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Dorsal bridging plates for the treatment of high and low energy distal radius fractures

  • Author Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Tobias Roberts
    Correspondence
    Corresponding author. Trauma & Orthopaedic Department, St. George's Hospital, London, SW17 0QT, UK.
    Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Affiliations
    Royal United Hospitals, Combe Park, Bath, Avon, BA1 3NG, UK
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  • Author Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Cezary Kocialcowski
    Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Affiliations
    Royal United Hospitals, Combe Park, Bath, Avon, BA1 3NG, UK
    Search for articles by this author
  • Author Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Alex Cowey
    Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
    Affiliations
    Royal United Hospitals, Combe Park, Bath, Avon, BA1 3NG, UK
    Search for articles by this author
  • Author Footnotes
    1 Present address: T&O department, St. Georges Hospital, London, SW17 0QT.
Published:October 20, 2022DOI:https://doi.org/10.1016/j.jcot.2022.102048

      Abstract

      Distal radius fractures are common and treatment of complex fracture pattens can be challenging. We assessed functional outcomes, radiographic analysis, and complications of 26 distal radius fractures treated with dorsal bridging plate (DBP) at a mean of 14 months post plate removal (6–34 months). Radiographic parameters were measured pre- and post-operatively and patient reported wrist evaluation scores, patient reported wrist range of movement and satisfaction scores. Mean post-operative total PRWE was 26 (range 0–76) and mean wrist mobility 52° flexion (range 10°–85°) and 50° extension (range 10°–85°). Mean post-operative patient satisfaction score was 89% (range 50–100%). Four patients developed complications (one EPL rupture and three developed CRPS). DBP can reliably restore distal radius anatomy and is associated with good functional outcome scores, return of functional range of wrist movement and high levels of patient satisfaction.

      Level of Evidence

      III

      Keywords

      1. Introduction

      The distal radius is the most commonly fractured bone in adults, forming a significant part of emergency department and orthopaedic workloads. These have a bi-modal distribution, affecting younger patients following high energy injuries and older individuals suffering low energy fragility fractures.
      • Court-Brown C.M.
      • Caesar B.
      Epidemiology of adult fractures: a review.
      Prevalence is significantly greater in women than in men, and risk increases with age.
      • O'Neill T.W.
      • Cooper C.
      • Finn J.D.
      • et al.
      Incidence of distal forearm fracture in British men and women.
      Indeed, the lifetime risk of distal radius fracture in women over 50 is estimated to be 15%.
      • Cummings S.R.
      • Nevitt M.C.
      • Haber R.J.
      Prevention of osteoporosis and osteoporotic fractures.
      In fractures requiring surgical management, the goals of treatment are to anatomically reduce the fracture and maintain this with a stable construct that will allow bone healing and restoration of wrist function.
      • Ikpeze T.C.
      • Smith H.C.
      • Lee D.J.
      • Elfar J.C.
      Distal radius fracture outcomes and rehabilitation.
      Popular fixation techniques have evolved over time. In the United Kingdom, since the publication of the DRAFFT study, there has been a shift towards fixation with Kirshner wires (K-wires) in dorsally displaced fractures.
      • Costa M.L.
      • Jameson S.S.
      • Reed M.R.
      Do large pragmatic randomised trials change clinical practice?: assessing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT).
      For volarly displaced and intra-articular fractures, which cannot be reduced closed, volar plate fixation remains an effective mode of fixation.
      • Woolnough T.
      • Axelrod D.
      • Bozzo A.
      • et al.
      What is the relative effectiveness of the various surgical treatment options for distal radius fractures? A systematic review and network meta-analysis of randomized controlled trials.
      Treatment of highly comminuted and unstable fracture patterns however remains challenging.
      • Ginn T.A.
      • Ruch D.S.
      • Yang C.C.
      • Hanel D.P.
      Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
      ,
      • Rhee P.C.
      • Medoff R.J.
      • Shin A.Y.
      Complex distal radius fractures: an anatomic algorithm for surgical management.
      Dorsal bridging plate (DBP) fixation has been described by several authors as an effective way to treat these fractures.
      • Ginn T.A.
      • Ruch D.S.
      • Yang C.C.
      • Hanel D.P.
      Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
      ,
      • Burke E.
      • Singer R.
      Treatment of comminuted distal radius with the use of an internal distraction plate.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      • Lauder A.
      • Agnew S.
      • Bakri K.
      • Allan C.H.
      • Hanel D.P.
      • Huang J.I.
      Functional outcomes following bridge plate fixation for distal radius fractures.
      Not only does it allow restoration of the anatomy of the distal radius in these complex injuries, it has also been described to facilitate early post-operative weightbearing through the injured wrist in polytrauma patients.
      • Hanel D.P.
      • Lu T.S.
      • Weil W.M.
      Bridge plating of distal radius fractures: the harborview method.
      The plate is inserted across the radiocarpal joint and fixed to the radius proximally and then to either the index or middle metacarpal, allowing indirect restoration and stable fixation of the wrist joint through ligamentotaxis. This method also avoids the risk of potential complications of pin-site infection, loosening, breakage, neuropathies and skin compromise reported in external fixation.
      • Anderson J.T.
      • Lucas G.L.
      • Buhr B.R.
      Complications of treating distal radius fractures with external fixation: a community experience.
      ,
      • Wang W.L.
      • Ilyas A.M.
      Dorsal bridge plating versus external fixation for distal radius fractures.
      Published literature on DBP functional outcomes and complications remains limited to several retrospective case series and one prospective study. These show good rates of fracture union, and low rates of complications and acceptable functional outcomes.
      • Ginn T.A.
      • Ruch D.S.
      • Yang C.C.
      • Hanel D.P.
      Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
      ,
      • Burke E.
      • Singer R.
      Treatment of comminuted distal radius with the use of an internal distraction plate.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      • Lauder A.
      • Agnew S.
      • Bakri K.
      • Allan C.H.
      • Hanel D.P.
      • Huang J.I.
      Functional outcomes following bridge plate fixation for distal radius fractures.
      The aim of this study was to assess the functional outcomes, radiographic analysis and complications of a case series of patients treated with dorsal bridging plate at our centre between 2018 and 2020, including during the coronavirus pandemic.

