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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 161-164

Volar plating vs. external fixator with cross k-wire for distal radius fracture: A comparative study


Department of Orthopaedics, M.L.B. Medical College, Jhansi, Uttar Pradesh, India

Date of Submission12-Oct-2022
Date of Acceptance24-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Saurabh Agarwal
Department of Orthopaedics, M.L.B. Medical College, Jhansi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_33_22

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  Abstract 

Background: Now a days there is increased utilization of volar locking plates fixation over external fixation. However, the comparative complications and outcomes of both surgical methods are still unclear. Purpose: The purpose is to compare if volar locking plate is superior to external fixation for distal radius fractures with comparison of complications associated with both surgical methods. Materials and Methods: An observational study was done from 2020 to 2022 among patients presented with displaced distal end radius of 30 patients in which 15 were treated with external fixator with cross k – wire and 15 were treated with volar locking plate with an average of 12 month or longer follow up. Results: Acceptable functional outcomes were observed with DASH scoring in 70% of study population. The functional outcome score was higher in younger population with an overall complication rate of 17% including pin track infection, hardware related issues, tendon injury, nerve dysfunction. Conclusions: In the volar plating patients outcomes (DASH SCORE), In the first 3 and 6 months is better than External fixation, However after 1 year the outcomes of both techniques found equal with little difference in terms of range of motion, grip strength, osteoarthritis.

Keywords: DASH score, distal radius, external fixation, volar plate


How to cite this article:
Agarwal S, Nagaich A, Jain N, Shah A. Volar plating vs. external fixator with cross k-wire for distal radius fracture: A comparative study. J Bone Joint Dis 2022;37:161-4

How to cite this URL:
Agarwal S, Nagaich A, Jain N, Shah A. Volar plating vs. external fixator with cross k-wire for distal radius fracture: A comparative study. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:161-4. Available from: http://www.jbjd.in/text.asp?2022/37/3/161/363855




  Introduction Top


In the fracture of upper extremity, “distal radius fractures” are most common type in aging population and in osteoporosis population.[1],[2],[3] Inspite this much high incidence, there is no consensus regarding optimal treatment strategy among the current treatment options including closed reduction, closed reduction with percutaneous pinning, external fixation and various open reduction internal fixation strategies.[4],[5],[6] There is high controversy in current literature concerning the treatment of distal radial fractures in elderly persons. However, for the stable fractures there is unanimity with closed reduction with cast immobilization.[7],[8] However, in recent years due to faster functional recovery, open reduction and internal fixation with dorsal and volar plates increases in use.[4] External fixation with or without percutaneous pinning is the most common treatment methods for the unstable fractures in past days. Many randomized trials have been carried out for the superior method in between traditional pin fixation with external fixation techniques and open reduction with internal fixation with volar plating techniques.[9],[10],[11],[12] As external fixation is of low-cost method and reliable with pin fixation for difficult distal radius fractures but closed reduction make it difficult for intra-articular fragments. Therefore, we want to determine that volar locking plate is superior to external fixation with adjuvant pin for unstable distal end radius fractures in terms of subjective and objective outcomes.[13],[14]

A distal radius fracture is unstable if three or more of the following factors are present: dorsal angulation exceeding 20°; dorsal comminution; intra-articular radiocarpal fracture; associated ulnar fracture; and age over 60 years.[15]


  Materials and Methods Top


Study design

A prospective survey, using a number of standardised questionnaires, was targeted at any patient who came with unstable distal radius fracture between 2020 and 2022, in the Jhansi and nearby districts. Potential research subjects (n = 30) were selected. Patients included were those adults who had experienced a unstable distal radius fracture, which was diagnosed via x ray on admission to Orthopaedics department. Total 30 patients with unstable distal radius fracture were identified from which 15 were managed with open reduction internal fixation with volar plating and 15 were managed by external fixation with cross k – wire.

Surgical methods

External fixation with adjuvant pins

In our study, we have used external fixator distractor which is based on the principle of ligamentotaxis of the distal radius fracture. It is consisting of 4 pins, two 3.5 mm schanz pins in the radial diaphysis 2 – 3 cm proximal to fracture under image intensifier, then two 2.5 mm schanz pin applied on the second metacarpals bare area between first dorsal interossei and extensor tendon. The distractor is then applied by ligamentotaxis. Augmentation done with two 2 mm cross k–wire after distraction and acceptable reduction under image intensifier.

PLATE FIXATION

For open reduction, distal radius was exposed by ‘Palmar approach’ (Modified Henry Approach). Incision was made in between flexor carpi radialis tendon and radial artery. Pronator quadratus muscle released from radial insertion and fracture site was exposed. Volar plate was seated on volar cortex after fracture reduction and fixed with screw after appropriate positioning under guidance of image intensifier. Pronator quadratus muscle was repaired to protect flexor tendons.


  Outcomes and Measurement Top


All patients included in the study were assessed clinically and radiographically in the post op periods on each visit by clinical examinations and a number of questions were asked including information on present medication usage for the wrist injury and the main outcome measures of the Disability of the Arm Shoulder and Hand (DASH) and Visual Analogue Scale (VAS). The demographic information included age, sex, hand dominance, injured hand, ongoing compensation, occupation, work status, smoking history, ethnic origin and previous injury to the same arm.[16] The DASH is a validated 30 item questionnaire that evaluates disability of the upper limb with a five likert-like response option for each item of the questionnaire.[16],[17] The VAS is a 0 – 10 numerical validated scale which the person rates their pain out of a maximum of 10 (10 meaning the greatest level of pain imaginable to the individual).[6]

By act of flexion-extension, pronation-supination, radioulnar deviation we evaluated range of motion of wrist with a standard goniometer. With the help of dynamometer, we measured grip strength and pinch strength.

