gms | German Medical Science

Objectives/Interrogation: The increasing number of fixed-angle plate systems used to treat DRF carries with it the problem of determining the optimal fixation for unstable fractures. Our goal was to analyse the clinical and radiological outcomes of patients with displaced, unstable DRFs treated with a palmar locking plate.

Methods: Over a mean 15-month period, 141 consecutive patients were treated for an unstable dorsally displaced DRF. Objective and subjective functional results (active ROM; strength; DASH score; VAS; Green and O'Brien Score) and radiographic assessment (palmar tilt, radial inclination, ulnar variance, fracture union) were assessed. Potentials for complications were given special attention.

Results and Conclusions: 114 patients with a mean age of 57 years were treated. Fractures were classified as type A2 (n=39), A3 (n=16), C1 (n=24), C2 (n=30), or C3 (n=5). The modified Green and O'Brien Score revealed 31 excellent, 54 good, 23 fair and 6 poor results. Active wrist motion averaged 54° extension (82% of uninjured side), 46° flexion (72%), 81° pronation (95%), and 82° supination (95%). Mean grip strength was 70% of the uninjured side. 81 patients (71%) were pain free, 17 patients (15%) had mild pain, 10 patients (9%) had moderate pain and 6 patients (5%) severe pain. Mean DASH score was 13 points. Fracture union was achieved in all patients. A mean loss of palmar tilt of 3.4°, radial inclination of 0.4° and ulnar variance of 1.2 mm was measured. Overall complication rate was 27%. Most frequent problems were flexor and extensor tendon irritation (57% of the total number of complications). CTS was observed in 3 patients, CRPS in 5 patients. In 2 cases, loosening of a single screw and loss of palmar fragment was seen. Delayed union occurred in 3 patients and intraoperative intraarticular screw displacement was recognized in 1 patient. Neither clinical outcome nor complication rate were dependent on fracture type (intra- vs. extraarticular).

Very distal palmar plate position can interfere with the flexor tendon system, too long screws can penetrate the extensor compartments and distal screws in comminuted fracture patterns can cut through the subchondral bone and penetrate into the radiocarpal joint. We present our algorithm to avoid these complications using the intra-operative dorsal horizon view, pronator quadratus flap and fragment specific plate fixation.