      2. Methods

      The trauma database at our institution, was reviewed and all patients with distal radius fractures, treated with DBP between 2018 and 2020 were identified. Electronic patient records (Millennium, Cerner EHR) were reviewed to identify demographic details, injury mechanism, operative details and complication rates. Patients were sent postal questionnaires to evaluate functional outcomes using the patient reported wrist evaluation (PRWE) score, post-operative range of movement using a visual chart and overall satisfaction using a visual analogue scale (VAS). Institutional approval for the study was obtained and ethical approval was not required as the study was conducted under audit framework.
      Inclusion criteria were any adult 18 years or older who had undergone dorsal bridging plate fixation for distal radius fracture, including bilateral injuries, open and closed fractures and revision from previous failed fixation other than DBP.
      Radiographs were reviewed using the Picture archiving and communication system (Fujifilm). Fracture classification was performed using the AO/OTA classification.
      • Meinberg E.G.
      • Agel J.
      • Roberts C.S.
      • Karam M.D.
      • Kellam J.F.
      Fracture and dislocation classification compendium-2018.
      Volar tilt, radial inclination, radial height and ulnar variance were measured as described by Kreder et al.
      • Kreder H.J.
      • Hanel D.P.
      • McKee M.
      • Jupiter J.
      • McGillivary G.
      • Swiontkowski M.F.
      X-ray film measurements for healed distal radius fractures.
      on pre-operative and post-operative radiographs after fracture union.

