|Year : 2021 | Volume
| Issue : 1 | Page : 3-8
Functional outcome of intra-articular fracture of distal end of radius treated by open reduction and internal fixation with locking distal radius system
Kumar Chandan1, Ravi Kumar2, Rahul Ranjan3, Rohit Amar4
1 Subdivisional Hospital, Bagaha, West Champaran, India
2 Senior Resident, Department of Orthopaedics, NMCH, Darbhanga, Bihar, India
3 Assistant Professor, Department of Orthopaedics, DMCH, Darbhanga, Bihar, India
4 Senior Resident, Department of Orthopaedics, AIIMS, Patna, Bihar, India
|Date of Submission||07-Dec-2020|
|Date of Decision||02-Jan-2021|
|Date of Acceptance||24-Jan-2021|
|Date of Web Publication||26-Apr-2021|
SDH, Bagaha, West Champara, Bihar
Source of Support: None, Conflict of Interest: None
Background: There is alays been a dilemma in the treatment of intra-articular distal radius fracture (DRF). Close reduction and cast application gives satisfactory result in extra-articular Distal Radial Fractures but there is alays been debate beteen open and close reduction in the intra-articular fracture. Hence, this study is to evaluate effectiveness of open reduction and internal fixation of intra-articular Distal Radial Fractures. Materials and Methods: This prospective observational study as carried out in the department of orthopedics, All India Institute of Medical Sciences, Patna, from August 2016 to March 2019. The patient ere included ho qualified the inclusion criteria. The included patient ere treated by open reduction and internal fixation ith distal radius plate. The outcome as assessed in term of anatomical variables (radial dorsal tilt, length, and angle), residual deformity, and subjective result evaluation using Sarmiento's modification of Lind Storm criteria. The complication if any as also noted. Results: This study included 30 cases of intra-articular DRF, 12 fractures of AO type B, and 18 fractures of AO type C. Anatomically, 24 patients (80%) had excellent restoration of anatomy, 4 patients (13%) had good restoration and 2 had fair (7%) restoration of anatomy. 93% of patients had excellent to good alignment of fragments and good reduction could not be achieved in 7% of patients resulting in fair or poor results. Functionally, 22 patients (73%) had excellent, 5 good (17%), and 3 patients had fair (10%) restoration of functions. Conclusion: Open reduction and internal fixation ith volar plate and scres fixation gives satisfactory (good to excellent) result in intra-articular Distal Radial Fractures.
Keywords: Functional outcomes, intra-articular distal radius fracture, open reduction and internal fixation
|How to cite this article:|
Chandan K, Kumar R, Ranjan R, Amar R. Functional outcome of intra-articular fracture of distal end of radius treated by open reduction and internal fixation with locking distal radius system. J Orthop Dis Traumatol 2021;4:3-8
|How to cite this URL:|
Chandan K, Kumar R, Ranjan R, Amar R. Functional outcome of intra-articular fracture of distal end of radius treated by open reduction and internal fixation with locking distal radius system. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 May 6];4:3-8. Available from: https://www.jodt.org/text.asp?2021/4/1/3/314643
| Introduction|| |
Distal radius fracture (DRF) is the most common Fracture of upper limb constituting 16% of all fractures. It has trimodal distribution, one in age 5–14 years, second in male aged more than 50 years and maximum in female aged more than 40 years due to decreased bone mineral density after menopause due to estrogen ithdraal.
Most of DRF are extra-articular in elderly due to lo energy trauma hereas intra-articular in younger patient due to high energy trauma. Risk factors for DRF are decreased bone mineral density, female sex, ethnicity, hereditary, and early menopause.
The method of management of DRF has changed dramatically over the previous to decades from almost universal use of cast immobilization to a variety of highly sophisticated operative intervention.
Functional impairment is seen in up to 26% of elderly patients even after 1 year of conservative management. Fernandez, Trumble, and others recorded that a orse functional outcome is correlated ith as little as 1 mm of articular incongruity.,
The advantage of stable internal Fixation in distal radial fractures is immediate mobilization and hence improved final functional arc of movement. To treat these fractures optimally, e must understand the extent of displacement, the degree of articular disruption,, the stability and reducibility of each fracture along ith careful assessment of concurrent injury to adjacent nerves, tendons, or carpal structures.
For an optimal result an accurate restoration of skeletal anatomy and most importantly supervised rehabilitation by skilled physiotherapy is required. The best method of obtaining and maintaining an accurate restoration of articular anatomy, hoever, remains a topic of considerable controversy.
