|Year : 2016 | Volume
| Issue : 3 | Page : 698-704
Comparison between results of management of recent intra-articular fractures of distal end radius by percutaneous pinning and volar locked plate
Hesham Ghoneem, Ahmed Zayda, Mohamed O Mostafa
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Web Publication||23-Jan-2017|
Mohamed O Mostafa
Orthopedic Department, El Menshawy Hospital, Tanta, 31511
Source of Support: None, Conflict of Interest: None
Distal radius fractures are considered the most common fractures in orthopedic practice. There are many different fracture patterns and injuries associated with articular cartilage and neighboring soft tissue that are found in different patient populations. Fractures of the distal radius are caused by high-energy trauma in young patients and by low-energy trauma in the elderly. Disruption of the ligaments and the displacement of the carpus and/or the triangular fibrocartilage complex will equally influence the functional outcome. Many methods have been established for the treatment of fractures of the distal radius. The main principle is to obtain anatomical reduction with rigid fixation to allow early mobilization. Comparison between the results of closed reduction and internal fixation by percutaneous Kirschner wires and open reduction and internal fixation (ORIF) by self-locked plates and screws in the treatment of recent intra-articular distal radial fractures was made in 30 patients in El-Menoufia University Hospital during a 33-month period.
This study compared clinical outcomes and complications in patients with recent intra-articular distal radius fractures treated using two methods of fixation: percutaneous pinning and self-locked plating.
While selecting treatment, a technique that makes alignment of articular surfaces a priority and restores more normal joint mechanics should be used. Closed reduction and percutaneous pinning is a good option, which preserves soft tissue as it is a minimal invasive procedure. On the other hand, open reduction and self-locked plate fixation is a unique option in supporting articular surface and preventing its collapse.
Materials and methods
Thirty patients were analyzed and divided into two groups. Patients in group A (n = 17) were treated with percutaneous pinning and patients in group B (n = 13) were treated with ORIF by self-locked plating. The major characteristics of the two groups in terms of age, sex, mode of injury, fracture location, and associated injuries were similar.
Primary union was achieved in all patients. The mean time to union was similar in the two groups. The mean operation time in the percutaneous pinning group (25 min) was shorter than that in the ORIF group (80 min). There were complications in four cases (13.33%). One case was treated by self-locked plates and screws and had extensor tendon irritation (3.33%). Three cases that were treated by percutaneous pinning had complications; one case had pin-tract infection (3.33%), one case had loss of reduction and complex regional pain syndrome (3.33%), and one case had pin-tract granuloma (3.33%). Functional outcome was satisfactory in both groups.
Percutaneous pinning technique achieves comparable results with the ORIF by self-locked plating method in intra-articular distal radial fractures. Percutaneous pinning reduces operation time and soft-tissue dissection. Self-locked plating reduces collapse and loss of reduction rates.
Keywords: closed reduction and internal fixation, distal radius, open reduction and internal fixation, percutaneous pinning, self-locked plate
|How to cite this article:|
Ghoneem H, Zayda A, Mostafa MO. Comparison between results of management of recent intra-articular fractures of distal end radius by percutaneous pinning and volar locked plate. Menoufia Med J 2016;29:698-704
|How to cite this URL:|
Ghoneem H, Zayda A, Mostafa MO. Comparison between results of management of recent intra-articular fractures of distal end radius by percutaneous pinning and volar locked plate. Menoufia Med J [serial online] 2016 [cited 2020 Feb 17];29:698-704. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/698/198780
| Introduction|| |
Distal radius fractures are considered among the first investigated and the most common fractures in orthopedic practice  . Many methods have been established for the treatment of fractures of the distal radius, including percutaneous pinning of the distal fragment  , pins in plaster  , metal external skeletal fixation devices, limited open reduction with or without bone grafting  , and extensive open reduction and internal fixation (ORIF)  . The gold standard is restoration of the anatomy, stable internal fixation, a decreased period of immobilization, and early return of wrist function  .