      3. Indications and surgical technique

      Indications for use of dorsal bridging plate was at the discretion of the Hand Surgery department and included multi-fragmentary and unstable distal radius fractures, open fractures, fractures where reduced bone quality would compromise surgical fixation and fractures that had failed alternative operative fixation techniques including K-wire or volar plate fixation. Operations were directly performed or supervised by consultant hand surgeons. Surgical technique was standardised in approach as has been previously described.
      • Hanel D.P.
      • Lu T.S.
      • Weil W.M.
      Bridge plating of distal radius fractures: the harborview method.
      The dorsal capsule was not opened, and reduction of the fracture occurred indirectly through ligamentotaxis. Plate fixation was to either the index or middle metacarpal as per surgeon preference, with proximal fixation to the radius. The plate used was the DePuy Synthes (Warsaw, USA) 3.5 mm 10, or 12 hole LCP metaphyseal plate. Fixation was with locking screws to create an ‘internal’ external fixator construct (Image 1). Standard postoperative treatment included immobilisation in a plaster for two weeks followed by additional support in a removable wrist splint. All patients commenced immediate hand therapy post-operatively, initially focussing on maintaining digit range of movement and subsequently concentrating on regaining wrist movement, after removal of the DBP.
      Image 1
      Image 1Pre-operative, immediate post-operative and post fracture union radiographs of complete articular fracture treated by dorsal bridge plating.