This study evaluates the anatomical and functional outcome of open reduction and volar locking plate fixation in distal radial fractures.
| Materials and Methods|| |
This as an observational study of 30 patients 30 patients age 20–70 years having closed intra-articular DRF ho ere admitted to the Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Patna, from August 2016 to March 2019 ere included for the study after qualifying inclusion criteria and obtaining their informed ritten consent.
- Male and female of age 20–70 years ith intra-articular fracture of distal end of radius ho have given consent for the procedure
- Patients ho are medically fit for surgery
- Patients ho are medically unfit for surgery
- Patient ith multiple fractures, severe comminution, associated carpal injuries and associated ith head injury
- Patients not illing for surgery
- Male and female <20 years or >70 years.
Method of collection of data
Data collection for patients ith intra-articular fracture of the distal end of the radius are as follos. DRF classification ill be carried out by AO classification. Open/close reduction and internal fixation in surgical management ould be the standard procedure. The patient as folloed up at 6, 12, and 24 eeks of surgery. The anatomic evaluation as done in terms of residual dorsal tilt, radial length, and radial angle. The clinical outcome ere recorded in terms of prominent ulnar styloid, residual dorsal tilt, and radial deviation of hand. Final functional outcome as evaluated subjectively in terms of excellent, good, fair and bad. The complications if any ere also recorded in details.
Data ere analyzed by Pie Charts and Bar Diagrams methods.
| Results|| |
The study comprised a total of thirty patients ith intra-articular fractures of the distal radius presenting to AIIMS, Patna from August 2016 to March 2019.
Age and sex distribution
The mean age of the patients taken up for the study as 42.6 years ith the youngest patient being 20 years and the oldest being 70 years. There ere 10 male patients (33%) and 20 female patients (67%) [Table 1] and [Graph 1] and [Graph 2].
Mode of trauma and type of fracture
The mode of injury as fall in 18 cases (60%), road traffic accident in 12 cases (40%). Telve fractures as AO type B and 18 fractures as AO type C [Table 2].
Ulnar styloid fracture
Ulnar styloid as fractured in 9 cases (30%) and intact in 21 cases (70%). The fracture as managed expectantly.
Time lapse beteen injury and surgery
Most of the cases ere operated on the same day or the next day of attending the OPD or the emergency. Out of the 30 cases, 24 cases (80%) ere operated ithin a eek of injury and 6 cases (20%) beteen 8 and 14 days. The delay, if any as on the part of the patients presenting late.
Duration of follo up
The average duration of follo-up as 39.6 eeks ith a minimum of 24 eeks and a maximum of 58 eeks [Table 3].
Residual dorsal tilt [Graph 3]
The dorsal tilt (from a neutral of 0°) of the distal radial articular surface varied from 4° to 26°. The dorsal tilt decreased from an average of 13° before the reduction to an average of 0.6° at the most recent follo-up evaluation. The dorsal tilt could be adjusted postoperatively to the anatomical palmar tilt or at least a neutral angle in 25 patients (83%), hile the dorsal tilt could not be restored even to a neutral angle in 5 patients (17%). Out of these 5 patients, 3 had an AO type C fracture hile 2 had an AO type B fracture. At the final follo-up, one patient (3%) had some loss of correction of dorsal tilt. This patient had a comminuted intra-articular fracture (AO type C). In 97% of the patients, the correction of tilt achieved at surgery as maintained till healing.
Radial length [Graph 4]
The radial shortening varied from 4 mm to 26 mm. It decreased from an average of 11 mm before the reduction to an average of 0.65 mm postoperatively and 0.8 mm at the most recent follo-up. In 1 patient (3%) there as 4 mm of the collapse of radial length from the immediate postoperative to the final follo-up period. This patient had AO type C fracture. The postoperative radial duration of 97% of the fractures as preserved before the union.
Radial angle [Graph 5]
The radial inclination loss ranged beteen 0° and 20°. It from an average of 12.1° before reduction to an average of 0.9° postoperatively to 1° at the final follo-up. In 1 patient (3%) there as a loss of 3° of correction of radial inclination. This patient had an AO Type C fracture.
Clinical and functional evaluation
- Prominent ulnar styloid– 3 patients (10%)
- Residual dorsal tilt– 3 patients (10%)
- Radial deviation of hand– 0 patients (0%).
Subjectively, out of 30 patients, 21 patients (70%) had excellent, 7 patients (23%) had good, and 2 patients had fair (7%) results [Table 4].
Objective evaluation [Table 5]
The objective evaluation included loss of dorsiflexion, loss of palmar flexion, loss of ulnar deviation, loss of radial deviation, loss of supination, loss of pronation, loss of circumduction, pain at distal radioulnar joint and grip strength.
