How Should the Shape of the Volar Rim Be Taken into Account in the Treatment of Distal Radius Fractures? A Radiological Study

Jean-Baptiste de Villeneuve Bargemon; Camille Brenac; Emile Dobelle; Charlotte Jaloux; Clément Prenaud; Alexis Motel

doi:10.1055/a-2678-7424

Journal of Wrist Surgery, Table of Contents

J Wrist Surg
DOI: 10.1055/a-2678-7424

Scientific Article

How Should the Shape of the Volar Rim Be Taken into Account in the Treatment of Distal Radius Fractures? A Radiological Study

Authors

Jean-Baptiste de Villeneuve Bargemon

¹Hand Surgery and Limb Reconstructive Surgery Department, La Timone Adult Hospital, Aix Marseille University, Marseille, France

²Hand, Wrist and Elbow Surgery, Saint Roch Private Hospital, Toulon, France

³International Wrist Center, Bizet Clinic, Paris, France
Camille Brenac

¹Hand Surgery and Limb Reconstructive Surgery Department, La Timone Adult Hospital, Aix Marseille University, Marseille, France
Emile Dobelle

¹Hand Surgery and Limb Reconstructive Surgery Department, La Timone Adult Hospital, Aix Marseille University, Marseille, France

⁴Department of Orthopedics and Traumatology ISM, CNRS, Institute of Movement and the Musculoskeletal System, Sainte-Marguerite Hospital, Aix-Marseille University, Marseille, France
Charlotte Jaloux

¹Hand Surgery and Limb Reconstructive Surgery Department, La Timone Adult Hospital, Aix Marseille University, Marseille, France
Clément Prenaud

⁵Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
Alexis Motel

⁶Avicenne Hospital, Bobigny, France

Abstract

Background

In the management of articular distal radius fractures, achieving an accurate reduction of joint fragments is essential for a favorable prognosis. Fixation of the volar rim remains a surgical challenge, as volar plates may be improperly positioned despite adequate joint reduction.

Purpose

This study aims to analyze anatomical variations in the distal radius, focusing on the distance between the watershed line (WL) and the radiocarpal articular surface. These anatomical variations may partially explain the difficulty in achieving optimal plate placement during distal radius fracture fixation.

Materials and Methods

We conducted a single-center study between October 2023 and May 2024, collecting three key measurements from computed tomography scans (CT scans) of healthy wrists. Based on distribution and correlation analyses, the wrists were categorized into two groups according to the distance from the most palmar point of the WL to the joint margin (SFWL). Group 1 included wrists with an SFWL ≥ 2.5 mm, and group 2 included those with an SFWL < 2.5 mm. The 2.5 mm threshold was selected based on the diameter of commonly used distal radius screws. This analysis revealed two emerging anatomical patterns. Then, four operators independently classified the CT scans as type 1 or 2 distal radius anatomy. Interoperators' variability was assessed using Cochran's Q test and Fleiss's kappa.

Results

A total of 100 wrists from 100 patients were included. Eighty-nine patients (89%) were classified in group 1 (SFWL ≥ 2.5 mm), and 11 (11%) in group 2 (SFWL < 2.5 mm). In group 1, three patients (3.4%) showed a negative or zero value in the minimal distance from the WL (MDFWL) to the articular surface, indicating a high risk of intra-articular screw penetration. This risk was notably higher in group 2, with three patients (27.3%) exhibiting similar findings. Interoperator variability was strong, with a Fleiss's kappa of 0.73.

Conclusion

Our findings suggest that the distal radius exhibits a spectrum of anatomical variation, which may contribute to suboptimal volar plate placement in some distal radius fractures. Recognizing these variations preoperatively may improve implant selection and reduce the risk of flexor tendon complications.

Level of Evidence

Level IIIA.

