|Year : 2023 | Volume
| Issue : 1 | Page : 18-23
To assess the functional and radiological outcomes of intra-articular fractures of distal end radius by open reduction and internal fixation with locking distal radius volar plate
Ashutosh Verma, Atul Kumar Saroj, Ankit Kumar, Upendra Patel, MC Prajwal
Department of Orthopaedics, K. G. Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||30-Nov-2022|
|Date of Acceptance||15-Mar-2023|
|Date of Web Publication||20-Apr-2023|
Department of Orthopaedics, K. G. Medical University, Shah Mina Rd, Chowk, Lucknow 226003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Intra-articular fracture distal radius is a common fracture and remains one of the most challenging fractures to treat without any complications. In unstable intra-articular fractures, re-establishment of intra-articular integrity of the wrist and maintaining the radiological parameters are often not possible with close methods. In such cases where an open reduction is required, various surgical methods and fixation materials can be used. Materials and Methods: A total of 35 patients with clinico-radiological diagnoses of intra-articular fractures of the distal end of the radius participated in the study. All the patients were followed up for a minimum of 6 months after the procedure, and the observations thus made were tabulated. Results: Functional outcome in terms of Quick DASH was excellent to good in 88.6% patients on the basis of Quick Dash Score Grading with no significant loss of radiographic reduction and a better range of movements throughout the follow-up period. Conclusion: Volar plate fixation is viable and one of the most favorable means of management with maximum anatomical restoration and functional gain.
Keywords: DASH score, distal end radius, volar plate
|How to cite this article:|
Verma A, Saroj AK, Kumar A, Patel U, Prajwal M C. To assess the functional and radiological outcomes of intra-articular fractures of distal end radius by open reduction and internal fixation with locking distal radius volar plate. J Bone Joint Dis 2023;38:18-23
|How to cite this URL:|
Verma A, Saroj AK, Kumar A, Patel U, Prajwal M C. To assess the functional and radiological outcomes of intra-articular fractures of distal end radius by open reduction and internal fixation with locking distal radius volar plate. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:18-23. Available from: http://www.jbjd.in/text.asp?2023/38/1/18/374431
| Introduction|| |
Fractures of the lower end radius are one of the most common fractures of the upper extremity encountered in practice and constitute 17% of all fractures and 75% of all forearm fractures. In the words of Dr. Abraham Colles, “the described fracture takes place about an inch and a half above the carpal extremity of the radius, and there is a 17% lifetime probability for distal radius fractures.” The majority of these injuries are “closed,” with no evidence of a breach of the surrounding skin.
Distal radius fractures have a bimodal age distribution. Among these one with a younger age group who sustained injury due to high-energy trauma, and another group of elderly patients with relatively low-energy trauma. Due to its high-energy association, now most of the distal radius fractures are associated with other long bone fractures. So much importance is given to treating long bone fracture fixation and neglecting distal radius fractures, which result in poor functional outcomes.
Restoration of radial length, radial tilt, and congruity of articular surfaces is important for good functional results. Failure to achieve and maintain near anatomic restoration can lead to various deformities and disabilities. The treating orthopedician has an armamentarium of treatment options to select from to accomplish this. Distal radial fractures are being treated by various methods, like closed reduction and immobilization in a POP cast, percutaneous pin fixation, Kapandji intrafocal pinning, external fixation devices that permit distraction and palmar translation, low-profile internal fixation plates, arthroscopically assisted reduction, and bone grafting techniques, including bone-graft substitutes, all of which have contributed to improved fracture stability and outcome.
