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Comment to: Dorsal bridge plating versus bridging external fixation for management of complex distal radius fracture

Published:January 03, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.011
      The authors report interesting results concerning distal radius complex lesions management [
      • Mohamed M.A.
      • ME Abdel-Wanis
      • Said E.
      • IA Abdel-Aziz
      • Ahmed A.M.
      • Addosooki A.
      Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures.
      ]. Indeed, dorsal bridge plating (DBP) allows a faster functional recovery with immediate joint loading [
      • Hyatt B.T.
      • Hanel D.P.
      • Saucedo J.M.
      Bridge plating for distal radius fractures in low-demand patients with assist devices.
      ]. This notion is essential for patients likely to lose their autonomy (elderly subjects needing a cane to move) or to start rehabilitation early (polytrauma). In complex traumas of radiocarpal fractures and dislocations, BPDs also seem to play an effective role in the ulnar translation of the carpus postoperatively by restoring tension to the capsuloligamentary structures. Still, they seem to lead to poor results with high risk of radiocarpal arthrosis [
      • Wahl E.P.
      • Lauder A.S.
      • Pidgeon T.S.
      • Guerrero E.M.
      • Ruch D.S.
      • Richard M.J.
      Dorsal wrist spanning plate fixation for treatment of radiocarpal fracture-dislocations.
      ]. The ligamentotaxis theory does not allow traction to be exerted on all the fragments (especially the intra-articular fragments or the dorsal wall, without any ligament attachment) [
      • Mandziak D.G.
      • Watts A.C.
      • Bain G.I.
      Ligament contribution to patterns of articular fractures of the distal radius.
      ]. Moreover, the traction is found to be globally dorsal and is, therefore, less effective in reducing of palmar fragments [
      • Hyatt B.T.
      • Hanel D.P.
      • Saucedo J.M.
      Bridge plating for distal radius fractures in low-demand patients with assist devices.
      ,
      • Rhee P.C.
      • Medoff R.J.
      • Shin A.Y.
      Complex distal radius fractures: an anatomic algorithm for surgical management.
      ]. Some reservations about BPD should be expressed in patients without damage control, without skin defect or in patients with high functional demand. However, they do provide an interesting alternative to external fixators by providing axial traction on all wrist joints whereas micromovements, leading to secondary displacements, are possible between the two pins of the external fixator. In addition, the authors report fewer complications when using the DBP, especially when its fixation is performed on the second metacarpal[
      • Mohamed M.A.
      • ME Abdel-Wanis
      • Said E.
      • IA Abdel-Aziz
      • Ahmed A.M.
      • Addosooki A.
      Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures.
      ,
      • Hyatt B.T.
      • Hanel D.P.
      • Saucedo J.M.
      Bridge plating for distal radius fractures in low-demand patients with assist devices.
      ]. Technological advances in bone fixation have considerably changed the management of comminuted joint injuries, particularly with the appearance of specific fragment fixation. Thus, Biondi and Lauri report on their experience with specific fixation of articular lesions in 63 patients suffering from radiocarpal fractures and dislocations, with satisfactory results, particularly in fractures that are sometimes very comminuted [
      • Biondi M.
      • Lauri G.
      Dorsal fracture-dislocation of the radiocarpal joint: a new classification and implications in surgical treatment.
      ]. In a review of the literature, Rhee et al. emphasize the importance of paying particular attention to the Volar Rim in complex radius trauma, as it requires specific fixation at the risk of developing a palmar radiocarpal subluxation, with disastrous functional consequences [
      • Rhee P.C.
      • Medoff R.J.
      • Shin A.Y.
      Complex distal radius fractures: an anatomic algorithm for surgical management.
      ]. Since this subluxation is poorly controlled or reduced when distracted by an external fixator, DBP, or even standard locked plates, it must have a specific fixation to bring the patient a good result. Although complex wrist injuries have specific management, the means of fixation are not limited to the DBP or external fixator. Based on our opinion and the available literature reviews [
      • Rhee P.C.
      • Medoff R.J.
      • Shin A.Y.
      Complex distal radius fractures: an anatomic algorithm for surgical management.
      ,
      • Meaike J.J.
      • Kakar S.
      Management of comminuted distal radius fractures: a critical analysis review.
      ]we believe that complex joint fractures of the distal radius should be managed on a case-by-case basis, with specific fixation in the presence of a patient with high functional demand and/or presence of a displaced and osteosynthesizable Volar Rim fracture. In contrast, DBP can be performed if functional demand is reduced and/or in the presence of an extensive comminution. External fixators should be used to control soft tissue or bone defect damage.

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