This retrospective study reviewed non-elderly patients who underwent surgical treatment for DRFs between January 2019 and December 2021 in our institution. Our research has been approved by the Ethics Committee of the Third Hospital of Hebei Medical University (W2021-050-1), and all procedures were carried out in accordance with relevant guidelines and regulations, informed consent was obtained from all subjects and/or their legal guardian(s). The inclusion criteria were adults under 60 years old with closed DRFs confirmed by radiologic tests, who underwent volar locking plating and internal fixation (Shandong Weigao Medical Instrument Co., Ltd., Zibo, China). Patients with associated carpal bone fractures, open fractures, bilateral limb fractures, previous history of DRFs, or history of hand or forearm surgery were excluded. The study was approved by the Local Ethics Committee of our institution, and all patients provided written consent for storing their information in the institution’s database for medical research purposes.
Surgery and follow-up process
Surgeries were performed under brachial plexus or general anesthesia, with a pneumatic tourniquet applied to the upper arm. A standard volar approach between the flexor carpi radialis and radial artery was used to expose the fractures. After clear exposure of the distal radius, the reduction procedure was performed, followed by volar locking plating with or without K-wire fixation. Fixation was completed once satisfactory reduction was confirmed by intraoperative X-ray. After saline irrigation, the pronator quadratus was repaired, and the wound was closed.
All procedures were performed by three experienced surgeons. Internal fixation alone usually provides sufficient stability for early range of motion, but external fixation with short-arm plaster/splint may be used based on the surgeons’ experience. Patients started shoulder, elbow, and finger exercises on the first day after surgery.
Follow-up visits were scheduled at 4, 6 and 8 weeks post-surgery. At each visit, X-ray tests were conducted to detect any early-stage problems. Once signs of fracture healing are observed (blurred fracture lines or formation of callus), the plaster/splint was removed, and range of motion exercises were initiated. At the 6-month follow-up, forearm rotation and functional assessment were recorded.
We collected patients’ basic data from medical records, which included age, gender, sides of injury, and body mass index (BMI). Other variables were measured or evaluated. Swelling degree was assessed preoperatively. By conducting the “wrinkle test,” swelling was considered slight if the skin textures on the wrist could be recognized, and severe if the skin textures were not clear or blisters occurred14. Fracture type, involvement of sigmoid notch, and intactness of the ulnar styloid process were classified based on preoperative images. If fracture lines or steps were found on CT images at the site of the sigmoid notch, it was considered as positive for involvement; otherwise, it was negative (Fig. 1). Postoperative radiologic parameters were measured on X-ray photographs after the fractures had healed to avoid measurement inaccuracy caused by reduction loss. Radial inclination degrees, volar tilt degrees, and ulnar variance were three parameters used to assess radial inclination loss, dorsal angulation deformity, and radial shortening deformity, respectively, and were measured as previously described4. All imaging parameters in this study were performed by two radiologists with more than 10 years of clinical experience. The third observer intervened twice, to improve the accuracy and reliability of the measurement results. The attending surgeon provides personalized rehabilitation instructions to patients prior to discharge. These instructions are verbally communicated and repeated by the patient to ensure comprehension. Compliance with the instructions and the effectiveness of functional rehabilitation exercises are evaluated during follow-up visits, leading to categorization of patients into appropriate or inappropriate exercise groups. The ability of the wrist was evaluated using the Patient-Rated Wrist Evaluation (PRWE) system at the end of follow-up. While The PRWE is a simple, brief, reliable, and valid clinical tool using pain, and work performance as subjective and objective outcome indicators15,16. Forearm rotation, including forearm pronation and supination, was assessed using a standard goniometer. Forearm rotation restriction was defined as a range of pronation-supination movement that was less than two-thirds of that in the contralateral forearm.
Continuous variables were presented as mean standard deviation, and categorical variables were presented as frequencies and percentages. The Fisher exact test was used for categorical variables, while the Mann–Whitney U test or the independent sample t-test was used for continuous variables to identify differences between groups. After univariate analyses, potential risk factors with a P-value less than 0.20 were entered into multivariate logistic regression models. The Statistical Package for the Social Sciences (SPSS, version 20.0) was used for all data analysis, and P-values less than 0.05 were considered statistically significant.
The research has been approved by the Ethics Committee of the Third Hospital of Hebei Medical University, and all procedures were carried out in accordance with relevant guidelines and regulations. We have no conflicts of interest to declare.