■ Feature Article

Long-term Results of Dorsally Displaced Distal Radius Fractures Treated With the Pi-Plate: Is Hardware Removal Necessary?

MINOS E. TYLLIANAKIS, MD; ANDREAS M. PANAGOPOULOS, MD, PHD; ALKIS SARIDIS, MD

abstract Full article available online at ORTHOSuperSite.com. Search: 20110526-10

The purpose of this study was to evaluate the outcome of patients treated with open re- duction and internal fi xation (ORIF) using dorsal plates and screws (AO/ASIF pi-plate) for dorsally displaced fractures of the distal radius. Although extensor tendon rupture is a recognized complication of all distal radial fractures, there appears to be an in- A B creased risk of this using dorsal plating. In addition, there is the added complication of extensor tendon irritation and dorsal pain, which may necessitate plate removal. The low-profi le pi-plates intended to overcome this problem have not done so, with quoted rates ranged from 19% to 55%.

We treated 32 completely evaluated patients (13 men and 19 women) in our depart- ment between 2000 and 2004, with an average age of 46 years. They underwent ORIF of dorsally displaced fractures of the distal radius using the specially designed pi-plate. Bone graft was used in 18 patients who had signifi cant metaphyseal defect. Clinical examination, plain radiographs, and functional assessments using the modifi ed Mayo Wrist Score were performed at an average follow-up of 86 months (range, 56-115 C D months). Satisfactory reduction was achieved in all 32 fractures at the time of operative Figure: Preoperative AP (A) and lateral (B) radio- fi xation with no instances of loss of fracture reduction during the study period. Ac- graphs of a type II fracture in a 42-year-old wom- an who sustained the fracture after a fall from a cording to the Mayo Wrist Score, 23 patients (72%) had excellent or very good results, height. AP (C) and lateral (D) radiographs at last 7 (22%) had fair results, and 2 (6%) had poor results. Two cases (6.25%) of extensor follow-up 91 months postoperatively. The Mayo tendon rupture were noted during the fi rst postoperative month, and 2 other patients score was 94. showed progressive weakness of index fi nger extension 6 months postoperatively. The remaining 28 patients had no soft tissue problems.

Drs Tyllianakis, Panagopoulos, and Saridis are from the Department of Surgery and Reconstruction, Orthopaedic Clinic of Patras University Hospital, Patras, Greece. Drs Tyllianakis, Panagopoulos, and Saridis have no relevant fi nancial relationships to disclose. Correspondence should be addressed to: Andreas Panagopoulos MD, PhD, Department of Upper Limb Surgery and Reconstruction, Orthopaedic Clinic of Patras University Hospital, Argira, 26504 Patras, Greece ([email protected]). doi: 10.3928/01477447-20110526-10