      4. Results

      There were 26 dorsal bridging plates identified during the study period, performed on 21 women (one bilateral DBP) and four men. Of these, full follow-up data were available for 24 (in two patients post-operative care was transferred). The mean age at operation was 66 years (range 39–85). The mean ASA was 2 (range 1–3). Mean length of operation was 55 min (range 38–70).
      There were 12 left wrists DBPs, 12 isolated right DBPs and one patient with bilateral DBPs. Twenty patients had isolated wrist fractures and in five patients the distal radius fracture was part of polytrauma. Polytrauma injuries included bilateral wrist fractures, pubic rami fracture, vertebral fracture and femoral condyle fracture. In eighteen cases (69%) the mechanism of injury was a low energy fall from standing height. In eight cases (31%) the mechanism was high energy including: falling from bicycle,
      • Cummings S.R.
      • Nevitt M.C.
      • Haber R.J.
      Prevention of osteoporosis and osteoporotic fractures.
      road traffic accident,
      • O'Neill T.W.
      • Cooper C.
      • Finn J.D.
      • et al.
      Incidence of distal forearm fracture in British men and women.
      fall from height
      • O'Neill T.W.
      • Cooper C.
      • Finn J.D.
      • et al.
      Incidence of distal forearm fracture in British men and women.
      and crush injury.
      • Court-Brown C.M.
      • Caesar B.
      Epidemiology of adult fractures: a review.
      Twenty three (88%) fractures were closed, and three (12%) were open.
      In 24 cases DBP was the primary mode of fixation. Two were revisions from previous fixation – one K-wire fixation in which fracture position was lost and one volar plate that was removed due to deep wound infection. One DBP was performed following failure of non-operative management at 25 days. Stabilisation procedures in addition to the DBP included K-wire fixation of the radial styloid in 4 cases, and K-wire stabilisation of the ulna in 1 case. There were no intra-operative or immediate post-operative complications recorded.
      The mean length of time from injury to primary DBP fixation was eight days.
      • Court-Brown C.M.
      • Caesar B.
      Epidemiology of adult fractures: a review.
      • O'Neill T.W.
      • Cooper C.
      • Finn J.D.
      • et al.
      Incidence of distal forearm fracture in British men and women.
      • Cummings S.R.
      • Nevitt M.C.
      • Haber R.J.
      Prevention of osteoporosis and osteoporotic fractures.
      • Ikpeze T.C.
      • Smith H.C.
      • Lee D.J.
      • Elfar J.C.
      Distal radius fracture outcomes and rehabilitation.
      • Costa M.L.
      • Jameson S.S.
      • Reed M.R.
      Do large pragmatic randomised trials change clinical practice?: assessing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT).
      • Woolnough T.
      • Axelrod D.
      • Bozzo A.
      • et al.
      What is the relative effectiveness of the various surgical treatment options for distal radius fractures? A systematic review and network meta-analysis of randomized controlled trials.
      • Ginn T.A.
      • Ruch D.S.
      • Yang C.C.
      • Hanel D.P.
      Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
      • Rhee P.C.
      • Medoff R.J.
      • Shin A.Y.
      Complex distal radius fractures: an anatomic algorithm for surgical management.
      • Burke E.
      • Singer R.
      Treatment of comminuted distal radius with the use of an internal distraction plate.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      • Lauder A.
      • Agnew S.
      • Bakri K.
      • Allan C.H.
      • Hanel D.P.
      • Huang J.I.
      Functional outcomes following bridge plate fixation for distal radius fractures.
      • Hanel D.P.
      • Lu T.S.
      • Weil W.M.
      Bridge plating of distal radius fractures: the harborview method.
      • Anderson J.T.
      • Lucas G.L.
      • Buhr B.R.
      Complications of treating distal radius fractures with external fixation: a community experience.
      • Wang W.L.
      • Ilyas A.M.
      Dorsal bridge plating versus external fixation for distal radius fractures.
      • Meinberg E.G.
      • Agel J.
      • Roberts C.S.
      • Karam M.D.
      • Kellam J.F.
      Fracture and dislocation classification compendium-2018.
      • Kreder H.J.
      • Hanel D.P.
      • McKee M.
      • Jupiter J.
      • McGillivary G.
      • Swiontkowski M.F.
      X-ray film measurements for healed distal radius fractures.
      • Medoff R.J.
      Essential radiographic evaluation for distal radius fractures.
      • Arora R.
      • Lutz M.
      • Hennerbichler A.
      • Krappinger D.
      • Espen D.
      • Gabl M.
      Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate.
      • Vakhshori V.
      • Rounds A.D.
      • Heckmann N.
      • et al.
      The declining use of wrist-spanning external fixators.
      • Harley B.J.
