|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 49-52
External fixator for distal radius fracture
Sandeep Kumar Yadav, Alok Chandra Agrawal, Rahul Ranjan, Rudra Narayan Das, Harshal Sakale, Bikram Keshari Kar
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||29-Jun-2020|
|Date of Decision||23-Jul-2020|
|Date of Acceptance||21-Aug-2020|
|Date of Web Publication||10-Sep-2020|
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Unstable distal radius fractures are challenging condition for orthopedic surgeons. Among an array of options, external fixator is a valuable instrument for the reduction and stabilization of these fractures. It is either joint spanning or joint sparing types. It may be used alone or in combination with other stabilization methods. Limited open reduction, augmentation with K-wires, early range of motion, and care of complex wounds are few of the benefits of external fixation. Moderate distraction at the carpus does not induce postoperative stiffness. Complications of external fixation are usually minor but must be anticipated and treated early.
Keywords: Distal radius, external fixator, fracture
|How to cite this article:|
Yadav SK, Agrawal AC, Ranjan R, Das RN, Sakale H, Kar BK. External fixator for distal radius fracture. J Orthop Dis Traumatol 2020;3:49-52
|How to cite this URL:|
Yadav SK, Agrawal AC, Ranjan R, Das RN, Sakale H, Kar BK. External fixator for distal radius fracture. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 21];3:49-52. Available from: https://www.jodt.org/text.asp?2020/3/2/49/294735
| Introduction|| |
Distal radius fractures are extremely common injuries faced by orthopedic surgeons on a daily basis. Its frequency is high in children and in elderly osteopenic women. In elderly patients, most of the distal radius fractures are low-energy fractures, which can be treated nonoperatively with some forms of closed immobilization. While young adults presenting with these fractures have articular comminution and displacement due to high-energy trauma, it requires open reduction and fixation. Some of the comminuted, osteoporotic low-energy fractures may be unstable, which requires operative stabilization. With an increase in life expectancy and active elderly population, operative treatment is preferred to conservative. Today, the current trend is toward open reduction and internal fixation (ORIF); still, external fixation is a valuable tool for distal radial fractures.
Etiology and pathophysiology
Distal radial fractures are commonly seen in females with the incidence of 1 in 5–7 females. The most common mode of trauma is fall on the outstretched hand. The simplest mechanism is bending force causing fracture through the metaphyseal area leaving the articular surface intact. There may be a degree of metaphyseal comminution based on the velocity of trauma. High-energy fractures can occur from various mechanisms including falls from a substantial height and motor vehicle accidents. These fractures can combine metaphyseal and articular comminution.
Patient with distal radius fracture usually presents with pain and swelling at the wrist over the fractured bone. There often is an angular deformity at the wrist, and it may assume the classic dinner-fork deformity with apex-volar angulation. Tenderness in the anatomic snuff box should also be examined for, as fractures and dislocations of the carpus may coexist with a distal radius fracture. Plain radiographs such as anteroposterior and lateral are sufficient to characterize the fracture. If there is a marked shortening of the radius or ulna, then an elbow radiograph should also be obtained to evaluate for forearm instability or elbow fractures. Computed tomography scans of the distal radius are occasionally helpful to evaluate the articular involvement of the radius. This information may help in planning operative approaches to gain better access to the most displaced and unstable fragments. The distal radioulnar joint reduction must be ensured for forearm stability.
Treatment options for the care of distal radius fractures range from operative to nonoperative methods. The method of treatment usually depends on anatomy and stability of fracture. Criteria for stability are defined by the following parameters. These parameters usually represent mechanical instability [Table 1].
|Table 1: Criteria for instability of distal radius fractures at presentation|
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Stable fractures are usually treated conservatively with reduction and cast application. A short-arm cast is sufficient for undisplaced extra-articular fracture. Displaced stable fractures are treated by closed reduction and cast application. Adequacy of reduction is debated and varies for age, handedness, and occupation of the patient. Radiographic values can be used as guidelines for the adequacy of reduction.
If closed reduction is successful in realigning the fracture, then immobilization usually is extended above the elbow. This can be a long-arm cast or sugar-tong splint. Long-arm immobilization limits the rotation of the forearm and minimizes the pull of the brachioradialis muscle.
If closed reduction does not restore or maintain alignment values, then operative intervention is warranted. Indications for operative interventions are unstable fractures, patients with lower extremity injuries who need weight-bearing through the upper extremity, associated fractures of the ipsilateral upper extremity that demand stable fixation of the radius to rehabilitate the arm, and open distal radial injuries.