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ne of the most common injuries in the immediate postoperative period (up fi xation (ORIF) with pi-plate unless severe in orthopedics is the distal radius to 6 months), it will not occur in the long intra-articular fragmentation excluded the Ofracture. Some of these fractures term; thus, scheduled plate removal is not use of the method. The latter cases were are caused by severe high-energy trauma, necessary. treated with external fi xation, augmented resulting in intra-articular involvement or not, and were excluded from the study. and comminution. Treatment of such in- MATERIALS AND METHODS The decision on the method of treatment juries is diffi cult. These fractures often are During a 4-year period (2000-2004), was made intraoperatively by the senior unstable, diffi cult to reduce anatomically, 95 patients underwent surgical treatment author (M.E.T.) based on fl uoroscopic and associated with a high prevalence of for a distal radius fracture in our depart- images under traction. Once the decision complications. Restoration of radial short- ment. Forty-nine patients were treated was made, no intraoperative shift from 1 ening, radial inclination, and sagittal tilt, with external fi xation and 34 patients with method to the other was done. as well as articular congruency, is required the pi-plate. Thirty-two were available for the best chance of good functional out- at the last follow-up. Thirteen men and SURGICAL TECHNIQUE come.1,2 Displaced, unstable fractures left 19 women had a mean age of 46.1 years All procedures were performed by the untreated may lead to instability,3,4 post- (range, 20-73 years). same surgeon (M.E.T). Under general an- traumatic osteoarthritis,5,6 or residual dis- Inclusion criteria were dorsally dis- esthesia and tourniquet use, a dorsal inci- ability.7 The fi xation method of choice is placed fractures with failure of initial re- sion was made over Lister’s tubercle. The the one that can maintain a satisfactory duction to restore: radial inclination у15Њ third extensor compartment was opened, reduction and allow early motion to avoid on posteroanterior radiographs; sagittal leaving the extensor pollicis longus tendon stiffness and disuse atrophy.8 tilt on lateral projection between 15Њ dor- free. With subperiosteal dissection toward While dorsal plates have yielded good sal tilt and 20Њ volar tilt; radial shortening the radial and ulnar site, the dorsal cortex results in dorsally comminuted or dis- of Ͻ5 mm at the distal radial ulnar joint of the distal radius was then exposed. The placed fractures through osseous synthesis compared with the contralateral wrist; and fragments were reduced with gentle ma- using a dorsal 3.5-mm T-plate, they were incongruity of the intra-articular fracture neuvers and temporarily stabilized with 1- largely abandoned because of unfavorable Ͻ2 mm at the radiocarpal joint. or 1.25-mm K-wires when necessary. experiences with the extensor tendons.9 All fractures were operated within 48 After fl uoroscopic guidance, the pi- With the anatomically precontoured AO/ hours of admission. In 4 cases, surgery was plate was applied. Three or four 2.7-mm ASIF pi-plate, extensor tendon problems performed after a week because of late re- screws were used in the proximal part. In can be lessened, and despite various au- displacement of the fracture. All fractures cases with intact opposite volar cortex, у3 thors advocating volar fi xed-angle plate were dorsally displaced, and 1 had both screws were used; otherwise, pegs were for dorsally displaced fractures,10,11 there dorsal and volar displacement. Accord- preferred. No posterior interosseous nerve are some fractures that are problematic to ing to AO classifi cation,14 four fractures resection was routinely performed in any reduce and stabilize from the palmar side were type A2 (extra-articular simple and case. Bone graft was inserted after pi-plate in which dorsal reduction may be easier impacted), 16 were type A3 (extra-articu- application in 18 patients who had signifi - to perform.12 lar multifragmentary), 4 were type B1 cant metaphyseal defect. Autografts were This article describes our experience (partial articular, sagittal), 4 were type B2 used in 11 patients and autografts and treating these dorsally displaced fractures (partial articular, dorsal rim), 3 were C1 allografts in 7 patients. Although the pi- of the distal radius with dorsally applied (articular simple, metaphyseal simple), plate was anatomically designed in 3 cas- pi-plates and early mobilization. The study and 1 was type C2 (articular simple, me- es, we had to precontour the vertical part group was homogeneous with respect to taphyseal multifragmentary). By defi ni- of the plate with special guides to match fracture as well as fi xation type. Removal tion, C3 (complete articular fracture, mul- anatomic variations of the dorsal cortex. of pi-plates has been recommended af- tifragmentary) and B3 (partial articular, Holes from the radial or ulnar edge or ter fracture healing to avoid late tendon volar rim) fractures were excluded from both of the vertical part of the plate were problems.13 However, in our department, the study. Associated injuries included 1 cut off in 5 cases because the plate inter- plate removal is not regularly performed scaphoid fracture, 1 tibial fracture, and vened with smooth extensor tendon glid- because of lack of adequate operating 1 multiple injured patient. All fractures ing. The third compartment was left open, time. We present the long-term clinical were closed, and no associated ligamen- and after a fi nal fl uoroscopic examination, outcome of the distal radius treated with tous injuries of the wrist were noted. the wound was closed. de- pi-plate that was not routinely removed. It The surgical treatment method of compression was performed if there was appears that if there is no tendon irritation choice was open reduction and internal preoperative clinical evidence of median

