|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 53-57
Outcome of comminuted distal-end radius fracture managed with Ulno-Carpal and distal radius stabilization using percutaneous K-wires
Bikram K Kar1, Anand Kumar Singh1, Sharath Kaushik1, Sandeep K Yadav2, Harshal S Sakale1, Alok Chandra Agrawal1
1 Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
2 Department of Trauma and Emergency, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||28-Jun-2020|
|Date of Decision||15-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||10-Sep-2020|
Anand Kumar Singh
Room No. B210, PG/Intern Hostel, AIIMS Campus, Tatibandh, GE Road, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: Distal radial fractures account for up to 20% of all fractures treated in emergency departments, many are not “completely exempt from pain” after treatment. Several treatment modalities have been described with their own merits and demerits. Stabilization of ulno-carpal articulation is an effective method to prevent radial collapse and other complications associated with external fixator during healing, and hence this study has been designed to get a solution with good outcome and minimal complication. Materials and Methods: A prospective study on eighty patients of comminuted intra-articular fracture of the lower end of the radius, between 30 and 65 years of age, irrespective of sex, treated by closed reduction and ulno-carpal stabilization maintaining ligamentotaxis and distal radius percutaneous K-wires fixation and a well-molded above-elbow Plaster of Paris cast for 4 weeks followed by removal of K-wire and below-elbow cast for 2 weeks, has been presented. Patients were evaluated at 6-month follow-up and functionally by Sarmiento's modification of Lindstrom criteria and Gartland and Werley's criteria. Results: Excellent results were seen in 85%, good in 11.25%, and fair in 4.75% of the cases. Complications observed were malunion (n = 2), subluxation of the inferior radio-ulnar joint (n = 2), Sudeck's osteodystrophy (n = 1), and posttraumatic arthritis of the wrist (n = 2). Conclusion: The closed reduction and percutaneous K-wire fixation is a least invasive, safer, and effective method to maintain the reduction, prevent radial collapse during healing, and maintain the stability of the distal radio-ulnar joint even when the fracture is grossly comminuted, intra-articular, or unstable.
Keywords: Comminuted fracture of the distal-end radius, K-wire fixation, percutaneous pinning, ulno-carpal stabilization
|How to cite this article:|
Kar BK, Singh AK, Kaushik S, Yadav SK, Sakale HS, Agrawal AC. Outcome of comminuted distal-end radius fracture managed with Ulno-Carpal and distal radius stabilization using percutaneous K-wires. J Orthop Dis Traumatol 2020;3:53-7
|How to cite this URL:|
Kar BK, Singh AK, Kaushik S, Yadav SK, Sakale HS, Agrawal AC. Outcome of comminuted distal-end radius fracture managed with Ulno-Carpal and distal radius stabilization using percutaneous K-wires. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Sep 22];3:53-7. Available from: http://www.jodt.org/text.asp?2020/3/2/53/294733
| Introduction|| |
The history of distal radius fractures reflects the evolution of the understanding of many conditions in orthopedic trauma. The true nature of distal radial injury was described by Petit, Pouteau, and Colles, prior to whom it was believed that the injury was a carpal or distal radio-ulnar joint (DRUJ) dislocation. The first description of distal radius fractures was brought to attention in English literature by Abraham Colles after publishing his views “On the fractures of the carpal extremity of the radius” in 1814.
Although distal radial fractures account for 20% of all fractures treated in emergency departments, many are not “completely exempt from pain” after treatment. Since the last few decades, more than 1000 peer-reviewed studies have been published on the subject, yet there is no consensus on which treatment is superior. Many confounding variables exist, all of which are somewhat controversial: the level to which the anatomy is restored, the quality of the bone, the emergence of new techniques and devices, the experience and ability of the surgeon, and outcomes in older populations.
The early method of closed reduction and cast immobilization has resulted in malunion, joint stiffness, and deformity. It adversely affects the wrist and hand function by interfering with the mechanical advantage of the extrinsic hand musculature.,, Closed reduction and Plaster of Paris (POP) immobilization often leads to collapse of the radius and subluxation of DRUJ.
