Comparative study between
Conservative and surgical management of intrarticular fracture of distal end radius and its clinical and functional outcome
Intra-articular fractures of the distal end of the radius in young adults
1
Knirk-JL; Jupiter-JB J-Bone-Joint-Surg-Am. 1986 Jun; 68(5): 647-59 Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnarstyloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.
2
Intraarticular fractures of the distal radius: a cadaveric study to
determine if ligamentotaxis restores radiopalmar tilt. Bartosh-R-A., Saldana [m-M-J. Orthopedic Department, Portsmouth Naval Hospital, Va. J-Hand-Surg-[Am]. 1990 Jan. 15(1). P 18-21. Nineteen fresh cadaver wrists were divested of all dorsal and palmar tissues to the wrist capsule and extrinic and intrinsic ligaments. A Frykman VII type fracture was established across the radiocarpal and radioulnar joints. The dorsal and palmar wrist ligaments were left intact. The forearms were stabilized in an arm board and an external fixation device and traction applied through a Kirschner wire at the base of the third metacarpal. Three positions of wrist flexion; neutral, 15, and 30 degrees, with 10 and 20 pounds of traction were used to attempt to reestablish radiopalmar tilt. Only when the entire palmarligamentous structures were transected at the radius was radiopalmar tilt reestablished. Ligamentotaxis alone is not a reliable method to reestablish radiopalmar tilt in intraarticular distal radius fractures. Author-abstract.
Treatment of displaced articular fractures of the radius. ³
Fernandez DL. Geissler WB. Journal of Hand Surgery - St Louis. [JC:ia9] 16(3):375-84, 1991 May. Forty patients with articular fractures of the distal radius in which anatomic reduction of the joint surface could not be obtained by closed manipulation or by ligamentotaxis with external fixators had a combination of percutaneous and/or open reduction techniques to restore articular congruity. X-ray films taken after treatment with an average follow-up of 4 years showed satisfactory extraarticular alignment in 85% of the cases, and 37 (92.5%) patients demonstrated an articular step-off of 1 mm or less at late follow-up examination. Radiographic evidence of radiocarpal arthritis was present in 5% of the cases at follow-up examination.
Dynamic external fixation for comminuted intra-articular fractures of the
distal end of the radius. Clyburn-T-A. J-Bone-Joint-Surg-[Am]. 1987 Feb. 69(2). P 248-54. An external fixation device that allows motion of the wrist was developed for the treatment of severely comminuted intra-articular fractures of the distal end of the radius, and in specimens from cadavera that motion was demonstrated with the device in place. Thirty patients who had thirty-two comminuted intra-articular radial fractures were then treated with fixation using this device during a six-month interval. Thirty-one of the wrists were examined at follow-up one and two years later. The first fifteen wrists that were allowed full flexion and extension immediately postoperatively had lost some volar tilt postoperatively. The other patients, for whom only flexion was allowed immediately postoperatively, while extension was allowed four weeks later, did not lose volar tilt. The device maintained the reduction of the fracture fragments and allowed the early return of a functional range of motion of the wrist. Author-abstract
Open treatment for displaced articular fractures of the distal radius
Melone [m-CP--Jr. Clin-Orthop.[1m1986 [m Jan. (202).P 103-11. Fifteen patients with severely displaced Type 4 articular fractures of the distal radius required open treatment for the reduction and fixation of disrupted articular surfaces and for the repair of associated nerve, tendon, or arterial injuries. These patients were predominantly young men whose wrists had been exposed to violent compression forces. Five cases were rated excellent, nine good, and one fair according to the McBride and Lidstrom systems of evaluation. In this study, distal radial fractures with wide displacement or rotation of the articular surfaces were treated by prompt and precise repair of skeletal and soft tissue damage. Author-abstract.
Displaced intraarticular fractures of the distal radius
Bassett-RL Clin-Orthop. 1987 Jan(214): 148-52 The treatment of intraarticular fractures of the distal radius has been dramatically altered over the past decade. Investigations into the pathomechanics of these injuries highlight the problems of arthritis, pain, swelling, weakness, limited range of motion and instability associated with nonanatomic reduction of both intraarticular fragments and their associated ligaments. Factors affecting the prognosis for these injuries include degree and location of articular involvement and the energy of the precipitating force as well as the anatomy of reduction. Operative treatment is reserved for displaced intraarticular fractures. Those extremely comminuted fractures are best fixed with distraction and external fixation. The operative approach to these fractures is dependent on the anatomy. Ligamentous instability, in particular with radial styloid fractures, must be sought and treated. Kirschner wires can be used as "joy sticks" to control unstable carpal bones or fracture fragments prior to fixation. Plates and screws are useful in the stabilization of volar and dorsal rim fractures. The use of intraoperative radiographs is emphasized. Postoperative early range of motion, when possible, greatly improves the long-term results
Comminuted intraarticular fractures of the distal radius
Szabo-R-M.Weber [m-S-C.Department of Orthopaedic Surgery, University of California, Davis Clin-Orthop. 1988 May. (230). P 39-48. The comminuted intraarticular fracture of the distal radius requires early, accurate reduction of the articular surfaces and sustained restoration of anatomic position. The most commonly employed methods are pins and plaster, external fixation, percutaneous pinning, and open reduction and internal fixation. There are pitfalls, advantages, and disadvantages inherent in each method. Careful preoperative analysis of individual patients and fractures determines the therapeutic options
Volume 31, Issue 2, Pages 75-79 (March 2000) /3 of 17
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Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation
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HarishKapoor, AshooAgarwal, B.KDhaon
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Abstract
Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. In this study 90 adult cases of acute displaced intra-articular fractures of the lower end of the radius were classified according to Frykman's and AO classifications after obtaining radiographs in antero-posterior and lateral planes. These were randomly treated by one of three methods: (1) closed reduction and plaster immobilisation, (2) external fixation and (3) open reduction and internal fixation, and were followed for an average of 4 yr. In the final functional assessment (Sarmiento) the results were (1) plaster 43% good and excellent, 50% fair and 7% poor, (2) external fixator 80% good and excellent, 20% fair and poor results, (3) open reduction and internal fixation 63% good and excellent, 26% fair, 11% poor. We recommend that displaced severely comminuted intra-articular fractures should be treated with an external fixator.
