Introduction

Distal radial fractures are the most common fractures requiring orthopedic intervention and surgery for dislocated fractures has been done for many years [1–3].

However, even with the development of modern implants which allow early mobilization, long-term outcome has not significantly improved [1, 2, 4, 5]. Concomitant lesions to ligaments and capsule or cartilage might be contributing to this problem. Studies using arthroscopy of the wrist were able to demonstrate a high percentage (74–98 %) of mostly ligamentous lesions concomitant to dislocated radial fractures [6–9]. The recently published study of 104 patients with dislocated distal radial fracture who underwent computer tomography (CT) and magnet resonance imaging (MRI) of the wrist prior to surgery demonstrates that all, but one patient demonstrated concomitant intracarpal osseous or ligamentous lesions (radio-carpal fracture, distal radio-ulnar fracture, acute TFCC lesion, rupture of the scapholunate ligament (SL) and radioulnar (RU) ligament) [10]. The prognostic relevance for early diagnosis (and treatment) of such concomitant lesions seems uncertain [11, 12]. Even very early publications failed to demonstrate ongoing symptoms due to ligamentous lesions after a period of regular follow-up [13, 14]. It is agreed that dislocated radial fractures are to be seen as combined injuries of the distal radio-ulnar functional unit [6, 7, 11, 15, 16].

What remains open to discussion is

  • What relevance do intracarpal lesions (concomitant to dislocated fractures of the distal radius) have after open reduction and plate fixation of the radial fracture and after a typical period of convalescence.

  • Whether there are distinct patterns of primary concomitant lesions, which can predict long-term outcome.

This study intends to address these questions with a standardized follow-up at 1 year postoperatively after distal radial fracture and operative treatment.

Methods

103 Consecutive patients with a total of 104 dislocated distal radial fractures were prospectively included into the study before undergoing surgery.

The indication for operative treatment was a comminuted fracture zone in combination with tilting of ≥20° and radial shortening of ≥5 mm on the initial X-ray according to the guidelines of the German society for trauma (DGU) for distal radius fractures [16].

Inclusion criteria were a dislocated radial fracture with indication for surgery, age >18 years, and an informed consent to allow examination for the duration of the study. Exclusion criteria were patient’s refusal to participate in the study, need for immediate surgery (e.g., open fractures), multiple fractures of various body regions (polytraumata) or serial fractures of the upper arm, and pre-existing functional impairment of the involved upper extremity. The study was approved by the Ethics Committee of the Ruprecht-Karls-University Heidelberg, Medical Faculty Mannheim on 11/26/2004, reference number 225/04. CT and MRI were reported by a single, senior radiologist with special qualification for musculoskeletal imaging.

Operation was done by surgeons of our department, including the authors of the present study. Orthopedic surgeons in training were supervised by senior surgeons.

The operating surgeon had access to the CT images while both, the surgeon and the physician doing the follow-up exam were blinded for the MRI results.

The first results of this study were nearly almost detectable concomitant lesions of carpal structures (Table 1).

Table 1 Gologan et al. [10] concomitant lesions in 104 dislocated distal radial fractures
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Follow-up of these patients was possible for 78 of the 104 fractures (74 %) 1 year after surgery with complete data (X-rays, CT, MRI, follow-up X-rays, and questionnaire). Three of the remaining patients lost to follow-up had passed away (not on account of the trauma), two had moved away, and four refused a repeat examination. 17 patients were unable to reach at the time of the scheduled follow-up.

The follow-up group consisted of 49 women and 28 men with an average age of 59.3 years (range 19–85 years). Patients included in the follow-up group had 39 fractures type A (AO classification), nine fractures type B, and 30 fractures type C. 76/78 patients had at least one additional radiocarpal lesion independently from the primary type of fracture (Fig. 1). The exact number of additional lesions related to fracture type is presented in Fig. 2.

Fig. 1
figure 1

Number of simultaneously lesions (from zero to six additional lesions) related to fracture type: AO 23, A, B, C

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Fig. 2
figure 2

Detailed description of additional lesions related to fracture type: AO 23, A, B, C

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We contacted patients by mail 1 year after surgery for a follow-up exam. This follow-up exam took place an average of 13.9 ± 6.5 months postoperatively. Follow-up comprised a questionnaire (Castaing Score, Fig. 2), physical exam with documentation of all findings (pain scale, ROM, wrist circumference, and X-ray of the wrist in 2 planes). The scoring system of Castaing (Table 2) comprises wrist function, radiographic data and subjective condition obtained from the patient. Depending on the number of points scored, the outcome is classified as excellent (0), good (1–5), sufficient (6–11), fair (12–15), poor (16–25), or very poor (>25).

Table 2 Castaing score [22]
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Results

Post-operative evaluation after 1 year showed an average Castaing score of 4.5 points ±2.5, means a “good” result of a scale of 0–27. No patient had more than 12 points (“fair”). 55/78 had an “excellent” or “good” result (<6 points). Only 1 out of the 78 fractures had a single additional lesion, both a lesion of the triangular fibrocartilage complex (TFCC). These patients resulted both with a Castaing score of 3 and 4, respectively (“good”). Patients demonstrating the worst outcomes with 11–12 points (“adequate–fair”, n = 4) had all suffered a combination of four lesions (radio-carpal fracture, distal radio-ulnar fracture, acute TFCC lesion, rupture of the scapholunate ligament (SL) and radioulnar (RU) ligament). However, three patients with the same pattern of additional lesions were found to have very favorable outcomes of 1 point (“excellent”, n = 3) and four points (“good”, n = 1). Furthermore, patients with 0–2 points (“excellent–good”) also demonstrated up to four additional carpal lesions. Number of additional injuries in related to fracture type (AO) is showed in Figs. 1 and 2. 55/78 were satisfied (no complains, or rare complains), 15/78 could do all movements, but complained often pain, 8/78 were unsatisfied. Subjective dissatisfaction could not be objectively quantified. Satisfied and unsatisfied patients had dorsal extension of ≥40° or pronation of >40°. Patients with a pronation <40° had a tendency to Castaing scores >6 (“adequate” or worse). Furthermore, no association was observed between subjective outcome and objective findings of dorsal extension or palmar flexion as well as radial or ulnar abduction. 8 out of 78 patients reported to be sensitive to temperature and weather changes, 3 out of 77 patients suffered from carpal tunnel syndrome, another four had recurrent pain in the distal distribution of the radial nerve (radial dorsum of hand and digit 1–3).

