The use of volar locking plates for surgical fixation of distal radius fractures has become popular. However, several complications associated with this type of surgery have been reported, including tendon rupture. Rupture of the flexor pollicis longus tendon and the extensor pollicis longus tendon associated with repair of distal radius fractures with such a plate was first reported in 19981 and 2000,2 respectively. The reported incidence of flexor pollicis longus tendon rupture associated with the use of a volar locking plate for distal radius fracture has ranged from 0.3% to 12%.3,4 To minimize the occurrence of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures, the authors paid attention to placement of the plate. In a series of patients with distal radius fractures, the authors investigated annual trends in the number of complications in relation to the treatment measures. The current study investigated the incidence of complications after surgery for distal radial fractures with a volar locking plate.
Materials and Methods
The study was approved by the institutional review board of the authors' medical faculty. A multicenter retrospective study was conducted at 11 institutions, including 4 tertiary and 7 secondary emergency care hospitals, as defined by the Japanese Association for Acute Medicine. Databases were searched for all distal radius fractures that were treated surgically between January 2010 and August 2012. A total of 824 patients were identified. Patients included in this study were older than 18 years and were observed for at least 12 weeks after surgery for distal radius fractures with a volar locking plate (Figure). Sex, age, fracture type according to AO classification, implants, wrist range of motion, grip strength, fracture consolidation rate, and intra- or postsurgical complications were studied. Grip strength was measured once as a single set with a dynamometer (TKK 5401 Grip-D; Smedley, Takei, Tokyo, Japan).5 Reduced range of motion was defined as total wrist flexion and extension of less than 90° and/or reduced grip strength of less than 75% compared with the unaffected side, according to the Mayo wrist score.
Surgery was performed under fluoroscopic guidance with a volar approach through the flexor carpi radialis flexor sheath. Fracture stabilization was achieved with a volar locking plate. Bone grafting was not performed. Attention was paid to positioning the plate proximal to the watershed line,6 repair of the pronator quadratus and the intermediate fibrous zone of the distal radius, and early removal of the plate if it was expected to cause irritation of the flexor pollicis longus tendon. The wrist was immobilized post-operatively in a plaster splint for several weeks. Some patients were instructed in active wrist motion exercises immediately after surgery.
This study analyzed 694 patients, including 529 women and 165 men, with a mean age of 64 years (range, 19–92 years) (AO classification: A2, 154; A3, 204; B1, 4; B2, 8; B3, 12; C1, 78; C2, 189; C3, 45). A Stellar plate (Japan Universal Technologies, Tokyo, Japan) was used in 231 cases, a Distal Volar Radius plate (Hand Innovations, Warsaw, Indiana) was used in 137, a Variable Angle Locking Compression plate (VA-LCP; Synthes, West Chester, Pennsylvania) was used in 115, an Acu-Loc plate (Acumed, Hillsboro, Oregon) was used in 93, a Distal Radius plate (Mathys, Salzburg, Austria) was used in 66, a Variable Angle Two-Column Volar Distal Radius plate (VA-TCP; Synthes) was used in 16, and other locking plates were used in 36. A total of 36 orthopedic surgeons participated, including 24 attending surgeons and 12 residents. Mean number of patients per surgeon was 19 (range, 1–54). The period of immobilization with a plaster splint was 0 to 8 weeks (0 weeks, 394 cases; 1 week, 136 cases; 2 weeks, 43 cases; 3 weeks, 37 cases; 4 weeks, 34 cases; 5 weeks, 14 cases; 6 weeks, 33 cases; 7 weeks, 1 case; 8 weeks, 2 cases), with a mean of 2.5 weeks in patients who had a splint. Mean follow-up was 27 weeks (range, 12–156 weeks). Mean total motion of the wrist was 126° (range, 40°–180°). Mean grip strength was 18 kg (range, 0–50 kg) on the affected side and 24 kg (range, 4–56 kg) on the unaffected side. The fracture consolidation rate was 100%. There were 146 implant removals in 694 patients (25%).