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nerve compression (5 cases). The mean operative time was 67 minutes. A short cast was used in all patients for 1 to 2 weeks postoperatively. Once in a removable splint, patients com- menced weekly therapy sessions, starting with early active movement and progressing to passive movement by 4 to 6 weeks. 1A 1B 1C 1D RESULTS Figure 1: Preoperative AP (A) and lateral (B) radiographs of a type II fracture in a 42-year-old woman who sustained the fracture after a fall from a height. AP (C) and lateral (D) radiographs at last follow-up 91 All patients were examined clinically months postoperatively. The Mayo score was 94. and radiologically at 2, 4, and 8 weeks and 6 months postoperatively. The mean time to union was 5.3 weeks (range, 4.5-8 weeks). At 6-month follow-up, no radio- logical differences were noted compared to immediately postoperatively. There was no clinical evidence of carpal insta- bility or any fracture subsidence. For the purpose of the present study, the patients were evaluated by 2 independent medical 2A 2B 2C 2D students an average of 86 months postop- Figure 2: Preoperative AP (A) and lateral (B) radiographs of an extra-articular fracture in a 57-year-old eratively (range, 56-115 months). woman who sustained the fracture after a fall from a height. AP (C) and lateral (D) radiographs at last fol- At most recent follow-up, patients low-up 78 months postoperatively. The Mayo score was 92. were given the modifi ed Mayo Wrist Score questionnaire to subjectively evalu- Table ate their pain (25 points) and satisfaction Radiographic Measurements with the fi nal outcome (25 points), where- as objective evaluation included measure- Median (range) ment of grip strength (25 points) with a Radial Radial Intra-articular Jamar dynamometer and range of motion Shortening, mm Sagittal Tilt, deg Inclination, deg Step, mm (25 points) with a standard goniometer. Preoperatively 5 (Ϫ5 to 14) Ϫ18 (Ϫ45 to 26) 10 (Ϫ20 to 21) 5 (0-9) There was no other communication in the Postoperatively 12 (8-16) 8 (Ϫ2 to 18) 18 (15-24) 0.5 (0-2) meantime except the cases mentioned be- Last follow-up 11 (7-16) 8 (Ϫ3 to 19) 17 (14-24) 0.5 (0-2) low. According to Mayo Wrist Score, 34% Normal wrist 13 (10-14) 11 (8-14) 22 (16-27) 0 of the patients had excellent results, 38% Abbreviation: deg, degrees. good, 22% fair, and 6% poor. No patient had refl ex sympathetic dystrophy, non- union, infection, or material failure. Radiological parameters (radial incli- tients had steps of 0 to 1 mm and one of 1 ment. Intraoperatively, the tip of 1 screw nation, radial shortening, sagittal tilt, and to 2 mm at the radiocarpal joint. These 3 was found to penetrate the cartilage and intra-articular step) were among the nor- patients also revealed evidence of grade 1 abrade the scaphoid or lunate articular mal values, and no case had statistically Knirk and Jupiter5 osteoarthritic change at surface. No substantial improvement in different values between postoperative the radiocarpal joint. range of wrist motion was noted postop- and last follow-up radiographs (Figures 1, Three patients were reoperated 6 weeks eratively after plate removal. 2). At the last follow-up, there was a mean postoperatively due to wrist stiffness at- Two cases of extensor tendons rupture sagittal tilt of 8Њ, radial inclination of 17Њ, tributed to material protrusion into the were noted during the fi rst postoperative and radial shortening of 11Њ (Table). In joint. All 3 had been under physiotherapy month. The ruptured tendons were re- terms of intra-articular congruity, 2 pa- for at least 1 month with little improve- paired side-to-side with the remaining

