“Does Hook Type Matter in Articular Distal Radius Fixation? Re. Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-specific Fixation”

Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-Specific Fixation

We would like to thank the authors for addressing the subject of distal radius fractures treated with fragment-specific fixation (FSF).[1] This is a new approach to the management of fractures that needs to be more widely known, to establish the framework of indications. The industry has developed various types of fixation, two of which are compared here: standard volar plating (SVP) versus FSF. The initial hypothesis was reduced mobility and a higher complication rate for FSF. However, their results on 92 patients show that, despite these adverse prognostic factors in the FSF group (higher rate of AO-C fracture), there are no significant differences in terms of outcome on the main judgment criteria in the FSF group.

From our point of view, the above-mentioned plates are not used for the same type of fracture. An intra-articular fracture beyond the watershed line lends itself to placement of an FSF, as a fracture this distal cannot be fixed by a standard plate. If the surgeon opts for an SVP anyway, there is a risk of positioning it distal to the watershed line, not only with the risk of placing screws through the radiocarpal joint, but also a risk of tendon rupture.[2] The two types of fixation are therefore compared in this study, even though they do not have the same indication.

On the illustrated radiographs, the hook plates may be misapplied, resulting in an anteroposterior protrusion (significant in figure 8). It seems radiologically obvious that reoperation to remove the material will be necessary after consolidation, at the risk of damaging the soft tissues.[3]

In our practice, we believe there are two types of “hook” plate: subarticular hooks and supra-articular hooks ([Fig. 1]). In their publication, the authors use subarticular “hook” plates, which fix into the distal fragment of the fracture. In our point of view, these are difficult to use for the fixation of very distal fragments but can be used if the articular fragment is large enough. In addition, their anatomical shape makes them difficult to position on the radius, and their use in fracture correction can lead to prominence of the fixation hardware, a source of conflict with palmar soft tissue. Finally, when these fragments are very distal or thin, we believe that their fixation is risky because of the risk of intraoperative fracture of the volar rim. In such cases, the intra-articular hook is more appropriate, enabling them to be held in place by “bridging” not only the fragment but also the fracture. In our opinion, volar rim fixation remains difficult, and the use of supra-articular hook plates seems more appropriate if the fragment appears to be small.[4] It therefore seems important to establish that there are two types of hook fixation: subarticular hooks will have their place in the fixation of large fragment articular fractures, but in small fragment or distal fractures, supra-articular hooks take their place.

Fig. 1 Representation of the different types of “hook plates.” (A) Illustration of a subarticular hook plate. (B) Illustration of a supra-articular hook plate. (C and D) X-ray profile of a supra-articular hook plate for volar rim fracture (C) and fracture beyond the watershed line (D).

Level of Incidence

4.

Publication History

Article published online:
08 March 2024

• References

• 1 Bowers M, Gruenberger E, Jardaly AH. et al. Does construct type matter? A retrospective review comparing outcomes of distal radius fractures treated with standard volar plating versus fragment-specific fixation. J Wrist Surg 2023; 12 (06) 500-508
• 2 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 (01) 3-9
• 3 Lari A, Nouri A, Alherz M, Prada C. Operative treatment of distal radius fractures involving the volar rim-a systematic review of outcomes and complications. Eur J Orthop Surg Traumatol 2023; 33 (08) 3419-3428
• 4 Orbay MC, Orbay JL. Classification and management of failed fixation of the volar marginal fragment in distal radius fractures. J Wrist Surg 2021; 11 (03) 219-223