There were 52 (7.5% of 694 analyzed) complications, including 18 cases of carpal tunnel syndrome, 12 cases of peripheral nerve palsy (median nerve, 5; radial nerve, 3; ulnar nerve, 3; posterior interosseous nerve, 1), 8 cases of trigger digit, 4 cases of tendon rupture (extensor pollicis longus tendon, 3; flexor digitorum profundus tendon, 1), 3 cases of blister, 3 cases of complex regional pain syndrome, 2 cases of secondary displacement (reoperation), 1 case of ulnar head dislocation, and 1 case of skin pigmentation (Table 1). Peripheral nerve palsy may have been caused by intraoperative traction in 7 cases, temporary fixation by percutaneous Kirschner wires in 3 cases, and axillary nerve block in 1 case (ulnar nerve); 1 case (posterior interosseous nerve) appeared to be idiopathic. Peripheral nerve palsy resolved within 8 to 52 weeks (mean, 28 weeks) without intervention (observation only). Tendon ruptures were mainly caused by mechanical stress (Table 2). Two cases of secondary displacement were caused by inadequate plate fixation (intrasurgical complications). One patient had both trigger digit and carpal tunnel syndrome, 48 patients (10% of 470 analyzed) had reduced range of motion, and 125 patients (38% of 333 analyzed) had reduced grip strength.
Flexor pollicis longus tendon rupture is a major complication that can occur after surgical fixation of distal radius fractures with a volar locking plate. The clinical outcome of this type of surgery was first reported in 2002,7 and in 2003, Drobetz and Kutscha-Lissberg3 reported 6 cases of flexor pollicis longus tendon rupture in 56 patients (12%) who were treated in this way. The watershed line is a useful surgical landmark for positioning a volar locking plate.6 Implants placed on or distal to the flexor pollicis longus tendon can impinge on the tendon and cause injury. In 2011, Soong et al4 reported a lower incidence of flexor pollicis longus tendon rupture (1 of 321 cases, 0.3%). In the current series of 694 cases, no rupture of the flexor pollicis longus tendon occurred because careful attention was paid to the relationship between the implant and the tendon. In a series that used an early volar locking plate design (Mathys),8 Drobetz and Kutscha-Lissberg3 reported a high risk of flexor pollicis longus rupture, and in a study conducted with distally placed plates, Casaletto et al9 reported 7 cases of flexor pollicis longus rupture in a series of 353 patients. However, Asadollahi and Keith10 showed that flexor pollicis longus rupture can occur with plates of various designs, including new-generation volar locking plates. The current series included 66 patients who were treated with an early design of a volar locking plate and 93 who were treated with distally placed plates.
The reported incidence of extensor pollicis longus rupture is 0.3% for conservative treatment11 and 0.3% to 8.6% for surgical treatment with a volar locking plate.4,12 The incidence in the current series was 0.4% (3 of 694 cases). In the current series, 3 cases of extensor pollicis longus tendon rupture were caused by mechanical stress from screw or bone fragments (Table 1). The size of Lister's tubercle varies from 2 to 6 mm, and the depth of the extensor pollicis longus groove varies from 1 to 6 mm.13 Use of the dorsal horizon (tangential) view is a useful means of preventing protrusion of the screw beyond the dorsal cortex when performing osteosynthesis of the distal radius.14
Carpal tunnel syndrome is a recognized complication of distal radius fracture, and its reported incidence in this setting is 17% (37 of 213 cases) for conservative treatment15 and 6.1% (3 of 49 cases) for operative treatment.16 In the current series, the incidence was 2.6% (18 of 694 cases). Previous studies identified an association between trigger digit and carpal tunnel syndrome.17 Both conditions are caused by limited space in an enclosed anatomic region, and they often coexist, suggesting a common pathophysiologic process. In the current series, the incidence of trigger digit was 1.2% (8 of 694 cases). The overall complication rate has been variable, perhaps reflecting differences in the way that complications are defined.
The current study had several limitations. First, identification of complications was dependent on the medical records, complications were defined by individual attending surgeons, and the follow-up period was relatively short. Second, the authors were unable to gather all clinical data for the patients. In a total of 694 patients, range of motion was recorded for 470 and grip strength was recorded for 333. However, this study included a large proportion of the local population; therefore, the results adequately reflect the surgical care of local patients with distal radius fractures.
There was a complication rate of 7% in the current series of patients with distal radius fractures treated with surgical fixation with a volar locking plate. Complications included carpal tunnel syndrome, peripheral nerve palsy, trigger digit, and tendon rupture. The watershed line is a useful surgical landmark for positioning a volar locking plate. No cases of flexor pollicis longus tendon rupture occurred among the 694 patients because careful attention was paid to the relationship between the implant and the tendon.