Article Outline
• Abstract
• 1.Introduction
• 2.Materials and methods
• 3.Frykman's classification
• 3.1.Grip strength
• 3.2.Dorsal tilt
• 3.3.Radial length
• 3.4.Articular step off
• 3.5.Functional score
• 3.6.Complications
• 3.6.1.Plaster
• 3.6.2.Fixator
• 3.6.3.ORIF
• 4.Discussion
• 5.Conclusion
• References
• Copyright
1.Introduction
Fractures of the distal end of the radius have often been considered primarily extra articular injuries of elderly female. The distal end of the radius is being exposed to increasingly severe trauma in younger patients. The carpus is drawn into the distal end of the radius like a diepunch resulting in comminution of its articular surface. The reports of treatment methods and results are conflicting. Treatment of such injuries is often difficult and demanding, particularly when the fracture is severely comminuted or displaced. Varying patterns of intra-articular fractures are common in adults. They are commonly referred to as Colle's Barton's or Smith's, depending upon the pattern of involvement of the distal radio ulnar and radio carpal joint surface and the displacement. Nonoperative management often includes the acceptance of some degree of displacement and emphasis is placed on function [1]. Cooney et al. [2] had stressed the importance of anatomical correction and chose various methods of external fixation to achieve it. Bradway et al. [3] had laid emphasis on achieving and maintaining an anatomical reduction of fracture fragments by open reduction and internal fixation. The study was undertaken to evaluate the results of various modalities of treatment in displaced intra-articular fractures of the distal radius.
2.Materials and methods
The study has been carried out in the department of orthopaedic surgery, Maulana Azad Medical College and associated LNJP and G.B. Pant Hospitals between July 1991 and July 1996.
Ninety adults cases of acute displaced intra-articular fractures of the lower end of the radius were included in the study and were followed up for an average of 4 yr. Assessment of the fracture was based on Frykman's and AO classifications [7] after obtaining anteroposterior and lateral radiographs. The patients were treated at random by any one of the following three methods (see Fig. 1, Fig. 2).
1.Closed reduction and plaster immobilisation.
2.External fixation.
3.Open reduction and internal fixation.
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Fig. 1.Preoperative Radiograph showing fracture lower end radius. Postoperative radiograph with external fixator in situ.
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Fig. 2.Full range of pronation and supination in the same patient.
For closed reduction and plaster immobilisation X-rays were taken at 1 and 6 weeks. One more attempt at closed reduction under anaesthesia was performed if the reduction was unacceptable. The plaster was maintained for 6–7 weeks.
We used the Roger and Anderson type of external fixator. Patients treated with the external fixator were taught daily pin track dressings and also encouraged to use the limb for activities of daily living like writing, eating, etc. Radiographic and clinical examinations were done at one, two and 6–7 weeks. The fixator was removed as an outpatient procedure after 6–7 weeks and a splint applied for 2 days after which mobilisation was begun.
Patients treated with open reduction and internal fixation by means of Kirschner wires, small T plates or both. Mobilisation began at 2 weeks. Active hand, elbow and shoulder exercises were carried out throughout: wax bath, wrist exercises and grip strengthening exercises were done regularly. Grip strength measurements of both involved and normal wrists were made. Range of motion was measured using a goniometer.
The data obtained were tabulated, analysed and subjected to standard statistical methods. Results were assessed based on the Sarmiento functional score.
The statistical tests included student t-test, p-value or χ2 tests and coefficient of correlation and ANOVA test (Table 1).
Table 1.χ=2.33, df 2, p=0.31 (not significant)
/ Mode of treatment / Male / Female / Total cases / Type VIII / VII / III / IV /
/ Plaster / 26 / 7 / 33 / 17 / 8 / 2 / 6 /
/ Fixator / 20 / 8 / 28 / 15 / 4 / 2 / 7 /
/ Open reduction / 19 / 10 / 29 / 13 / 3 / 5 / 8 /
/ Total / 65 (72.2%) / 25 (27.8%) / 90 /
3.Frykman's classification
The three groups were also similar in the fracture distribution according to Frykman's classification. Frykman's type VII and type VIII formed 67% of the study.