In most activities of daily living, the dorsum of the distal radius is subject to tensile forces, whereas the volar surface is subject to compression. This is reflected in the bony architecture of the distal radius, with its strong volar buttressing cortex and thinner cancellous dorsal surface. When the wrist is subjected to a nonphysiologic load, as in a dorsally directed compression force (e.g. a fall on the outstretched hand), predictable fracture patterns result  . Additional shearing forces influence the injury pattern, resulting in articular surface involvement  . Associated injuries must be considered in any comprehensive treatment plan for patients with distal radius and ulna fractures. Up to 68% of distal radius fractures are associated with soft-tissue injuries, such as partial or complete tears of the triangular fibrocartilage complex, scapholunate ligament, and/or lunotriquetral ligament  . Many classification systems described fractures of the distal radius Frykman  , Melone  , Fernandez et al.  , AO classification  ([Figure 1]), and most recently columnar classification  ([Figure 2]). Fractures with loss of at least 2 mm of radial height, change in radial inclination of at least 5°, loss of volar tilt of at least 10°, loss of reduction of the distal radioulnar joint, and/or those with greater than 1-2 mm of intra-articular step-off should be reduced ([Figure 3]). Surgical intervention is considered when an acceptable reduction cannot be achieved or maintained by closed means  . A balance then between achieving anatomic reduction, securing stable fixation, minimizing soft-tissue disruption, and allowing early rehabilitation should be the rationale for choosing between closed reduction and open reduction  .
|Figure 1: Distal radius anatomy. The fracture line between the volar medial and dorsal medial columns extends into the sigmoid notch, and thus it must also be evaluated on postreduction radiographs. Inset, columnar classification of distal radius and ulna. Reproduced with permission from Trumble et al. .Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.|
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|Figure 3: The various angles to assess in distal radius fractures. (a) Radial inclination (RI) (normal, 22°). (b) Radial length (RL) (normal, 12 mm). (c) Ulnar variance (UV) (normal, 0 to −2 mm). (d) Radial tilt (RT) (normal, 11° volar).|
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| Materials and methods|| |
Thirty patients with intra-articular distal radius fractures were included in this study. They were randomly divided into two groups - group A: this group comprised 17 patients treated surgically with percutaneous pinning ([Figure 4]); group B: this group comprised 13 patients treated surgically with ORIF by self-locked plate ([Figure 5]). The patients were admitted over the period between January 2012 and October 2014 in El-Menoufia University Hospital and El Menshawy General Hospital after taking consents for fracture study and case presentation and publishing.
Criteria of inclusion
The inclusion criteria were skeletally mature patients, patients with intra-articular fractures, unstable fractures, unaccepted functional range variance, and osteoporotic patients.
Criteria of exclusion
Exclusion criteria were open fractures with associated neurovascular injury, amputated wrist, and extra-articular fractures.
Group A: There were seven male and 10 female patients, with a mean age of 36.824 years (range 25-54 years). The fracture was on the right side in 10 cases, on the left side in five cases, and bilateral affection in two cases. The mechanism of injury was fall on the ground in 12 cases, road traffic accident (RTA) in three cases, and fall from a height in two cases - one case from the stairs and one case from a chair ([Figure 6]).
Group 2: There were eight male and five female patients with a mean age of 38.692 years (range 22-57 years). The fracture was on the right side in six cases and on the left side in seven cases. The mechanism of injury was fall on the ground in seven cases, RTA in one case, and fall from a height in five cases - three cases from a donkey and two cases from a chair ([Figure 6]).
Technique of percutaneous pinning
Position of the patient
0The patients were placed supine on the operating table, and the wrist to be operated on was kept free in range of image intensifier.
Under fluoroscopic control, closed reduction of distal radial fracture was performed; percutaneous pinning with an appropriate K-wire was bicorical through the lateral nonarticular portion of the styloid radius, with the K-wire or wires being drilled into the opposite proximal cortex and the other wire through the dorsoulnar part of the radius to the opposite proximal cortex.
Subarticular transverse wire was used in cases with distal radioulnar joint (DRUJ) subluxation to fix the radius to the ulna temporarily.
Reduction and fixation stability was checked by image fluoroscopy.
The K-wires were bent and kept outside the skin to be removed later on.
Below-elbow cast or slap was done for 4-8 weeks after padding of wires.
Wires were removed 6 weeks postoperatively.
Technique of open reduction and internal fixation with self-locked plates and screws
Position of the patients
In supine position, the involved hand was kept on the side table or on the table side arm. The fracture was exposed under general or local intravenous anesthesia and tourniquet control.