      • Scharfenberger A.
      • Beaupre L.A.
      • Jomha N.
      • Weber D.W.
      Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial.
      • Weber S.C.
      • Szabo R.M.
      Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques.
      • Ryu J.
      • Cooney W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.S.
      Functional ranges of motion of the wrist joint.
      • Li Z.M.
      • Kuxhaus L.
      • Fisk J.A.
      • Christophel T.H.
      Coupling between wrist flexion-extension and radial-ulnar deviation.
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      • Brumfield R.
      • Champoux J.
      A biomechanical study of normal functional wrist motion.
      Plates were removed after a mean of 95 days (45–200). There was a negative correlation between days before plate removal and patient reported post-operative flexion and extension (p < 0.05) i.e. longer durations were associated with reduced ROM. There was no correlation between duration of plate insertion and PRWE scores or patient satisfaction scores.
      All fractures were intra-articular with 23 (88%) complete articular fractures (AO OTA C1-3) and three (12%) partial articular fractures (AO OTA B1-3) (Table 1).
      Table 1Frequency of fracture pattern by AO classification.
      A) Partial Articular radius … (2R3B2)A) with associated ulnar fracture (2U3A1)B) complete articular radius … (2R3C1-3)B) With associated ulnar fracture (2R3A1-3)
      13814
      Pre-operatively the mean sagittal angulation was 27° in a dorsally angulated fractures (range - 1 to 59°) and 20.5° in volarly angulated fractures (range 11°–23°). The mean radial inclination was 17.5° (range 8°–27°). Mean ulnar variance (radial shortening) was 5.9 mm (range −6.9 mm to 12 mm). Post-operatively the mean sagittal angulation was 4.4° in a dorsally angulated fractures (range 1°–15°) and 6.1° in volarly angulated fractures (range 1°–20°). The mean radial inclination was 19° (range 12°–26°). Mean ulnar variance was 0.7 mm (range −4.1 mm–5.5 mm). (Table 2). Pearson correlation found no correlation between these post-operative radiographic parameters and PRWE scores (p < 0.05).
      Table 2Pre- and post-op radiographic analysis.
      Preop – (frequency): mean [range]Post-op
      Sagittal angulationSagittal angulation
      • Volar
        • Ikpeze T.C.
        • Smith H.C.
        • Lee D.J.
        • Elfar J.C.
        Distal radius fracture outcomes and rehabilitation.
        : 20.5° [11°–23°]
      • Dorsal
        • Ginn T.A.
        • Ruch D.S.
        • Yang C.C.
        • Hanel D.P.
        Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
        : 4.4° [1°–15°]
      Radial inclination
      • Taylor S.S.
      • Noor N.
      • Urits I.
      • et al.
      Complex regional pain syndrome: a comprehensive review.
      : 17.5° [8°–27°]
      Radial inclination
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      : 19° [12°–26°]
      Radial height
      • Taylor S.S.
      • Noor N.
      • Urits I.
      • et al.
      Complex regional pain syndrome: a comprehensive review.
      : 9.4 mm [3.9–17.6]
      Radial height
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      : 9.7 mm [6.7–13.5]
      Ulnar varianceUlnar variance
      • +ve
        • Ginn T.A.
        • Ruch D.S.
        • Yang C.C.
        • Hanel D.P.
        Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution.
        : 3 mm [1–5]
      PRWE scores were available for 22 fractures (85%) and were obtained at a mean of 14 months after plate removal (range 6 months–34 months). The mean total PRWE was 26 (range 0–76). Within this, mean pain subscale was 15 (range 0–37) and function subscale was 11 (range 0–43.5).
      Self-reported wrist mobility at the same time point was mean 52° flexion (range 10°–85°) and 50° extension (range 10°–85°). The mean post-operative patient satisfaction score was 89% (range 50–100%). Pearson correlation found no correlation between severity of fracture pattern and PRWE scores (p = 0.51).
      Four patients (15%) developed post-operative complications. One patient sustained an extensor policis longus (EPL) tendon rupture, which was repaired at the time of DBP removal. Three patients developed complex regional pain syndrome (CRPS). This was diagnosed clinically by consultant hand surgeons in the hand clinic and included symptoms of continued pain and stiffness, altered skin colouration, shiny appearance to skin and abnormal hair distribution. All CRPS diagnoses occurred in women between the ages of 40 and 64 years and in patients who underwent primary fixation with a DBP. All cases were treated with urgent hand physiotherapy with resolution in two patients and ongoing symptoms in one patient. The degree of sagittal angulation in the CRPS cohort compared with the non-CRPS cohort was statistically significant (p < 0.05) (Welch's T-test). No other radiographic parameters were statistically significant.