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intact tendons and the plate was removed gap motion than did the 4 types of volar Incidence of posttraumatic arthritis in because callus formation was already plate fi xation. In this particular model, the our series was low, as most of the frac- present. A plaster cast was applied for 4 presence of a volar gap is not addressed, tures (28/32) were extra- or partially in- weeks. Intraoperatively in both cases, the and the pi-plate would likely become more tra-articular. head of a distal screw was found slight- unstable as the other types of volar plating The most common complaint in our ly protruding from the plate at the point do. However, Kandemir et al19 showed that study was dorsal wrist pain (19% of the where the rupture had occurred. In 2 other the fi xation obtained with volar locking patients), and the same is found in other cases, the patients reported progressive plates is as stable as fi xation with a dor- studies.21 Kambouroglou and Axelrod25 weakness of index fi nger extension 6 sal plate in acute healing period and can reported 5 cases of extensor tenosynovitis months postoperatively. The tendons were withstand the functional demands of the and 2 cases of extensor tendon rupture in found frayed, and no cause could be iden- immediate postoperative period in dorsally 8 patients who had been treated with a ti- tifi ed. The overall rate of reoperation was comminuted unstable extra-articular distal tanium pi-plate. Khanduja et al26 reported 21.8% (7/32 patients). Six patients (19%) radius fractures. removal of plate in 4 of 19 patients (23%) reported dorsal wrist pain. At fi nal clinical Initial studies with low-profi le plates due to extensor tenosynovitis and restric- assessment, all patients reported gradual report good results. Using the Gartland tion of fl exion. Chiang et al13 attempted diminishing of the pain within 1 year post- and Werley scoring system, Campbell20 to avert pain by creating a retinacular fl ap operatively. reported 4 very good, 11 good, and 10 sat- with limited success. In their series of 20 isfactory results in 25 patients; Ring and consecutive patients, there was a 60% in- DISCUSSION Jupiter21 reported 6 very good, 7 good, cidence of dorsal wrist pain and the need The treatment of distal radius fractures and 9 satisfactory results; and Rozental et for plate removal in 45% of them. Possible remains controversial. In 48 international al22 reported 19 excellent and 9 very good explanations for dorsal pain could be the randomized studies cited in the Cochrane results. Using the New York Orthopaedic chronic gliding of the tendons on a hard database, we found no evidence of superior, Hospital wrist rating scale, Suckel et al12 surface. Since in our series we did not rou- long-term, functional advantages from any reported 17 very good and 25 good results tinely ligate the terminal articular branch surgical procedure, including external fi xa- in 42 patients. In our series, we used the of the posterior interosseous nerve, irrita- tion, K-wire osteosynthesis, and open reduc- Mayo Wrist Score and had excellent or tion of that nerve under the plate could tion and plate osteosynthesis.15 Controversy very good results in 23 patients (72%), have also been a contributing factor. also exists about various surgical methods. fair in 7 (22%) and poor in 2 (6%). The close contact of the extensor ten- Results of 4 randomized controlled trials Some authors suggest early implant don mechanism to the head of the distal comparing external fi xation with ORIF for removal to avoid possible complications. screws is a matter of concern because of the treatment of intra-articular distal radius In previous studies, dorsal hardware was possible tendon attrition. In the 2 cases fractures describe no consistent benefi t of 1 removed in 18% to 36% of cases.9,21,23 with early rupture of the extensor ten- treatment over another.16 Sánchez et al,24 in a retrospective review don mechanism, the site of lesion was Locked volar plates for dorsally dis- of 389 patients with distal intra-articular found right over the head of 1 of the distal placed fractures have been proposed to fractures of the radius treated with the screws that was slightly loose and protrud- address problems of the dorsal plates. The dorsal pi-plate, reported a complication ing. The cause for the 2 late ruptures was former are better covered under soft tis- rate of only 6.7% within the fi rst 2 post- not clear. There was no malposition of the sues and do not interfere with the extensor operative months. Hardware was removed distal fragment that could have led to fric- mechanism. However, Rein et al17 found no in 75.5% of patients after 6 to 8 months. tional stress of the overlying tendons, nor statistically signifi cant difference between In the remaining 24.5% of patients, the was there any head screw protrusion at the patients operated with dorsal or volar ap- plates were left in situ for Ͼ33 months, site of tendon fraying. In both cases the proach for distal radius fractures, and in 4 and 89% of these patients were pain free lesion was at the extensor tendon of the retrospective cohort studies, there is insuf- and had excellent movement in the wrist. index fi nger of patients working heavily fi cient evidence to infer the advantage of Materials are not ordinarily removed in on a computer. either the volar or dorsal plating approach our department due to lack of adequate sur- The second-generation pi-plate with for treatment of distal radius fractures.16 gical time. That allowed us to observe the larger fl anges introduced to facilitate ten- Willis et al,18 in a biomechanical model of potential problems related to low-profi le pi- don gliding obscured the articular line of dorsally comminuted extra-articular distal plates when they remain in situ for years. To the radius in the radiographs. This was a radial fractures, demonstrated that the dor- our knowledge, this is the longest series in signifi cant drawback, and in 3 cases the sal pi-plate had better resistance to fracture the literature of nonremoved pi-plates. tips of distal screws were found in post-