Percutaneous pinning provides additional stability and is one of the earliest methods of fixation. Depalma described ulno-radial pinning at 45° angle. Stein advocates an additional dorsal 2-mm K-wire with radio-ulnar pinning. Kapandji described double intrafocal pinning into the fracture surface using 2-mm K-wires, and Raycheck recommended ulno-radial pinning along with the fixation of the DRUJ.
Joint spanning external fixation and ligamentotaxis indirectly reduce the impacted articular fragments and directly neutralize the axial load over the radius. Ruch and Ginn, Schumr, and many others described open reduction and internal fixation of the distal radius for unstable intra-articular fractures. Doiatal described arthroscopic-guided fracture reduction.
This study evaluates the functional and radiological outcomes of distal radius fractures treated by percutaneous pinning in ulno-carpal joint and distal radius.
| Materials and Methods|| |
Eighty patients (47 males and 33 females) with unstable, comminuted, and intra-articular distal radius fracture presenting within 7 days of injury were prospectively selected for the study between 2018 and 2019 in our institute. The mean age of the patients was 53 years. In 51 patients, the dominant hand was fractured. The common cause of injury was fall on an outstretched hand in 58 patients, 18 cases were due to road traffic accident, and the remaining 4 cases were due to fracture sustained due to sports-related injury. All are closed fracture and classified according toArbeitgemeinschaft fur Osteosynthesefragen/ Orthopaedic Trauma Association (AO/OTA) using anteroposterior (AP) and lateral view X-rays.
The various radiological parameters are described as follows [Figure 1]:
- The radial angle (or inclination), measured on posteroanterior (PA) view. Radial inclination represents the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius. Loss of radial inclination will increase the load across the lunate. This angle should be around 20°–25°
- The radial tilt (or palmar tilt) is measured on the lateral radiograph as the angle created between the articular surface of the distal radius and a line perpendicular to the long axis of the radius and is between 0° and 22° with an average of 11°
- The radial length measured on the PA radiograph, relates the length of the radius to the ulna distance between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid. A second line intersects the distal articular surface of the ulnar head. Normally, the radial length averages 11–12 mm
- Ulnar variance (also known as Hulten variance) refers to the relative lengths of the distal articular surfaces of the radius and ulna (mean being 0.9 mm) measured on PA radiograph of the wrist in neutral supination/pronation; draw a transverse line at the level of the lunate fossa and a second transverse line at the level of the ulnar head, and the difference indicates ulnar variance
- The radial shift (or radial width), also measured on the PA view, is the distance between the longitudinal axis through the center of the radius and the most lateral point of the radial styloid process. Both the injured and uninjured wrists are measured and compared. The measurement should be within 1 mm of each other in length.
The operations were performed either under general anesthesia or brachial block.
The patient is positioned in supine and the forearm is placed on a hand table. By abducting the shoulder, it is possible for the surgeon and the assistant to sit on either side of the hand table. The position of the limb should allow complete imaging in the frontal and sagittal planes of the distal radius.
The wrist fracture is reduced by longitudinal traction along the long axis of the forearm with the wrist in 30° of supination. The displaced distal fragments are gently manipulated under the guidance of an image intensifier for anatomical reduction. Later, as the assistant is holding the fracture in reduced position, the first 2-mm K-wire is introduced from the ulna to the carpal bones obliquely in proximal to distal direction and another K-wire passed parallel to it; this prevents radial collapse and maintains the ligamentotaxis.
Now, the K-wires are passed from the dorso-radial aspect of the distal radius fragment across the fracture into the proximal fragment of the radius under the control of the image intensifier. A second K-wire is passed through a dorso-medial aspect of the distal fragment to the proximal fragment.
In few cases of comminuted intra-articular fractures, radio-ulnar pinning is done to stabilize the articular fragments and also the DRUJ, as described by Stein. The wires are drilled across the outer cortices for better fixation. The fracture is finally checked once again for stability in AP and lateral views [Figure 2].
