fixation or repeat reduction were identified as the primary outcome measure. The 6-week radiographs were assessed for radiographic malunion as our secondary outcome measure. A statistical analysis was then performed to assess the factors that influenced a loss of position and the need for delayed surgical intervention.
Results Of the 105 patients, 22 patients required delayed surgery, 3 patients underwent a repeat manipulation, and 12 patients had a radiographic malunion at 6 weeks. During the study period, the proportion of patients requiring surgery or repeat manipulation in the displaced group was 10/21 (47.6%), in the opposed group it was 11/50 (23.4%), and in the anatomic group it was 4/36 (11.1%; p = 0.008). We then included the patients with a radiographic malunion and found the proportion of patients with an adverse outcome in the displaced group was 14/21 (66.7%), in the opposed group it was 17/47 (36.2%), and in the anatomic group it was 6/36 (16.7%; p = 0.001). At the 1-week time point, this association was equally significant, as the proportion in the displaced group was 17/33 (51.5%), in the opposed group it was 15/45 (33.3%) and in the anatomic group it was 1/22 (4.5%; p = 0.001). The patients' age, quality of cast, presence of dorsal comminution, and degree of initial displacement did not predict the subsequent need for surgery or remanipulation.
Conclusion The most important factor in our study for significant redisplacement of an initially dorsally displaced distal radius fracture is the association of the volar cortex. This parameter maintains significance at the 1-week time point. This data shows that volar cortex reduction is a useful clinical measurement in assessing which distal radius fractures will undergo delayed displacement requiring intervention.
Level of evidence Level 3–Retrospective comparative study.
Keywords
distal radius - volar cortex - volar cortical hinge - fracture - displaced - remanipulationHDEC out of scope confirmation and Local Bay of Plenty District Health Board approval.
Research conducted at Bay of Plenty District Health Board – Tauranga Hospital.
Publication History
Received: 22 January 2023
Accepted: 28 June 2023
Article published online:
21 August 2023
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References
- 1 Alemdaroğlu KB, İltar S, Aydoğan NH, Say F, Kilinç CY, Tiftikçi U. Three-point index in predicting redisplacement of extra-articular distal radial fractures in adults. Injury 2010; 41 (02) 197-203
- 2 LaMartina J, Jawa A, Stucken C, Merlin G, Tornetta III P. Predicting alignment after closed reduction and casting of distal radius fractures. J Hand Surg Am 2015; 40 (05) 934-939
- 3 Arora R, Gabl M, Erhart S, Schmidle G, Dallapozza C, Lutz M. Aspects of current management of distal radius fractures in the elderly individuals. Geriatr Orthop Surg Rehabil 2011; 2 (5-6): 187-194
- 4 Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006; 88 (09) 1944-1951
- 5 Walenkamp MMJ, Aydin S, Mulders MAM, Goslings JC, Schep NWL. Predictors of unstable distal radius fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2016; 41 (05) 501-515
- 6 Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand 2003; 74 (01) 98-100
- 7 Einsiedel T, Freund W, Sander S, Trnavac S, Gebhard F, Kramer M. Can the displacement of a conservatively treated distal radius fracture be predicted at the beginning of treatment?. Int Orthop 2009; 33 (03) 795-800
- 8 Leone J, Bhandari M, Adili A, McKenzie S, Moro JK, Dunlop RB. Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. Arch Orthop Trauma Surg 2004; 124 (01) 38-41
- 9 Jeong GK, Kaplan FTD, Liporace F, Paksima N, Koval KJ. An evaluation of two scoring systems to predict instability in fractures of the distal radius. J Trauma 2004; 57 (05) 1043-1047
- 10 Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The unstable distal radius fracture-how do we define it? A systematic review. J Wrist Surg 2015; 4 (04) 307-316
- 11 Myderrizi N. Factors predicting late collapse of distal radius fractures. Malays Orthop J 2011; 5 (03) 3-7
- 12 Daniels AM, Janzing HMJ, Wyers CE. et al. Association of secondary displacement of distal radius fractures with cortical bone quality at the distal radius. Arch Orthop Trauma Surg 2021; 141 (11) 1909-1918
- 13 Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989; 20 (04) 208-210
- 14 Bain GI, MacLean SBM, McNaughton T, Williams R. Microstructure of the distal radius and its relevance to distal radius fractures. J Wrist Surg 2017; 6 (04) 307-315
- 15 Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005; 21 (03) 279-288
- 16 Bushnell BD, Bynum DK. Malunion of the distal radius. J Am Acad Orthop Surg 2007; 15 (01) 27-40
- 17 Slutsky DJ. Predicting the outcome of distal radius fractures. Hand Clin 2005; 21 (03) 289-294
- 18 Phillips AR, Al-Shawi A. Restoration of the volar cortex: predicting instability after manipulation of distal radial fractures. Injury 2014; 45 (12) 1896-1899
- 19 Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: a systematic review and meta-analysis. J Hand Surg Am 2016; 41 (03) 404-413
- 20 Hruby LA, Haider T, Laggner R. et al. Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study. Arch Orthop Trauma Surg 2022; 142 (06) 1075-1082