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operative computed tomography scans to tra-articular distal radius fractures. J Hand Fracture Management. New York, NY: AO Surg Am. 1994; 19(2):325-340. Publishing; 2000. protrude 1 to 2 mm within the joint. Im- 2. Jupiter JB, Marent-Huber M; LCP Study 15. Handoll HH, Madhok R. Surgical inter- plant removal only slightly improved wrist Group. Operative management of distal ra- ventions for treating distal radial fractures motion. Other authors have also failed to dial fractures with 2.4-millimeter locking in adults. Cochrane Database Syst Rev. fi nd any signifi cant decrease in wrist pain plates. A multicenter prospective case series. 2003;(3):CD003209. J Bone Joint Surg Am. 2009; 91(1):55-65. after plate removal.13 16. Intraarticular distal radius fractures: external 3. Kim JP, Park MJ. Assessment of distal radio- fi xation versus open reduction with internal ulnar joint instability after distal radius frac- fi xation (update to November 2006 report). CONCLUSION ture: comparison of computed tomography Orthopaedic Trauma Directions. 2008; Displaced and/or comminuted frac- and clinical examination results. J Hand Surg 6(4):11-20. Am. 2008; 33(9):1486-1492. tures of the distal radius yield predictably 17. Rein S, Schikore H, Schneiders W, Amlang 4. Nesbitt KS, Failla JM, Les C. Assessment of in- M, Zwipp H. Results of dorsal or volar plate poor results unless accurately reconstruct- stability factors in adult distal radius fractures. J fi xation of AO type C3 distal radius fractures: ed, especially in young and more active Hand Surg Am. 2004; 29(6):1128-1138. a retrospective study. J Hand Surg Am. 2007; 32(7):954-961. patients. In addition, due to the natural 5. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. 18. Willis AA, Kutsumi K, Zobitz ME, Cooney tendency for posttraumatic stiffness in J Bone Joint Surg Am. 1986; 68(5):647-659. WP III. Internal fi xation of dorsally displaced these fractures, results may still be poor fractures of the distal part of the radius. A 6. Catalano LW III, Cole RJ, Gelberman RH, biomechanical analysis of volar plate frac- unless measures, such as early mobiliza- Evanoff BA, Gilula LA, Borrelli J Jr. Dis- ture stability. J Bone Joint Surg Am. 2006; placed intra-articular fractures of the distal tion, are taken. In the subgroup of dorsally 88(11):2411-2417. aspect of the radius. Long-term results in displaced fractures, we found that the dor- young adults after open reduction and in- 19. Kandemir U, Matityahu A, Desai R, Puttlitz sal approach allowed good restoration and ternal fi xation. J Bone Joint Surg Am. 1997; C. Does a volar locking plate provide equiva- maintenance of both extra- and intra-ar- 79(9):1290-1302. lent stability as a dorsal nonlocking plate in a dorsally comminuted distal radius fracture?: 7. Gliatis JD, Plessas SJ, Davis TR. Outcome of ticular parameters. Although extensor ten- a biomechanical study. J Orthop Trauma. distal radial fractures in young adults. J Hand 2008; 22(9):605-610. don rupture is a recognized complication Surg Br. 2000; 25(6):535-543. 