Complications [Table 6]
The major complications noted ere joint stiffness, paresthesia. None of the patients had reflex sympathetic dystrophy, impingement of tendons and median nerve compression.
Results of anatomical score of healed fracture
The scoring as done according to Sarmiento's modification of Lind Strom Criteria [Graph 6].
Anatomically 24 patients (80%) had excellent restoration of anatomy, 4 patients (13%) had good restoration and 2 had fair (7%) restoration of anatomy. 93% patients had excellent to good alignment of fragments and the good reduction could not be achieved in 7% of patients resulting in fair or poor results.
Functional end result of healed fracture
The scoring of healed fracture as done according to the demerit point system of Gartland and Werley ith Sarmiento et al. modification [Graph 7].
Functionally 22 patients (73%) had excellent, 5 good (17%), and 3 patients had fair (10%) restoration of functions. Residual displacement and poor patient compliance ere associated ith poor function.
| Discussion|| |
Melone is one of the proponents of open reduction of displaced intra-articular fracture of the distal radius. He has proved in his series the maximum functional recovery folloing such fractures is dependent to a great extent on the accurate and stable restoration of articular surfaces.
Ruch and Papadonikolakis in the year 2006 revieed retrospective results of DRF s treated ith open reduction and internal fixation of a multifragmentary intra-articular DRF s ith either a nonlocking volar or dorsal plate-locking or non locking conducted a that functional outcome in terms of Gartland and Werley scores as better in the volar plating group.
Knirk et al. conducted a retrospective study of intra-articular fracture distal end radius in young adults. Treatment included the application of a cast, insertion of pins and application of plaster cast, external fixation and open reduction, and internal fixation. A follo-up of 6.7 years as done and 26% ere rated as excellent, 35% as good, 33% as fair, and 6% as poor.
Kapoor et al. studied displaced intra-articular fracture of the distal end of the radius in adults after classifying according to Frykmans and AO classification. They concluded that operative treatment generates significantly better anatomical and functional results than closed reduction and casting.
Fittousi and Cho and others studied displaced intra-articular fracture distal end of radius ho ere treated ith plates and scres. According to the updated method of Green and O'Brien, 26% had a high rate of complications and 82% had decent or excellent performance. 59% had strong performances.
Chen et al. (2017) performed bi-columnar plating for unilateral DRF on 30 patients. There ere 3 cases of AO type A fracture, 5 of AO type B, and 16 cases of AO type C fracture, and evaluated using the modified Gartland and Werley scoring system, results ere excellent in 14 patients, good in 7 patients, and fair in 3 patients. The average correction of deformity as 4.1 mm for radial height, 7.6° for radial inclination, and 20.7° for volar tilt. They concluded MIPO ith a dorsal approach is a feasible option for the management of displaced DRF s and can result in favorable surgical outcomes.
Marlo et al. conducted a retrospective study comparing clinical advantage beteen fixed angle volar locking plate and variable angle in 107 patients of distal end radius fractures and they concluded that complex and unstable fractures of distal radius can be optimally managed ith volar locking plates.
Kundu et al. performed volar plating for intra-articular DRF ith AO TYPE B3, B4, and C pattern and outcome as analyzed A/C to Gartland and Werley demerit score system, results of range of rist movement as very satisfactory.
Gill et al. performed a comparative study beteen volar plating and external fixator on 60 patients ith 30 in each group and found that palmer tilt, radial length, and radial inclination ere significantly greater in the volar plate group. And concluded Open reduction and internal fixation ith plate fixation had better functional outcome ith less complication rate than close reduction and external fixation in the management of intra-articular fractures of distal end radius.
McCamley et al. performed a study on 180 patients having intra/extra articular fracture distal radius for comparison beteen volar locking plating and other means of treatment. They concluded that Volar Locking Plate is better to maintain fracture reduction over 12 eeks compared to alternative fixation methods.