Discussion

Dislocated distal radial fractures are nowadays considered to represent an extensive injury of the radiocarpal complex [6, 10]. Several studies have evaluated the extent of additional lesions to non-osseous structures in the setting of dislocated distal radial fractures and have concluded the ubiquitous existence of associated lesions to structures which are not amenable to visualization on plain films [9–11, 17–21]. MRI, CT, and cinematography were used in addition to plain films for diagnostic purposes. These can confirm high percentage of additional lesions to ligaments and other bony structures which had been missed on regular X-rays (Fig. 3).

Fig. 3
figure 3

78-year-old female patient, AO C1 fracture, multiple carpal lesions, Castaing score 3 (good result). a coronary CT layer. b sagittal CT layer. c coronary (STIR) and transversal MRI layer (T2). d Post-operative X-ray

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It remains open to discussion:

  • How do these lesions influence the final outcome after conventional treatment of dislocated distal radial fractures?

  • Do these lesions require extra attention in addition to ORIF and immobilization?

The previously published study analyzed the outcome of 104 consecutive patients with dislocated distal radial fracture undergoing MRI and CT evaluation for additional injuries [10]. At least one additional lesion (osseous, ligamentous, or TFCC) was found in 102 patients (Table 1).

The patients were examined for SL or RU instability. We found no relevant instability though the SL or the RU joint shows hematoma or the SL distance seems widened.

All patients underwent surgery with ORIF with early functional mobilization and additional thermoplastic splint to give discharge to the joint for 6 weeks in individually fitted forearm (thermoplastic) splints. We have now reached 78 patients (74 %) of these 104 to undergo repeat evaluation 1 year postoperatively.

Clinical and radiographic outcomes evaluated by Castaign Score showed 71 % of patients with excellent or good results. No poor or very poor results were found. Those four patients with the worst outcome (adequate/fair) were found to have four additional lesions. However, other patients with similar extent of lesions (four additional lesions) had also demonstrated good and excellent results. A correlation of the extent of additional lesion and final outcome can therefore not necessarily be deducted.

Most scoring systems comprise only subjective measures. The Gartland-Werley Score not only includes subjective criteria (residual deformity, pain, compromise of range of motion, and restriction of activity), but also includes objective data (loss of ROM) and complications (osteoarthritis, median nerve complications, poor finger function due to cast). 0–2 points represent an “excellent” outcome, 3–8 points represent a “good” outcome, 9–20 points represent a “fair” and >20 points a “poor” outcome. However, the point system allows different investigators significant variation regarding the distribution of points for deformity and signs of osteoarthritis.

The Castaing Score is another system which is frequently used to evaluate post-operative outcomes, including subjective and objective measures. It includes subjective discomfort with activity as well as objective findings of ROM and radiographic changes of angulation [22–26].

More recent studies of dislocated distal radial fractures [27, 28] with similar post-operative interval (12, 13, 17 months) and similar interventions (ORIF with palmar plate and forearm splinting for 4 weeks) have also shown promising results with good functional outcome. However, additional lesions have not been documented or presented. This makes one believe that current means of intervention (ORIF and immobilization) are sufficient measures to achieve good 1-year outcomes despite the presence of additional lesions; a more extensive diagnostic evaluation with extended imaging of the wrist might be unnecessary [29, 30]

This is further supported in a study by Frank demonstrating 55 % of dislocated distal radial fractures to have additional ligamentous lesions. The functional 1-year outcome did not depend on differences in surgery.

Tang’s study with only 20 SL ruptures as seen on imaging (SL-dissociation on X-ray) out of 424 patients with distal radial fractures has more controversy, and all patients had persistent complaints postoperatively due to SL rupture. Eight patients underwent repeat surgery. When the current literature is taken into account, one has to consider that only a small percentage of existing primary lesions are actually visualized on plain films. These could be considered “primary decompensated lesions” where conservative approaches immediately bear only very limited chance of success. Radiographically identified additional lesions appear to have more significant impact on future outcome than those not visualized on initial imaging.

Table 3 shows an overview of studies with short-term post-operative results after dislocated distal radius fracture including data for their peri- and post-operative management, additional injuries, complications and outcome. The effect of additional lesions on future functional outcome cannot be estimated in the current study since 97 % already present radial fractures with additional lesions. This ought to be taken into account for all dislocated distal radial fractures. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later [7, 31, 32], give symptoms and became of therapeutic relevance [30, 33–35]. The presented means of therapy with open reduction and plate, followed by 6 weeks relief through thermoplastic splint appear adequate for a good functional outcome after 1 year even for complex lesions to the wrist [10, 16, 36]. The nearly ubiquitous presence of additional injuries cannot be prognostically rated nor do these lesions appear to persist after above mentioned intervention.

Table 3 Overview of studies with short-term post-operative results after dislocated distal radial fracture
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Our follow-up of 1 year is probably too short to make a definitive statement. Future evaluations after five-year interval will be done.