AP and lateral radiographs were done for the measurement of volar tilt, radial inclination and volar height immediate post – operatively and in follow up x rays was done to check for union and delayed union.

Scores on the DASH questionnaire


  Results Top


In the volar plating patients outcomes (DASH SCORE), In the first 3 and 6 months is better than External fixation, However after 1 year the outcomes of both techniques found equal with little difference in terms of range of motion, grip strength, osteoarthritis.

Patients in the open reduction and internal fixation group had greater range of motion and strength than patients in the closed reduction and pin fixation group at six and nine weeks, and more patients in the open reduction and internal fixation group were very satisfied with the overall wrist function and motion.


  Complications Top


In External Fixator application [Figure 1], 2 patients developed pin tract infections which was managed by antibiotic treatment and pin track dressing, complex regional pain syndrome was managed conservatively. In 3 cases the k-wire inserted through radial styloid was pulled out accidentally.
Figure 1: External fixator group

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In volar plating group [Figure 2], 2 patients presented with carpel tunnel syndrome, one with serous discharge up to 1 month which was managed by oral antibiotic.
Figure 2: Volar plate group

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  Discussion Top


In our study, we used External fixator with supplemented cross k – wire and volar plate in two different groups for unstable distal radius fracture. Although there were no significant difference in pain, range of motion, grip strength, fracture union with functional mobility or functional scores between External fixator group and volar plating group. However, there was high short term good result in volar plate group. Intense physiotherapy and early mobilization of the wrist leads to normalization of blood supply, early resolution of wrist swelling, decreased joint stiffness and fast functional recovery.

Major complications in open reduction and internal fixation group is carpel tunnel syndrome, tendon related complications and hardware related complications.

In External fixator group, the major complications was pin tract infection, complex regional pain syndrome.

Previous studies shows that volar plating patients had overall decrease in complications and resume their daily activity earlier than External fixator patients.


  Conclusion Top


External fixation is highly effective with acceptable functional outcome, minimal complication and is a cost-effective technique but in the volar plating patients outcomes (DASH SCORE), in the first 3 and 6 months is better than external fixation. However, after 1 year the outcomes of both techniques found equal with little difference in terms of range of motion, grip strength, osteoarthritis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Roh YH, Lee BK, Baek JR, Noh JH, Gong HS, Baek GH A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures. The Journal of Hand Surgery 2015;40:P34-41.  Back to cited text no. 1
    
2.
Grewal R, MacDermid JC, King GJ, Faber KJ Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: A prospective, randomized clinical trial. J Hand Surg Am 2011;36:1899-906.  Back to cited text no. 2
    
3.
Kreder HJ, Hanel DP, Agel J, McKee M, Schemitsch EH, Trumble TE, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: A randomised, controlled trial. J Bone Joint Surg Br 2005;87:829-36.  Back to cited text no. 3
    
4.
Alter TH, Sandrowski K, Gallant G, Kwok M, Ilyas AM Complications of volar plating of distal radius fractures: A systematic review. J Wrist Surg 2019;08:255-62.  Back to cited text no. 4
    
5.
Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am 2009;91:1568-77.  Back to cited text no. 5
    
6.
Wilcke MK, Abbaszadegan H, Adolphson PY Wrist function recovers more rapidly after volar locked plating than after external fixation but the outcomes are similar after 1 year. Acta Orthop 2011;82:76-81.  Back to cited text no. 6
    
7.
Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: Nonoperative treatment versus volar locking plating. J Orthop Trauma 2009;23:237-42.  Back to cited text no. 7
    
8.
Kapoor H, Agarwal A, Dhaon BK Displaced intra-articular fractures of distal radius: A comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury 2000;31:75-9.  Back to cited text no. 8
    
9.
Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am2009;91:1837-46.  Back to cited text no. 9
    
10.
Chen NC, Jupiter JB Management of distal radial fractures. J Bone Joint Surg Am2007;89:2051-62.  Back to cited text no. 10
    
11.
Handoll HH, Madhok R Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;3:CD003209.  Back to cited text no. 11
    
12.
Leung F, Tu YK, Chew WY, Chow SP Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. A randomized study. J Bone Joint Surg Am 2008;90:16-22.  Back to cited text no. 12
    
13.
Williksen JH, Frihagen F, Hellund JC, Kvernmo HD, Husby T Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: A randomized, controlled study. J Hand Surg 2013;38A:1469-76.  Back to cited text no. 13
    
14.
Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N Bridging external fixation and supplementary kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: A randomised, prospective trial. J Bone Joint Surg Br 2008;90:1214-21.  Back to cited text no. 14
    
15.
Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW The unstable distal radius fracture-how do we define it? A systematic review. J Wrist Surg 2015;4:307-16.  Back to cited text no. 15
    
16.
Moore CM, Leonardi-Bee J The prevalence of pain and disability one year post fracture of the distal radius in a UK population: A cross sectional survey. BMC Musculoskelet Disord 2008;9:129.  Back to cited text no. 16
    
17.
Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C Disabilities of the Arm, Shoulder and Hand (DASH). The DASH and QuickDASH Outcome Measure User’s Manual. 3rd ed. Toronto, Ontario: Institute for Work & Health; 2011.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
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