20. Campbell DA. Open reduction and inter- of all distal radial fractures, there appears 8. Leung F, Zhu L, Ho H, Lu WW, Chow SP. nal fi xation of intra articular and unstable Palmar plate fi xation of AO type C2 fracture to be an increased risk of this using dor- fractures of the distal radius using the AO of distal radius using a locking compression sal plating. In addition, there is the added distal radius plate. J Hand Surg Br. 2000; plate—a biomechanical study in a cadaveric 25(6):528-534. complication of extensor tendon irritation model. J Hand Surg Br. 2003; 28(3):263-266. 21. Ring D, Jupiter JB. Operative fi xation of frac- and dorsal wrist pain, which may neces- 9. Carter PR, Frederick HA, Laseter GF. Open tures of the distal radius using the pi plate. Tech reduction and internal fi xation of unstable sitate plate removal. The low-profi le pi- Hand Up Extrem Surg. 1997; 1(2):125-130. distal radius fractures with a low-profi le plates intended to overcome this problem plate: a multicenter study of 73 fractures. J 22. Rozental TD, Beredjiklian PK, Bozentka DJ. have not done so, with quoted rates rang- Hand Surg Am. 1998; 23(2):300-307. Functional outcome and complications fol- 21,23-25 lowing two types of dorsal plating for unstable ing from 19% to 55%. 10. Rozental TD, Blazar PE. Functional outcome fractures of the distal part of the radius. J Bone and complications after volar plating for dor- However, our study found that if pa- Joint Surg Am. 2003; 85(10):1956-1960. sally displaced, unstable fractures of the distal tients are not having dorsal problems in the radius. J Hand Surg Am. 2006; 31(3):359-365. 23. Herron M, Faraj A, Craigen MA. Dorsal plat- ing for displaced intra-articular fractures of the early stages, they probably will not have a 11. Arora R, Lutz M, Hennerbichler A, Krap- distal radius. Injury. 2003; 34(7):497-502. problem later. Therefore, routine removal pinger D, Espen D, Gabl M. Complications of this device may not be warranted. There following internal fi xation of unstable distal 24. Sánchez T, Jakubietz M, Jakubietz R, Mayer radius fracture with a palmar locking-plate. J J, Beutel FK, Grünert J. Complications after are times when dorsal hardware is a better Orthop Trauma. 2007; 21(5):316-322. Pi Plate osteosynthesis. Plast Reconstr Surg. 2005; 116(1):153-158. option for some fracture patterns than the 12. Suckel A, Spies S, Münst P. Dorsal (AO/ volar approach and fi xation. Knowing that ASIF) pi-plate osteosynthesis in the treat- 25. Kambouroglou GK, Axelrod TS. Complica- ment of distal intraarticular radius fractures tions of the AO/ASIF titanium distal radius long-term dorsal soft tissue problems are [published online ahead of print October 19, plate system (pi plate) in internal fi xation of unlikely in the absence of short-term rup- 2006]. J Hand Surg Br. 2006; 31(6):673- the distal radius: a brief report. J Hand Surg tures may be helpful. 679. Am. 1998; 23(4):737-741. 13. Chiang PP, Roach S, Baratz ME. Failure of a 26. Khanduja V, Ng L, Dannawi Z, Heras L. Com- retinacular fl ap to prevent dorsal wrist pain after plications and functional outcome following REFERENCES titanium Pi plate fi xation of distal radius frac- fi xation of complex, intra-articular fractures 1. Trumble TE, Schmitt SR, Vedder NB. Factors tures. J Hand Surg Am. 2002; 27(4):724-728. of the distal radius with the AO Pi-Plate. Acta Orthop Belg. 2005; 71(6):672-677. affecting functional outcome of displaced in- 14. Rüedi TP, Murphy WM. AO Principles of

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