      5. Discussion

      This study demonstrates that DBP is an effective treatment for restoring the anatomy of the wrist joint following complex intra-articular distal radius fractures. Radiographic analysis of the fracture patterns showed significant disruption of the normal anatomy, with marked dorsal or volar angulation and ulnar variance. This was corrected to within normally accepted parameters
      • Medoff R.J.
      Essential radiographic evaluation for distal radius fractures.
      in the majority of cases. The postoperative functional outcomes were also encouraging for restoration of function in this cohort. Published literature on DBP fixation for distal radius fractures is limited to mainly small retrospective case series and a small prospective study. To our knowledge only one other study has reported both clinical and radiological outcomes in a larger cohort of patients – with 33 patients included.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      Their study reports outcomes in a similar cohort of patients, although they look specifically at patients over 60, with a mean age of 70 in their study. Our mean study age of 66 reflects the greater than 75% of the cohort over 60, and the preponderance of complex intraarticular wrist fractures that may not be amenable to conventional volar or dorsal plate fixation in this group. Combined with the likelihood of osteoporotic bone, these factures can be very challenging to treat, with high rates of complication using the single plate techniques.
      • Arora R.
      • Lutz M.
      • Hennerbichler A.
      • Krappinger D.
      • Espen D.
      • Gabl M.
      Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate.
      In our study, the decision to proceed with DBP primarily was following multi-consultant discussion and with consideration of the likelihood of significant difficulty or failure with other surgical techniques. It can also, as demonstrated here, be used effectively to manage other failed fixation methods – being successfully used up to 4 weeks after primary immobilisation or fixation had failed. We suspect that this is likely to be close to the upper limit of its useful time frame, as beyond this, indirect reduction through ligamentotaxis is unlikely to be effective due to healing around the fracture site.
      The technique of indirect reduction through ligamentotaxis offers itself as a useful alternative when the complexity of the fracture pattern does not allow for percutaneous pinning alone. It also avoids the high complication rates of loosening, pin site infection and poor patient satisfaction that has been reported with external fixation of the wrist and which have led to decline in its use in recent years.
      • Vakhshori V.
      • Rounds A.D.
      • Heckmann N.
      • et al.
      The declining use of wrist-spanning external fixators.
      Similar rates of complex regional pain syndrome as those seen in our study have also been observed with use of external fixators.
      • Harley B.J.
      • Scharfenberger A.
      • Beaupre L.A.
      • Jomha N.
      • Weber D.W.
      Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial.
      Direct comparisons between the two techniques have not been published to our knowledge, and this could form the basis of a prospective trial in the future, although our results suggest that DBP can provide satisfactory outcomes in similar hard to treat fracture patterns, and without the complications reported with external fixation alone.
      • Weber S.C.
      • Szabo R.M.
      Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques.
      Original studies using both goniometers, and more recently motion analysis using infrared cameras, have found the mean flexion and extension arc of the healthy wrist to be in the region of 130–140°, with greater flexion than extension.
      • Ryu J.
      • Cooney W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.S.
      Functional ranges of motion of the wrist joint.
      ,
      • Li Z.M.
      • Kuxhaus L.
      • Fisk J.A.
      • Christophel T.H.
      Coupling between wrist flexion-extension and radial-ulnar deviation.
      However, very little range of movement (ROM) is necessary to carry out activities of daily living.
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      Indeed personal care activities may require as little as 10° of flexion and 15° of extension.
      • Brumfield R.
      • Champoux J.
      A biomechanical study of normal functional wrist motion.
      Our study shows self-reported ranges of motion well within this functional range. This could explain the positive PROMs, even in those patients with a relatively reduced ROM. Furthermore, our radiological outcomes are similar to those reported by Richard et al.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      although they only provide outcome data, but demonstrate restoration of palmar tilt to an average of 5° in all but two patients.
      Complications were limited to one EPL tendon rupture, a known complication of distal radius fractures, and three patients (11.5%) who developed CRPS. Richard et al.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      report a complication rate of 12% - one CRPS, one nerve injury, one infection and one patient with digital stiffness requiring tenolysis. Pathogenesis of CRPS is poorly understood, with multiple factors thought to be influential. These include neuropathic inflammation, autonomic dysregulation, genetic influences, psychological factors and risk factors such as female sex, fibromyalgia and rheumatoid arthritis.
      • Taylor S.S.
      • Noor N.
      • Urits I.
      • et al.
      Complex regional pain syndrome: a comprehensive review.
      The prevalence of CRPS following distal radius fracture is uncertain, with large population studies demonstrating rates below 1%,
      • Crijns T.J.
      • Van Der Gronde B.A.T.D.
      • Ring D.
      • Leung N.
      Complex regional pain syndrome after distal radius fracture is uncommon and is often associated with fibromyalgia.
      ,
      • Jo Y.H.
      • Kim K.W.
      • Lee B.G.
      • Kim J.H.
      • Lee C.H.
      • Lee K.H.
      Incidence of and risk factors for complex regional pain syndrome type 1 after surgery for distal radius fractures: a population-based study.
      but also as high as 37%.
      • Gradl G.
      • Gradl G.
      • Wendt M.
      • Mittlmeier T.
      • Kundt G.
      • Jupiter J.B.
      Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius.
      • Roh Y.H.
      • Lee B.K.