Volar radial approach
The volar radial (Henry) approach was used to expose the entire volar radial surface up to the DRUJ ([Figure 7]).
|Figure 7: Volar approach distal radius. (a) The volar radial approach uses the interval between the flexor carpi radialis tendon and the radial artery. The pronator quadratus is elevated sharply, starting at its insertion on the distal radius. (b) Top detail, the volar ulnar approach can be extended distally to release the median nerve from the carpal tunnel. Bottom detail, at the level of the distal radius, the flexor tendons and the median nerve are retracted radially to expose the volar medial distal radius.|
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A 5-cm-long skin incision was made just lateral to the flexor carpi radialis tendon in the distal radial region. flexor carpi radialis (FCR) tendon sheath was exposed and the interval between it and radial artery was used to expose the pronator quadrates muscle, and in some cases the approach was through the FCR sheath floor.
Pronator quadrates muscle was elevated subperiosteally or mid-incised to visualize the volar distal radial aspect.
Fracture reduction and fixation
The fracture site was exposed and the hematoma and soft tissue were removed, and then the fracture and the articular surface were reduced anatomically by traction and derotation and provisionally held in place with small bone-holding forceps. Self-locked plate was properly applied. It was held by small plate holder locking sleeve that was used to guide the drill bit and then removed. After that measuring of the proper length of screws was one then locked screws was used to fix subarticular region. The proximal screws was inserted by the same manner.
Three screws were used in the distal transverse part of the plate and three screws or more were used in the proximal part of the plate.
Rotation and angulation alignment were checked before and after internal fixation of the fracture by direct visualization.
After internal fixation, the tourniquet was removed, followed by hemostasis, and then pronator quadrates was sutured back to cover the plate by wide loose sutures.
No drain was used in any case after good hemostasis.
Closure of subcutaneous tissue after fasciotomy was performed in cases with severe edema by absorbable sutures; then, the skin was closed by nonabsorbable sutures.
Below-elbow slap was applied until the stitches were removed after 10-15 days.
Postoperative care and result evaluation
Postoperative treatment was described for patients with antiedematous NSAIDs when indicated only, and antibiotics.
In both methods, immediate radiography was done after 2 weeks, 4 weeks, and 6 weeks.
Cases were followed up for 3-6 months with instructions of range of motion under warm water, wrist exercise, and grip power exercise as early as possible.
Clinical results were evaluated in the follow-up period according to Cooney's modification of the Green and O'Brien scheme (Cooney et al., 1980;Green and O'Brien, 1978)  ([Table 1]).
After 12 weeks, bilateral grip and pinch strengths, as well as range of motion of the wrists, were reported. All the results were presented as fraction of that parameter in the operated side compared with that in the nonaffected extremity.
Statistical presentation and analysis of the present study was conducted, using the mean, SD, Student's t-test (unpaired), χ2 -test, analysis of variance, and by SPSSV17 (version 17; SPSS Inc., Chicago, Illinois, USA).
| Results|| |
All the patients were divided into two groups. Group A comprised 17 patients fixed by percutaneous pinning and group B comprised 13 patients fixed by volar locked plate.
Overall results in both groups
The results obtained for 30 patients suffering from intra-articular distal end radius fractures were excellent in seven patients (23.33%), good in six patients (20%), fair in 15 patients (50%), and poor in two patients (6.67%). No statistically significant differences were found between the two groups in comparing the outcome (P = 0.575) ([Table 2]).
The results of 17 patients who suffered from intra-articular distal end radius fractures treated with percutaneous pinning were excellent in four patients (23.53%), good in two patients (11.76%), fair in 10 patients (58.82%), and poor in one patient (5.88%).
The results of 13 patients who suffered from intra-articular distal end radius fractures treated with self-locked plates and screws were excellent in three patients (23.08%), good in four patients (30.08%), fair in five patients (38.46%), and poor in one patient (7.69%).
Men showed better results in both groups, but this was statistically significant only in group A, with χ2 = 10.818, P = 0.013 (P < 0.05), whereas in group B it was χ2 = 6.094 and P = 0.107 ([Table 3]).
There was a statistical significant difference between the mean ages of poor, fair, good, and excellent results in group B. In group A, F = 1.093 and P = 0.387, whereas in group B, F = 10.569 and P = 0.003 (P < 0.05) ([Table 4]).