Internal fixation of metaphyseal bending fractures has definite advantages over external fixation: (i) it can directly control and maintain physiologic palmar tilt; (ii) it can prevent collapse with external fixation; and (iii) it can avoid bridging the radiocarpal joint. The distal fragment typically has sufficient size and integrity to provide adequate purchase and may be approached from either a dorsal or a volar approach. Volar plating is preferred, as the screws directly buttress against collapse. The advantages of volar plating also include faster functional recovery and lower complication rates, including extensor tendon irritation and rupture., Volar plates for fractures of the distal radius can be (i) conventional plates or (ii) locking compression plates. When using conventional plates, comminution must be lower. They poorly hold the cancellous bone fragments; hence, screws can toggle in the distal holes of the plate, leading to loss of reduction and collapse during axial loading. With locking plates, the locking screws support subchondral bone, resist axial loading forces, prevent collapse, and maintain reduction, especially in intra-articular fractures. Compression of plate to bone is not necessary and thus preserves periosteal blood supply. Locking plates also provide additional strength by transferring the load from the intact subchondral bone across the compromised metaphysis to the intact diaphysis, which would theoretically permit an early range of motion postoperatively. The development of fixed angular stable fixation techniques theoretically improves stability to maintain the reduction of fractures in osteoporotic bones and fractures, especially in the elderly, which are usually unstable.
| Materials and Methods|| |
This was a prospective interventional study conducted on patients with intra-articular distal end radius fractures and managed by a distal radius volar plate. Cases satisfying the inclusion and exclusion criteria are admitted to our department. We started the study with 37 patients, but two were lost during follow-up. Thirty-five patients were evaluated until the final follow-up. So this is the study of 35 patients in which open reduction internal fixation with distal radial volar plate was done. All cases were selected on the basis as follows:
- Closed and open fractures, distal end radii up to compound grade, Gustilo–Anderson type.
- Radiological findings confirming an intra-articular fracture of the distal end radius, or type B/C fracture according to the AO classification.
- Patients who are medically fit and willing for surgery.
- Patients between the age group of 20 and 70 years of both sexes.
- Compound fracture Gustilo–Anderson type 2 and 3.
- Pathological fractures.
- Distal end-radius fracture associated with neurovascular deficit.
- Patients with medical comorbidities for which surgical fitness could not be done.
Preoperative Informed consent was taken. X-ray wrist joint AP and lateral views for assessment of radio-ulnar angulation, volar angulation, radial length, radial shift, associated ulnar styloid fracture, and distal radio-ulnar joint dissociation [Figure 1]. Regional anesthesia (local anesthesia/brachial block) as per requirement the standard volar approach, called the “modified Henry Approach,” was used in most of the cases to address the distal radius fragments.
|Figure 1: Preoperative x-ray showing intra-articular fracture of distal end radius|
Click here to view
Open reduction and internal fixation with locking compression plates and 2.7 and 3.5 mm screws were used in all our study patients since all had intra-articular fractures with varying degrees of comminution [Figure 2]. These screws had better purchase in the distal radial comminuted fragment with poor bone stock.
The average duration of surgery was one hour and 20 min with the range being 40 min to 2 h. The average loss of blood during the surgery was 100 mL ranging between 50 and 250 mL. All the patients were followed up at 1, 2, 3, and 6 months. Functional evaluation was done according to the Quick DASH Score at 1, 2, 3, and 6 months.
where n* is equal to the number of completed response
Our primary outcome measure was the Quick DASH score, and the secondary outcome measure was range of movements, radiographic outcome, and complications.
| Results|| |
This study was conducted to analyze the results obtained by management of intra-articular fractures of distal end radius by open reduction and internal fixation with distal radius volar plate. In this study, the duration of fracture union in which 88.6% patients had union within 3 months and 11.4% patients had union after 3 months [Table 1]. There was no case of nonunion and malunion in our study.
In our study, the mean and standard deviation of the quick dash score were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 4811 and P value is <0.00001; statistically significant, which denotes progressive improvement in the Quick DASH score calculated at regular follow-up showing improvement in functional outcome [Table 2].
The mean and standard deviation of the palmar flexion score were evaluated at 1, 2, 3, and 6 months, respectively [Table 3]. The F value is 41.8 and the P value is 0.00001; statistical significance, which denotes progressive improvement in palmar flexion calculated at regular follow-up, showing improvement in clinical outcome.
The mean and standard deviation of dorsiflexion were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 19.2 and P value is <0.00001; statistically significant, which denotes progressive improvement in dorsiflexion calculated at regular follow-up, showing improvement in clinical outcome [Table 4].