The K-wires are cut and bent to the outside for easy removal at a later date. A sterile dressing with a pad is applied at the pin insertion site to prevent skin irritation. The wrist is immobilized in neutral position with an above-elbow POP cast. Postoperatively, the limb is elevated for 24 h and then given a sling support. Active finger and shoulder exercises started at the earliest. Patients are discharged the next day with advice for regular follow-up.
At 1-week follow-up, wrist X-ray is taken to check for the fracture position and pin displacement.
The above-elbow POP cast is continued for 4 weeks, and the patients are advised to continue range of motion (ROM) exercises of shoulder and finger.
At 4-week follow-up, the POP cast is removed and wrist X-rays are repeated to confirm the fracture union. The K-wires are then removed under local anesthesia, and below-elbow cast is applied for another 2 weeks. After that, the POP cast is removed, and the patient is advised regular wrist ROM and hand grip exercises for another 2–4 weeks.
The results are evaluated clinically and radiologically at 3 and 6 months, respectively, using Sarmiento's modification of Lindstorm criteria [Table 1], and functional evaluation is performed by the Demerit point system of Gartland and Werley's scoring [Table 2].
|Table 2: Demerit point system of Gartland and Werley with Sarmiento et al.'s modification (functional evaluation)|
Click here to view
| Results and Discussion|| |
All the eighty cases of distal radius fractures united in an average period of 6.8 weeks. Excellent anatomical results were observed in 68 patients (85%), good results in 9 cases (11.25%), while 3 cases (3.75%) had fair results. The duration from the date of injury to the date of operation ranged from 1 to 7 days (average 2.50 days).
As per the functional assessment, seventy cases (87.5%) had excellent wrist and hand function, seven cases (8.75%) had good functional outcome, while three cases (3.75%) had fair outcome due to wrist stiffness and residual deformity [Table 3] and [Table 4].
|Table 3: Results based on Sarmiento's modification of Lindstrom criteria|
Click here to view
|Table 4: Results based on demerit point system of Gartland and Werley with Sarmiento et al.'s modification|
Click here to view
The complications encountered in our study were malunion (n = 2), subluxation of the inferior radio-ulnar joint (n = 2), Sudeck's osteodystrophy (n = 1), and posttraumatic arthritis of the wrist (n = 2).
Closed reduction and POP immobilization is still practiced in many parts due to limited facilities. However, this method has a high failure rate in unstable distal radius fracture as it cannot prevent early radial collapse and consequent complications of malunion, wrist pain, and stiffness. It is ideal for stable extra-articular distal radius fracture as described by Sarmiento.
Malalignment and poor outcome are mostly correlated with an intra-articular incongruity exceeding 2 mm. Dorsal angulation of >20° is associated with loss of wrist flexion and function. Radial shortening of >4 mm is associated with loss of forearm rotation, and radial shortening of >5 mm is associated with ulnar wrist pain.
Therefore, reasonable treatment goals for an active person include a sustained reduction with <1–2 mm of articular displacement, 10° of dorsal angulation, and 2–3 mm of radial shortening.
External fixation can maintain the radial length and radial inclination by ligamentotaxis, but cannot effectively maintain the palmar tilt. Complications as high as 55% are directly related to the pin insertion such as infection and tendon injury, as reported by Sanders et al., 1991, and Chang, 1999.
Closed reduction and percutaneous pinning is a well-known method described as early as 1976 by Kapandji. He has advocated classical double intrafocal pinning of unstable, distal radius fracture.
Nonnenmaclor and Kempfe in 1988 and later Green in 1992 have described pinning for the same fracture and found good results.
Naidu et al. in 1997 found that cross pinning of distal radius fracture is a biomechanically rigid construct in both torsion and cantilever bending forces. In distal radius fracture with unstable DRUJ, Depalma described ulno-radial pinning drilled at 45° angle, 4 cm proximal to the ulnar styloid.
Rayhack described ulno-radial pinning with fixation of DRUJ. Whereas, in comminuted unstable distal radius fractures, Py and Desmanet have advocated elastic pinning to effectively prevent the secondary displacement of fractured fragments.