Keywords

wrist - anatomy - joint - distal radius - fracture

Full Text

References

References
1 MacIntyre NJ, Dewan N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. J Hand Ther 2016; 29 (02) 136-145
2 Mauck BM, Swigler CW. Evidence-based review of distal radius fractures. Orthop Clin North Am 2018; 49 (02) 211-222
3 Rhee PC, Medoff RJ, Shin AY. Complex distal radius fractures: an anatomic algorithm for surgical management. J Am Acad Orthop Surg 2017; 25 (02) 77-88
4 Meaike JJ, Kakar S. Management of comminuted distal radius fractures: a critical analysis review. JBJS Rev 2020; 8 (08) e2000010
5 Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005; 21 (03) 279-288
6 Mandziak DG, Watts AC, Bain GI. Ligament contribution to patterns of articular fractures of the distal radius. J Hand Surg Am 2011; 36 (10) 1621-1625
7 Orbay JL, Rubio F, Vernon LL. Prevent collapse and salvage failures of the volar rim of the distal radius. J Wrist Surg 2016; 5 (01) 17-21
8 Teunis T, Bosma NH, Lubberts B, Ter Meulen DP, Ring D. Melone's concept revisited: 3D quantification of fragment displacement. J Hand Microsurg 2016; 8 (01) 27-33
9 Geissler WB, Clark SM. Fragment-specific fixation for fractures of the distal radius. J Wrist Surg 2016; 5 (01) 22-30
10 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
11 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
12 De Villeneuve Bargemon JB, Jaloux C, Tomczak S, Emery A. 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. J Wrist Surg 2024;
13 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
14 Yoneda H, Iwatsuki K, Hara T, Kurimoto S, Yamamoto M, Hirata H. Interindividual anatomical variations affect the plate-to-bone fit during osteosynthesis of distal radius fractures. J Orthop Res 2016; 34 (06) 953-960
15 Mizuno K, Sato K, Takahashi G, Mimata Y, Murakami K, Doita M. Three-dimensional imaging of the distal radius with reference to volar locking plate surgery. Orthop Traumatol Surg Res 2022; 108 (07) 103372
16 Tay K, Bin Abd Razak HR, Yew AKS, Koh JSB, Howe TS. Bony anatomy around the watershed line of the distal radius. J Wrist Surg 2021; 10 (04) 276-279
17 Bergsma M, Doornberg JN, Borghorst A, Kernkamp WA, Jaarsma RL, Bain GI. The watershed line of the distal radius: cadaveric and imaging study of anatomical landmarks. J Wrist Surg 2020; 9 (01) 44-51
18 Bergsma M, Doornberg JN, Hendrickx L. et al. Interpretations of the term “watershed line” used as reference for volar plating. J Wrist Surg 2020; 9 (03) 268-274
19 Tanner JL, Wang M, Le Nen D, Di Francia R, Andro C, Letissier H. Study of the position of six volar locking plates for distal radius fracture relative to the watershed line. Hand Surg Rehabil 2023;
20 Bouman HW, Messer E, Sennwald G. Measurement of ulnar translation and carpal height. J Hand Surg [Br] 1994; 19 (03) 325-329
21 Tang JB, Giddins G. Why and how to report surgeons' levels of expertise. J Hand Surg Eur Vol 2016; 41 (04) 365-366
22 Truong JL, Doherty C, Suh N. The effect of socioeconomic factors on outcomes of distal radius fractures: a systematic review. Hand (N Y) 2018; 13 (05) 509-515
23 Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am 2004; 86 (09) 1900-1908
24 Shaerf DA, Halsey TJ. Mechanical failure of the distal radius volar rim plate: a case report. J Hand Surg Eur Vol 2019; 44 (10) 1094-1096
25 Chua WS, Hassan S, Anoar AF. Incidence of flexor tendon injuries in complex intra-articular distal radius fractures fixed with volar rim plate osteosynthesis. Cureus 2022; 14 (10) e29852
26 Biondi M, Poggetti A, Fagetti A. et al. Fragment specific fixation with APTUS wrist system for volar rim fractures of the distal radius: a multicentric study. Eur J Trauma Emerg Surg 2022; 48 (06) 4577-4584
27 Goorens CK, Geeurickx S, Wernaers P, Staelens B, Scheerlinck T, Goubau J. Midterm follow-up of treating volar marginal rim fractures with variable angle LCP volar rim distal radius plates. J Hand Surg Asian Pac Vol 2017; 22 (02) 184-187
28 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
29 Chelli M, Bronsard N, Gonzalez JF, Blasco L, Gauci MO, Boileau P. The distal-medial pilot hole: a simple way to ease volar plate positioning in extra-articular distal radius fractures. Injury 2020; 51 (03) 779-782
30 Hubbard J, Berry D, Chauhan A, Casstevens C, Shin AY, Abrams RA. A three-dimensional computed tomography study of the palmar ulnar corner fragment in distal radial fractures. J Hand Surg Eur Vol 2023;
31 Valerio T, Lupon E, Quemener-Tanguy A, Masse E, Brenac C, de Villeneuve Bargemon JB. Morphometric and curvature CT-based study of the distal radius watershed line. Hand Surg Rehabil 2025; 102168