      • Noh J.H.
      • et al.
      Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture.
      • Zollinger P.E.
      • Tuinebreijer W.E.
      • Kreis R.W.
      • Breederveld R.S.
      Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial.
      Women are reported to be two to three times more likely than men to develop CRPS, with those aged between 61 and 70 years at highest risk.
      • de Mos M.
      • de Bruijn A.G.J.
      • Huygen F.J.P.M.
      • Dieleman J.P.
      • Stricker B.H.C.
      • Sturkenboom M.C.J.M.
      The incidence of complex regional pain syndrome: a population-based study.
      ,
      • Zyluk A.
      Complex regional pain syndrome type I. Risk factors, prevention and risk of recurrence.
      This was similarly reflected in our study. A meta-analysis analysing the risk of development of CRPS in surgically treated distal radius fractures found no difference in the method of fixation,
      • Wang J.H.
      • Sun T.
      Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome.
      although DBP was not included in this analysis. Interestingly, our study found a significant difference between the mean sagittal angulation in patients who developed CRPS compared with those that did not, suggesting that extremes in sagittal angulation may be associated with development of this condition and further work should focus on this.
      Historical studies have stressed the importance of restoration of normal radiographic parameters and functional outcomes in distal radius fractures. Loss of volar tilt was shown to be associated with decreased grip strength,
      • Rubinovich R.M.
      • Rennie W.
      Colles' fracture: end results in relation to radiologic parameters.
      whilst radial shortening has been suggested as being the most important factor in loss of function.
      • Villar R.N.
      • Marsh D.
      • Rushton N.
      • Greatorex R.A.
      Three years after Colles' fracture. A prospective review.
      ,
      • Batra S.
      • Gupta A.
      The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures.
      More recently only restoration of volar tilt and radial shortening have been suggested as necessary to obtain good functional outcomes.
      • Dario P.
      • Matteo G.
      • Carolina C.
      • et al.
      Is it really necessary to restore radial anatomic parameters after distal radius fractures?.
      Restoration of radiographic parameters has not been found to be associated with better functional outcomes in patients over 60.
      • Chung K.C.
      • Cho H.E.
      • Kim Y.
      • Kim H.M.
      • Shauver M.J.
      Assessment of anatomic restoration of distal radius fractures among older adults: a secondary analysis of a randomized clinical trial.
      Further, correlation between restoration of normal radiographic parameters and restoration of function is controversial, with only weak correlations found between these and functional outcomes.
      • Plant C.E.
      • Parsons N.R.
      • Costa M.L.
      Do radiological and functional outcomes correlate for fractures of the distal radius?.
      Our study supports the more recent views, finding no correlation between postoperative radiographic parameters and PRWE scores.
      The coronavirus pandemic occurred around half-way through the study period. During its initial phases there was an emphasis on reducing in-hospital face-to-face contact where possible, as well as the reduction in capacity of orthopaedic operating. This resulted in several patients (23% of the study group) whose DBP remained in-situ for more than 100 days. This was accompanied by a reduction in post-operative face-to-face hand physiotherapy (patients were offered telephone consultations). Interestingly, whilst this is associated with a reduced ROM, this had no correlation with patient PRWE scores or overall satisfaction, suggesting that delays to plate removal do not significantly alter outcomes.
      Limitations of the study include issues relating to reporting of range of movement. We only sought information on flexion and extension and did not obtain information on functional measures such as grip strength. Similarly, a control group (for instance measurements of the unaffected contralateral wrist) may have provided further useful data and insights into the effects of DBP on wrist function. As we included bilateral injuries this was not possible, but such a design would improve a future study. Flexion and extension were self-reported by patients using a visual chart, which may have resulted in inaccuracy values compared to goniometric or surface marker measurement. However, it has been shown that there is no significant advantage in accuracy using a goniometer over visual assessment of wrist position by clinicians
      • McVeigh K.H.
      • Murray P.M.
      • Heckman M.G.
      • Rawal B.
      • Peterson J.J.
      Accuracy and validity of goniometer and visual assessments of angular joint positions of the.
      and it is therefore likely that the self-reported ROM scores reported here are reliable. This is further corroborated by Richard et al.
      • Richard M.J.
      • Katolik L.I.
      • Hanel D.P.
      • Wartinbee D.A.
      • Ruch D.S.
      Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.
      paper which showed similar ROM results. Indeed, the functional outcome scores that complement this data, show excellent function post-surgery and we can therefore surmise that ROM is adequate to provide a good function for these patients. Alternative techniques such as the use of smartphones to aid patient self-reporting have been shown to be effective and could be employed in further similar studies.
      • Modest J.
      • Clair B.
      • DeMasi R.
      • et al.
      Self-measured wrist range of motion by wrist-injured and wrist-healthy study participants using a built-in iPhone feature as compared with a universal goniometer.

      6. Conclusions

      Dorsal bridging fixation is a safe and effective treatment for complex distal radius fractures, where other surgical fixation techniques may be unsuccessful. DBP is able to reliably restore distal radius anatomy and is associated with good functional outcome scores, return of functional range of wrist movement and high levels of patient satisfaction.

      Competing and conflicting interests

      None.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

      Ethical review

      Ethical review was not required as this study was conducted under audit framework.

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