Our study included 30 cases of intra-articular DRF, 12 fractures of AO type B, and 18 fractures of AO type C. The mode of injury as fall in 18 cases (60%), road traffic accident in 12 cases (40%). There ere 10 male patients (33%) and 20 female patients (67%). The mean age of the study patients as 42.6 years, ith 20 years for the youngest patient and 70 years for the oldest. Out of the 30 cases, 24 cases (80%) ere operated on ithin a eek of injury and 6 cases (20%) beteen 8 and 14 days. The average duration of follo-up as 39.6 eeks ith a minimum of 24 eeks and a maximum of 58 eeks. In our study, e did not have any intraoperative complications. The average hospital stay period as 3 days. All patients ere folloed up at 1.5, 3, 4.5, and 6 months, respectively. The follo-up period for patients as a minimum of 6 months and a maximum of 1 year. Subjectively, out of 30 patients, 21 patients (70%) had excellent, 7 patients (23%) had good, and 2 patients had fair (7%) results. Anatomically 24 patients (80%) had excellent restoration of anatomy, 4 patients (13%) had good restoration and 2 had fair (7%) restoration of anatomy. Thus 93% of patients had excellent to good alignment of fragments and good reduction could not be achieved in 7% of patients resulting in fair or poor results. Functionally 22 patients (73%) had excellent, 5 good (17%), and 3 patients had fair (10%) restoration of functions. Residual displacement and poor patient compliance ere associated ith poor function.
| Conclusion|| |
A 93% anatomical and 90% functional, excellent to good results, suggest that stabilizing the fracture fragments ith volar plate and scres in the management of DRF is an efficient ay to sustain the decrease before the union and prevent the fracture fragments from collapsing, even though the fracture is grossly comminuted/intra-articular/unstable and/or the bone is osteoporotic.
The technique emphasizes that open reduction and internal fixation ith volar plating have excellent functional outcomes ith minimal complications thus proving that it is the prime modality of treatment for DRFs. The procedure is applicable for AO types B and C fractures of the distal radius, in young patients ith a good bone stock as ell as in elderly osteoporotic patients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ruch DS, McQueen MM. Distal radius and ulna fractures. In: Bucholz RW, Heckman JD, Court-Bron CM, editors. Rockood & Green's Fractures in Adults. 8th
ed. Philadelphia: Wolters Kluer, Lippincott Williams and Wilkins; 2010. p. 830.
Court-Bron CM, Caesar B. Epidemiology of adult fractures: A revie. Injury 2006;37:691-7.
Masud T, Jordan D, Hosking DJ. Distal forearm fracture history in an older community-delling population: The Nottingham Community Osteoporosis (NOCOS) study. Age Ageing 2001;30:255-8.
Lester GE, Anderson JJ, Tylavsky FA, Sutton WR, Stinnett SS, DeMasi RA, et al
. Update on the use of distal radial bone density measurements in prediction of hip and Colles' fracture risk. J Orthop Res 1990;8:220-6.
Madhok R, Green S. Longer term functional outcome and societal implications of upper limb fractures in the elderly. J R Soc Health 1993;113:179-80.
Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg (America) 1991;16:375-84.
Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19:325-40.
Melone CP Jr. Articular fractures of distal radius. Orthop Clin North Am 1984;15:217-36.
Melone CP Jr. Distal radius fractures: Patterns of articular fragmentation. Orthop Clin North Am 1993;24:239-53.
Simic PM., Weiland AJ. Fractures of distal aspect of the radius: Changes in treatment over past to decades. J Bone Joint Surg (Am) 2003;85-A: 552-64.
Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop Relat Res 1986;202:103-11.
Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intraarticular distal radius fractures. J Hand Surg (Am) 2006;31:9-16.
Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68:647-59.
Kapoor H, Ashoo A, Dhaon BK. Displaced intra-articular fractures of the distal radius: A comparative evaluation of results folloing closed reduction, external fixation and open reduction ith internal fixation. Int J Care Inj 1991;31:75-9.
Fittousi F, Cho SP. treatment of displaced intra-articular fractures of the distal end of the radius ith plates. J Bone Joint Surg 1997;79A: 1303-12.
Chen AC, Chou YC, Cheng CY. Distal radius fractures: Minimally invasive plate osteosynthesis ith dorsal bicolumnar locking plates fixation. Indian J Orthop 2017;51:93-8.
] [Full text]
Marlo WJ, Singhal R, Dheerendra S, Ralte P, Fischer J, Waseem M. Distal radius volar locking plates: Does a variable angle locking system confer a clinical advantage? Acta Orthop Belg 2012;78:309-16.
Kundu AK, Wale N, Phuljhele S, Ghritlahre D, Gurudatta HS. Intra articular distal radius fractures and volar plate fixation: A prospective study. Int J Res Orthop 2017;3:589.
Gill SP, Raj M, Singh S, Rajpoot A, Mittal A, Yadav N. Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study. J Orthop Traumatol Rehabil 2019;11:31. [Full text]
Fractures of Distal Radius: A randomized controlled Trial of 180 patients comparing volar locking plates and alternative fixation methods. J orthop Trauma and Treatment 2016, 5: 308. Doi 10. 4172/ 2167 – 1222:1000308.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]