In the last one decade, many young orthopedic surgeons across the world had published many articles advocating a method of open reduction and internal fixation for comminuted, intra-articular distal radius fractures. Volar and dorsal plating with newer designs of implants and techniques are found to be quite promising for giving stable fixation and functional improvement in the early postoperative period. However, long-term follow-up have shown that both percutaneous pinning and plating methods have found to be efficient in functional outcome as shown in studies by Tamara D. Rozental. Randomized Controlled Trial by Alexia Karantana, FRCS (Orth) 2013 JBJS.
| Conclusion|| |
The closed reduction and percutaneous K-wire fixation is a least invasive, safer, and effective method to maintain the reduction, prevent radial collapse during healing, and maintain the stability of the DRUJ even when the fracture is grossly comminuted, intra-articular, or unstable.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McQueen MM. Rockwood and Greens Fractures in Adults. 8th
ed., Vol. 1. Lippincott William and Wilkins: Fractures of the Distal radius and Ulna; 2014. p. 1057.
Terry Canale S, Beaty JH. Campbell's Operative Orthopaedics. 12th
ed., Part 15, Fractures and Dislocations in Adults. Mosby: Distal Radius Fracture; 2012. p. 3147.
Zemel NP. The prevention and treatment of complications from fractures of the distal radius and ulna. Hand Clin 1987;3:1-11.
Gofton W, Liew A. Distal radius fractures: Non-operative and percutaneous pinning treatment options. Orthop Clin North Am 2007;38:175-85.
Fernandez DL, Jupiter JB, editors. Fractures of the distal radius: A practical approach to management. New York, NY: Springer-Verlag; 1996.
Arora J, Kapoor H, Malik A, Bansal M. Closed reduction and plaster cast immobilization Vs. external fixation in comminuted intra-articular fractures of distal radius. Indian J Orthop 2004;38:113-7. [Full text]
Depalma AF. Comminuted fractures of the distal end of the radius treated by ulnar pinning. J Bone Joint Surg Am 1952;24 A: 651-62.
Stein AH Jr., Katz SF. Stabilization of comminuted fractures of the distal inch of the radius: Percutaneous pinning. Clin Orthop Relat Res 1975;108:174-81.
Kapandji A. Internal fixation by double intrafocal pinning: Functional treatment of nonarticular fractures of the distal radius [French]. Ann Chir Main 1987;6:57.
Rayhack JM, Langworthy JN, Belsole RJ. Transulnar percutaneous pinning of displaced distal radial fractures: A preliminary report. J Orthop Trauma 1989;3:107-14.
Nagi ON, Dhillon MS, Aggarwal S, Deogaonkar KJ. External fixators for intra-articular distal radius fractures. Indian J Orthop 2004;38:19-22. [Full text]
Ruch DS, Ginn TA. Open reduction and internal fixation of distal radius fractures. Op Tech Orthop 2000;13:138-43.
Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-articular fractures of the distal aspect of the radius: Arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg Am 1999;81:1093-110.
Meena S, Sharma P, Sambharia AK, Dawar A. Fractures of distal radius: An overview. J Family Med Prim Care 2014;3:325-32.
] [Full text]
Kim JY, Tae SK. Percutaneous distal radius-ulna pinning of distal radius fractures to prevent settling. J Hand Surg Am 2014;39:1921-5.
Srinivas C, Vadlamani K V P, Moorthy G V S, Satish P. Functional outcome of unstable distal radius fractures-Treated by closed reduction and percutaneous K-wire fixation. J Evolut Med Dent Sci 2015;4:14989-97.
Green DP. Pins and plaster treatment of comminuted fractures of the distal end of the radius. J Bone Joint Surg Am 1975;57:304-10.
Naidu SH, Capo JT, Moulton M, Ciccone W 2nd
, Radin A. Percutaneous pinning of distal radius fractures: A biomechanical study. J Hand Surg Am 1997;22:252-7.
Alexa O, Popia I. Py-Desmanet pinning in distal radius fractures. Rev Med Chir Soc Med Nat Iasi 2009;113:1155-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]