In this study, the mean and standard deviation of supination were evaluated at 1, 2, 3, and 6 months, respectively [Table 5]. The F value is 25.1 and P value is <0.00001; statistically significant, which denotes progressive improvement in supination calculated at regular follow-up, showing improvement in clinical outcome.
The mean and standard deviation of pronation were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 20.3 and P value is <0.00001; statistically significant, which denotes progressive improvement in pronation calculated at regular follow-up, showing improvement in clinical outcome [Table 6].
The mean and standard deviation of radial deviation were evaluated at 1, 2, 3, and 6 months, respectively [Table 7]. The F value is 59.9 and the P value is 0.00001; statistically significant, which denotes progressive improvement in radial deviation calculated at regular follow-up, showing improvement in clinical outcome.
The mean and standard deviation of ulnar deviation were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 105.4 and P value is <0.00001; statistically significant, which denotes progressive improvement in ulnar deviation calculated at regular follow-up, showing improvement in clinical outcome [Table 8].
The mean and standard deviation of volar tilt were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 2.26 and the P value is >0.05, which is statistically nonsignificant and denotes no significant changes in volar tilt throughout the postop period [Table 9].
The mean and standard deviation of radial inclination were evaluated at 1, 2, 3, and 6 months, respectively. The F value is 0.175 and the P value is >0.05; these values are statistically nonsignificant, which denote no significant changes in radial inclination throughout the postop period [Table 10].
The mean and standard deviation of radial length were evaluated at 1, 2, 3, and 6 months, respectively [Table 11]. The F value is 0.11 and P value is >0.05; statistically nonsignificant, which denotes no significant changes in radial length throughout the postop period.
There were no immediate postop complications in our studies, but during the follow-up period, we encountered wrist stiffness in 8.5% of patients; stiffness was primarily due to a lack of mobilization on the patient’s side. They were told to strictly adhere to aggressive physiotherapy protocols in order to recover quickly. We also encountered wrist infections in 2.8% of patients, which improved upon treatment with antibiotics. Acute nerve injuries, compartment syndrome, carpal tunnel syndrome, shoulder–hand syndrome, or tendon rupture were not present.
| Discussion|| |
A better understanding of wrist anatomy and function through the studies conducted in recent years, as well as the increasing expectations of patients, have expanded the borders of surgical treatment. Besides, improvements in fixation materials have provided new opportunities. According to the literature, B- and C-type distal radius fractures of the AO system are primarily treated surgically due to their intra-articular and unstable nature. Today, open positioning and plate fixation are widely recognized surgical methods. Locked plates are in the process of replacing conventional buttress plates. While facilitating positioning, screw-plate interlocking anatomical plates have greater biomechanical strength against forces applied to fracture surfaces. Because of their biomechanical strength, locked plates are preferred in osteoporotic and comminuted fractures. However, there is no consensus neither about how to approach the distal radius nor the positioning of the plate. In recent years, volar approaches have become more popular. This study was undertaken to assess the functional outcome of the management of an intra-articular distal end radius fracture by a distal radius volar plate. We evaluated our results and compared them with those obtained by various other studies utilizing different modalities of treatment.
Phadnis et al. reported that 74% of patients had good or excellent DASH and MAYO scores. In our study, each patient’s Quick DASH score was taken at 1, 2, 3, and 6 months intervals along with a range of motion, which showed a progressive decrease in the mean Quick DASH scores calculated at 1 month (mean 67.8), 2 months (mean 32.7), 3 months (mean 18.7), and 6 months (mean 8.07), which was statistically significant (P = 0.00001) and reflected an improvement in functional outcome over time. At 6 months follow-up, the functional outcome in terms of Quick DASH Score was excellent to good in 88.6% of patients.
In our study, the mean range of motion achieved at 6-month follow-up was as follows: Palmer flexion (72.55.5), dorsiflexion (63.35.4), radial deviation (18.82.1), ulnar deviation (22.62.03), supination (72.67.0), and pronation (75.76.9). The dominant side, when injured, recovered early, and pronation improved more rapidly than supination during the follow-up period in our study. Gangadhar et al. reported palmar flexion of 77.333.144°, dorsiflexion of 72.674.097°, radial deviation of 19.004.983°, ulnar deviation of 34.175.584°, supination of 75.004.355°, and pronation of 69.536.044°. These results were taken at 6 months postoperatively and were compared with the normal side.