A nonsignificant relation was found between the two groups with respect to the mechanism of injury, side of injury (right or left), occupations, time-lapse before surgery, associated injuries, and history (medical and habits) (P > 0.05).
| Discussion|| |
In this series, 30 patients with displaced comminuted intra-articular fractures of the distal radius were treated during the period from January 2012 to October 2014. The period of follow-up ranged from 6 to 8 months, with an average of 7 months.
The most commonly affected age group was between 22 and 57 years. Men and women were equally affected in this series.
On reviewing other studies conducted by Nana et al.  , Kotwal et al.  , Jupiter  , Orbay and Fernandez  , it was found that, as reported by most authors, comminuted distal radial fractures occurred more in women and more in older age groups.
The most common mechanism of injury in this study was fall on the ground (63.33%), and this was also reported by others.
It was noted that motor vehicle accidents have become an important cause of comminuted distal radial fractures. It was the second mechanism of injury (13.33%) in this series, whereas it was 60% in the study by Dienst et al.  .
Associated injures were present in 60% of cases in this study and styloid ulna was present in 43.33% of the patients because of its close relation to bony and ligamentous wrist joint structures.
In the present study, it was suggested that percutaneous fixation of the distal radial fractures with K-wires had less satisfactory results than ORIF with self-locked plates and screws but without statistical significance, whereas ORIF of distal radial fractures with self-locked plates and screws gave less complications than percutaneous pinning.
In this series, the results were as follows:
The satisfactory results (excellent and good) constitute 35.29%, whereas the unsatisfactory results (poor and fair) constitute 64.71% for group A treated by percutaneous pinning. The satisfactory results (excellent and good) constitute 53.85%, whereas the unsatisfactory results (poor and fair) constitute 46.15% for group B treated by self-locked plates and screws.
There was a highly significant correlation between the type of fracture and the final results. The more comminuted fractures attained more bad results than the less comminuted fractures.
Kotwal et al.  noted that distal radial fractures are often associated with poor results and high complication rates.
In this study, 35.29% of satisfactory results (excellent and good) were obtained by percutaneous fixation with Kirschner wires, whereas 53.85% of satisfactory results were obtained with self-locked plates and screws, with the total end result of 43.33% satisfaction for all cases.
Orbay and Fernandez  examined the use of the volar plate with locking pegs for the treatment of dorsally displaced fractures of the distal radius; they reported 100% good-to-excellent results.
In this study, the complications to be noticed were pin-tract infection, loss of reduction after K-wire removal, Sudkey's atrophy, and pin-tract granuloma with group A treated by percutaneous pinning, and extensor tendon irritation in one case in group B treated by self-locked plate and screws.
Jupiter  found that fractures associated with high-energy trauma and comminution of the metaphyseal bone stock had an excellent or good result in 62% of cases and a fair or poor result in 38% in a study of compression fractures associated with higher-energy trauma treated by self-locked plates and screws.
In the present study, rigid fixation was obtained in all cases treated with self-locked plate screws, whereas rigid fixation was obtained in 94.12% of fractures treated with K-wires, with only one case with loss of reduction of 5.88%.
As regards comparison between percutaneous pinning versus self-locked plate screw fixation of intra-articular distal radial fractures, Jupiter reported no significant differences in the clinical outcomes using either technique. Although operative time was shorter in the percutaneous pinning group than in the self-locked plate screw group, the incidences of loss of reduction and infection rate were much higher in the percutaneous pinning group. Secondary surgeries for hardware removal in the operating room were much higher in the self-locked plate screw group. Similar results were found in our study, but no hardware was removed in the operation theater  .
| Conclusion|| |
ORIF with self-locked plates and screws and closed reduction and internal fixation with K-wires are reasonable options for treating recent intra-articular fractures of the distal end radius as they provide anatomical reduction and rigid fixation, which is sufficient to allow early mobilization of the adjacent joints, thus helping to achieve satisfactory functional results.
Although K-wires showed less satisfactory results than plates and screws, there were no significant statistical differences in the clinical outcomes using either technique; this may be because of a low number of cases.
Prolonged postoperative immobilization should be avoided and patients must start active movement as early as possible to avoid stiffness.
The occurrence of postoperative complications directly affects the functional outcome of the hand.
The more comminuted the fracture, the more unsatisfactory the final result.
The patient should avoid any aggressive movements or trauma to the hand in the early postoperative period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4]