The dominant side was involved in 65% of cases. The three groups were followed up for an average of 4 yr. On comparing loss of dorsiflexion and palmarflexion we found the least loss with the fixator following by open reduction and internal fixation and then plaster (Fig. 3).
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Fig. 3.Full range of dorsiflexion and palmarflexion in the same patient.
3.1.Grip strength
For restoration of grip strength, the fixator was significantly better than plaster immobilisation (p=0.05).
3.2.Dorsal tilt
Correction of dorsal tilt was achieved best by open reduction and internal fixation and fixator technique. Increase in dorsal tilt due to late collapse was seen as follows:
Plaster: eight cases
Fixator: four cases
ORIF: two cases
There were 11 cases of volarangulation of the distal fragment
Plaster: three cases
Fixator: three cases
ORIF: five cases
3.3.Radial length
Radial length was best restored with fixator, followed by open reduction and internal fixation and then plasterimmobilisation.
3.4.Articular step off
Open reduction and internal fixation is better than plaster immobilisation for reducing articular step off while fixator is also better than plaster immobilisation for reducing the articular step off. The maximum percentage of excellent and good anatomical results are seen with open reduction followed by external fixation then plaster application.
3.5.Functional score
It includes residual deformity, subjective evaluation, objective evaluation and complications. The maximal percentage of excellent and good functional results were seen with the external fixator followed closely by open reduction and internal fixation. These findings are not statistically significant. (Table 2).
Table 2.Optained results
/ Excellent / Good / Fair / Poor /
/ PLASTER / 2 / 8 / 11 / 2 /
/ FIXATOR / 6 / 8 / 2 / 2 /
/ Open reduction / 7 / 5 / 5 / 2 /
3.6.Complications
3.6.1.Plaster
Four patients had severe finger stiffness after plaster removal which gradually resolved with physiotherapy. One patient had carpal tunnel syndrome which resolved spontaneously without operative treatment.
3.6.2.Fixator
One case of pin track infection controlled with antiseptic dressings and antibiotics. Two cases of residual cosmetic deformity, one case of sympathetic dystrophy resolved by physiotherapy.
3.6.3.ORIF
One case of superficial infection subsided with antibiotics and antiseptic dressings. The fixation was not rigid in four cases with severe comminution and all these cases had fair and poor functional results.
4.Discussion
The three groups were similar in age, sex and deformity. The average age was 39 yr. In other reported series the average age was 63 [2], 27.6 [4] and 37 [5].
The mode of injury was road traffic accident in seventy percent of cases. This is similar to the findings of Jupiter and Knick [4].
The average loss of the arc with plaster was 37° in comparison with 19° by external fixator. Cooney et al. [2] reported an average loss of 17° by external fixator with loss of 10° if pronation and supination and loss of 14° of radial and ulnar deviation. With the external fixator loss of pronation and supination was 23° and radial and ulnar deviation 13°. Our results tally with the work of Cooney et al. [2]. With the use of a plaster case, the average loss of dorsiflexion and palmar flexion was 37°, radial and ulnar deviation was 16° and pronation–supination was 40°. This is in conformity with the work of Kongsholm and Olerud[6] who in their comparative study between plaster cases and fixator found a similar high loss of range of motion with the use of a cast. With open reduction and internal fixation, the average loss of dorsipalmar flexion was 30°, radio-ulnar deviation was 15° and pronation–supination was 30°. Similar loss of motion was seen in the study by Bradway et al. [3] on open reduction and internal fixation of displaced intra-articular fractures of the distal radius.
Pronation and supination was best restored with the use of an external fixator. Frykman had pointed out in 1967 that increased range of pronation and supination is due to better alignment of the distal radio-ulnar joint. The realignment of the distal radio-ulnar joint is best achieved with a fixator. Hence a better range of motion is observed with the fixator. Patients were also encouraged to perform pronation and supination as this motion is not restricted by this device.
The average grip strength (in comparison with the normal side) in our groups was fixator 70%, open reduction and internal fixation 68% and plaster 63%. The better grip strength in the wrist treated by external fixation is probably due to a combination of decreased pain and better joint and muscle mechanics as explained by Kongsholm and Olerud[6]. In their comparative study, average grip strength in the fixator group was 90% while in the plaster group was 65%.
Emphasis has been given to restoration of radial length and its relationship with the functional ability of patients [7]. Out study supports this concept. The radial length was best restored and maintained with external fixation. Aro and Koivenum[7] in a study on axial shortening of radius had reported similar findings and suggested that external fixation should always be considered if there are any signs of persistent axial shortening. We find in our study, persistence of some residual radial shortening in the three treatment groups. Aro and Koivenum[8] had suggested that complete restoration of the original radial length inevitably calls for the need of bone grafting to fill the created diastasis between with fracture fragments. Since we did not perform primary bone grafting, some radial shortening persisted. Radial shortening was strongly correlated with the final functional outcome in out study. Jupiter [4] had also found a similar correlation between the ultimate functional outcome and radial shortening.