In our study, the average postoperative radial inclination at 6 months was 20.173.63°, which is comparable to Egol et al. who reported a prereduction radial inclination of 14.68° and 13.87.9° in the external fixation and volar plate fixation groups, respectively, and a postoperative reduction of 18.86.5° in the external fixation group and 17.14.7° in the plating group.
Our study reported an immediate postoperative radial length of 10.83 ± 2.52 mm, comparable to Tamara et al. who reported an immediate postoperative reduction of radial height to 112 mm in the ORIF group as well as the CRPPP group, and their results did not change throughout the follow-up.
In our study, mean palmar angulation at the final follow-up was 9.2 ± 1.98. The mean palmar angulation at the end of our study was 9.21.98.ees in 92% of patients. In our study, the mean ulnar variance at 6 months was -1.190.47 and comparable to other studies. Gogna et al. showed an ulnar variance of 0.77–0.88 mm.
In our study, no significant difference (P > 0.05) in the radiological parameters was noted at the end of 6 months as compared to 1 month of follow-up, indicating that the fracture fixation was rigid and no further significant collapse of the fracture occurred.
| Conclusion|| |
From our study, we conclude that early primary fixation of the intra-articular distal radius fractures is essential for a good functional outcome and to avoid the complications of prolonged immobilization, which facilitates an early return to regular activities. Patients with unstable, either volar or dorsally displaced fractures of the distal radius had excellent or good functional outcomes when treated with a fixed-angle volar locking plate. With a stable DRUJ after fixation of distal radius fractures by means of an angle-stable volar locking plate, DRUJ stability is maintained. The coexistence of an ulnar styloid fracture in these patients did not affect their functional outcome. However, long-term follow-up is needed to further validate our findings.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Frank A, Liporace MD, Mark R, Adams , John TC, Kenneth JK Distal radius fractures. J Orthop Trauma 2009;23:739-48.
Colles A On the fracture of the carpal extremity of the radius. Edinburgh Med Surg 1814;10:182-6.
Knirk JL, Jupiter JB Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68A:647-59.
Bassett RL Displaced intraarticular fractures of the distal radius. Clin Orthop Relat Res 1987;214:148-52.
Jakubietz MG, Gruenert JG, Jakubietz RG Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: Is there an advantage of palmar plates in the long term? J Orthop Surg 2012;7:8.
Ruch DS, Papadonikolakis A Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg 2006;31:9-16.
Earp BE, Foster B, Blazar PE The use of a single volar locking plate for AO C3-type distal radius fractures. Hand N Y N 2015;10:649-53.
Levin SM, Nelson CO, Botts JD, Teplitz GA, Kwon Y, Serra-Hsu F Biomechanical evaluation of volar locking plates for distal radius fractures. Hand N Y N 2008;3:55-60.
Martinez-Mendez D, Lizaur-Utrilla A, de-Juan-Herrero J Intra-articular distal radius fractures in elderly patients: A randomized prospective study of casting versus volar plating. J Hand Surg Eur 2018;43:142-7.
Phadnis J, Trompeter A, Gallagher K, Bradshaw L, Elliott DS, Newman KJ Mid-term functional outcome after the internal fixation of distal radius fractures. J Orthop Surg Res 2012;7:4.
Gangadhar G, Khan A, Habib SD, Pandey A, Verma A, Nirala SK, et al
. A prospective study on functional evaluation of volar locking plate fixation of distal radius fractures. IOSR-JDMS 2019;18:73-86.
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.
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 Am 2009;91:1837-46.
Gogna P, Selhi HS, Singla R, Devgan A, Magu NK, Mahindra P, et al
. Dorsally comminuted fractures of the distal end of the radius: osteosynthesis with volar fixed angle locking plates. Int Sch Res Notices. 2013;2013.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]