- Bell JS, Wollstein R, Citron ND. Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius. J Bone Joint Surg Br. 1998; 80(2):225–226. doi:10.1302/0301-620X.80B2.8351 [CrossRef]
- Lowry KJ, Gainor BJ, Hoskins JS. Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without associated plate failure: a case report. Am J Orthop (Belle Mead NJ). 2000; 29(10):789–791.
- Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop. 2003; 27(1):1–6.
- Soong M, van Leerdam R, Guitton TG, Got C, Katarincic J, Ring D. Fracture of the distal radius: risk factors for complications after locked volar plate fixation. J Hand Surg Am. 2011; 36(1):3–9. doi:10.1016/j.jhsa.2010.09.033 [CrossRef]
- Watanabe T, Owashi K, Kanauchi Y, Mura N, Takahara M, Ogino T. The short-term reliability of grip strength measurement and the effects of posture and grip span. J Hand Surg Am. 2005; 30(3):603–609. doi:10.1016/j.jhsa.2004.12.007 [CrossRef]
- Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006; 445:58–67.
- Orbay JL, Femandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002; 27(2):205–215. doi:10.1053/jhsu.2002.32081 [CrossRef]
- Tyllianakis ME, Panagopoulos AM, Saridis A. Long-term results of dorsally displaced distal radius fractures treated with the pi-plate: is hardware removal necessary?Orthopedics. 2011; 34(7):e282–e286.
- Casaletto JA, Machin D, Leung R, Brown DJ. Flexor pollicis longus tendon ruptures after palmar plate fixation of fractures of the distal radius. J Hand Surg Eur Vol. 2009; 34(4):471–474. doi:10.1177/1753193408100964 [CrossRef]
- Asadollahi S, Keith PP. Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature. J Orthop Traumatol. 2013; 14(4):227–234. doi:10.1007/s10195-013-0245-z [CrossRef]
- Hove LM, Fjeldsgaard K, Reitan R, Skjeie R, Sörensen FK. Fractures of the distal radius in a Norwegian city. Scand J Plast Reconstr Surg Hand Surg. 1995; 29(3):263–267. doi:10.3109/02844319509050137 [CrossRef]
- Al-Rashid M, Theivendran K, Craigen MA. Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures. J Bone Joint Surg Br. 2006; 88(12):1610–1612. doi:10.1302/0301-620X.88B12.17696 [CrossRef]
- Clement H, Pichler W, Nelson D, Hausleitner L, Tesch NP, Grechenig W. Morphometric analysis of Lister's tubercle and its consequences on volar plate fixation of distal radius fractures. J Hand Surg Am. 2008; 33(10):1716–1719. doi:10.1016/j.jhsa.2008.08.012 [CrossRef]
- Joseph SJ, Harvey JN. The dorsal horizon view: detecting screw protrusion at the distal radius. J Hand Surg Am. 2011; 36(10):1691–1693. doi:10.1016/j.jhsa.2011.07.020 [CrossRef]
- Stewart HD, Innes AR, Burke FD. The hand complications of Colles' fractures. J Hand Surg Br. 1985; 10(1):103–106. doi:10.1016/S0266-7681(85)80032-2 [CrossRef]
- Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996; 78(12):1817–1828.
- Phalen GS. The carpal-tunnel syndrome: seventeen years' experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am. 1966; 48(2):211–228.
|Complication||No. of Cases||Incidence|
|Carpal tunnel syndrome||18||2.6%|
|Peripheral nerve palsy||12||1.7%|
| Extensor pollicis longus||3||0.4%|
| Flexor digitorum profundus (index)||1||0.1%|
| Flexor pollicis longus||0||0%|
|Complex regional pain syndrome||3||0.4%|
|Secondary displacement (reoperation)||2||0.3%|
|Ulnar head dislocation||1||0.1%|
|Patient No./Sex/Age, y||Fracture AO Classification||Implant||Rupture Site||Time of Rupture, wk||Cause|
|1/F/58||A3||Distal radius platea||Flexor digitorum profundus (index)||15||Plate breakout|
|2/F/56||C2||Stellar plateb||Extensor pollicis longus||2||Screw irritation|
|3/F/57||A3||Stellar plate||Extensor pollicis longus||3||Bone fragments|
|4/M/61||C3||Acu-Loc platec||Extensor pollicis longus||13||Bone fragments|