Operative treatment options may involve a wide range of surgical techniques such as percutaneous pinning, external fixation, external fixation augmented with K-wires, and ORIF with plates and screws. Various combinations of the preceding methods can be used simultaneously. Indications for external fixator include younger patients with intra-articular distal radius fractures, unstable extra-articular fracture with significant comminution, failure to maintain reduction after an initial attempt of closed management in cast, open fracture with significant tissue injury and neurovascular compromise, and dysfunctional contralateral limb. The advantages of external fixators include their ease of application, access to soft tissue, and their ability to allow easy combination with other fixation techniques [Figure 1] and [Figure 2]. Its primarily goal is to maintain radial length and neutralization of various forces acting across the fracture site. The principle of external fixator is indirect reduction by ligamentotaxis. Distraction, ulnar deviation, and slight flexion can aid in reducing fragments that have capsular attachments. External fixator may reduce large peripheral fragments effectively, but impacted central (die-punch) articular pieces are hard to get in position. Flexion alone cannot restore volar tilt because of dorsal capsular ligaments are more expansible compared with volar ligaments and cannot rotate the fracture fragments effectively. Unloading the carpus is easily achieved with moderate distraction in external fixator, allowing better healing of tenuous articular fragments, osteopenic metaphyseal bone, and inserted bone graft. In recent years, the use of external fixator has decreased in frequency and seems to be falling out of favor. However, the fixator is a technique that is well proven in the orthopedic literature, and it should not become a forgotten tool.
|Figure 1: Clinical picture of distal radius fracture treated by external fixator|
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|Figure 2: Clinical picture of distal radius fracture treated by external fixator|
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Contraindications for surgical repair include patient's intolerance to general or regional anesthesia and severely osteoporotic bones that cannot accept screws or pins for fixation.
The advantage of external fixation includes the ability to stabilize the fracture at a distance from the site of injury, allow better access to the injury site for wound care or additional procedures, permit adjustment of length and alignment after application, and mobilization of the involved extremity. The rigidity of the fixator bone construct increases with crossbar proximity to the bone, pin fracture proximity, increased pin diameter, and increasing pin spread. In addition, stacking of crossbars and placement of pins in more than one plane also increase construct stiffness.
Bridging external fixation
Radiocarpal spanning external fixation is a widely used method of distal radius fracture stabilization with the help of ligamentotaxis in achieving the indirect reduction of fracture fragments mainly in stable distal radius fracture pattern with good results.
Augmented external fixation
Distal radius fractures often require the addition of K-wires to an external fixation construct to increase rigidity and stability. The main indication of addition of extra fixation device to construct if fracture reduction cannot be obtained by ligamentotaxis, or if fracture reduction requires an excessive, nonphysiologic position of the wrist.
Nonbridging external fixation
Nonbridging external fixation is a technique that allows more direct control of the distal fracture fragments, more stable fixation, and earlier improved range of motion (ROM) of the wrist mainly indicated to treat unstable distal radius fractures.
This is ideal for severe high-energy fractures that have metaphyseal and articular comminution [Figure 3]. The external fixator is used to buttress the metaphyseal fragmentation, while small plates or percutaneously placed wires are used to align and fix the articular fragments.
|Figure 3: Intraoperative picture of external fixator augmented with K-wires|
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Stabilization of the distal radioulnar joint
The importance of addressing the distal radioulnar joint cannot be overstated. Distal radioulnar joint injury with the incidence of 10% is primarily source of discomfort in distal radial fracture even after successful fracture healing. At the completion of distal radius fixation, the distal radioulnar joint should be assessed for stability and adequately to be stabilized with K-wire if needed.
Pin tract irritation and infection may occur with the use of external fixator, so daily pin care must be reinforced to patients. Caregivers responsible for the elderly or patients who are ill must also understand the importance of compliance with pin care. After the first postoperative dressing change, pin site care is begun. Daily exercises of the involved extremity are equally important [Figure 4],[Figure 5],[Figure 6],[Figure 7]. The decision for therapy is made in the first few weeks after fixation. External fixation across the wrist allows for early and free digital and elbow ROM. Forearm rotation can also be initiated if there is no distal radioulnar joint instability. Nonbridging external fixators allow additional motion at the radiocarpal joint allowing complete digital and elbow ROM at the time of fixator removal.
Complications associated with external fixation of distal radius fractures are minor pin tract infections and transient neurapraxias. However, deep infection, tendon rupture, loss of reduction, nonunion, and complex regional pain syndrome can also occur. Wrist stiffness and finger stiffness also are complications that may be associated with an external fixator.
| Discussion|| |
Distal radius fractures are common fractures that are seen in all age groups. These fractures represent a large percentage of nearly all orthopedists' clinical practice. The appropriate method for the management of distal radius fracture depends on the personality of the fracture and the patient and also the experience of the surgeon. Many fractures can be treated nonoperatively with alignment that is not ideal, but that may provide function that is adequate for a low-demand patient. As patients' functional demands and activity level increase, the necessity for anatomic reduction is more critical. An external fixation is a tool that can help in achieving this required reduction. The use of an external fixator is often adequate by itself or can be combined with other fixation methods. One of the advantages of standard external fixators is the flexibility it provides with the choice of pin placement location. Pins may be placed out of the zone of injury, may be extended to the ulna to stabilize the DRUJ, or extended to different areas of the hand to fix associated injuries.
| Conclusion|| |
External fixation can be used for various injuries about the wrist and in combination with other fixation methods.
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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]