Research articles
 

By Dr. Jeewan S Prakash , Dr. Vivek David , Dr. Shiraz Bhatty , Dr. Anit Deane , Dr. Anupam Mahajan
Corresponding Author Dr. Jeewan S Prakash
CMC & Hospital, CMC & Hospital ,Ludhiana - India 141008
Submitting Author Dr. Jeewan S Prakash
Other Authors Dr. Vivek David
Deptt.Orthopedics ,CMC, CMC - India 141008

Dr. Shiraz Bhatty
Deptt. Orthopedics , BFUHS , GGS Medical College , Faridkot , Pb. IndianPunj - India 151203

Dr. Anit Deane
Deptt. Orthopedics , HIMS/ HIHT, HIMS / HIHT , Dehradoon ,Uttarakhand , - India 248140

Dr. Anupam Mahajan
Deptt. Orthopedics , CMC , CMC - India 141008

ORTHOPAEDICS

External fixation , across wrist , distal radius fractures

Prakash JS, David V, Bhatty S, Deane A, Mahajan A. Across wrist external fixation for distal radius fractures in adults. WebmedCentral ORTHOPAEDICS 2015;6(8):WMC004959

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
No
Submitted on: 09 Aug 2015 03:45:28 PM GMT
Published on: 11 Aug 2015 10:05:19 AM GMT

Abstract


Distal radius fractures , closed or open , are common upper limb injuries . Many classifications help understand them from different perspectives including correlations and comparisons between various management modalities , their outcome , complications etc . Over a period of 5 years 32 adults with 35 distal radius fractures managed with 35 across wrist external fixators were followed up for an average period of 85.9 weeks [1.65yrs] in a retrospective and prospective study.

Introduction


Distal radius fractures are common  injuries accounting for over 15%    of orthopaedic  trauma [4] .Incidence of distal radius fractures appears to be both age and gender specific with a bimodal peak of distribution[8] .The sharpest increase in its incidence  is seen in both elderly females and younger adult males [5] .Distal radius fractures in elderly are  mostly ascribed to insufficiency osteoporotic fractures [7] 

Review


Since 1814 when the commonest fracture was first described by the legendary  Abraham Colles  numerous classifications have evolved over the last two centuries .   Frykman’s [3] and alpha numeric classification by AO group are  relatively  more popular presently for their greater utility : in better understanding of distal radius fractures , their management , complications , correlations  and  comparative studies [9] .

Depending on multiple factors management option/s indicated in a particular patient may be chosen from reduction ± POP cast immobilization , percutaneous pinning ,transfixation and cast , Kapandji’s  K wire fixation , open reduction and plating , external fixation , and from  a variety of recent advances like : fragment specific fixation ,  intramedullary fixation with micro nail and dorsal nail plate , bio absorbable plates , and arthroscopically assisted repair[9] .

External fixators in general have been in vogue for over a century .  Studies trace some analogous apparatus even to Hippocrates . External fixators have been applied for preliminary or definitive management on different bones [17] . However for distal radius fractures   its application dates close to a century now .  External fixation employs the concept of continuous distraction , commonly known as  “ ligamentotaxis”  to both obtain and maintain reduction of fragments [6] . It has been seen to neutralize the compressive , torsional and bending forces across the fracture site [14].

Material & method


In a preliminary study carried out between December 2008 and November  2013 , 32 patients with 35 distal radius fractures  were  selected based on fulfilment of inclusion and exclusion criteria . Inclusion criterion was patients above 18 years of age . Exclusion criteria : pathological  fractures other than osteoporosis , and unwilling patients . Fractures were reduced and under image intensification external fixation was done . Second metacarpal was drilled with 2.5 mm drill bit , radius shaft with 3.5 mm , Schanz pins were inserted and construct was completed . In case of unstable , comminuted fractures   K wire stabilization was done prior to applying fixator . In some cases fixator was applied on ulna and  fifth metacarpal too  . In patients with compound injuries vacuum suction drain was initially applied which was full or partial vacuum suction in a randomized manner [11] .  Patients were started on rehabilitation program including physiotherapy from first post operative day.

After fixation patients were followed up at 2 weeks , 6 weeks and after fixator removal  up to 3 months minimum in prospective cases , and up to the  last follow up in retrospective cases . This was a 4 years retrospective and 1 year prospective study . In each case all relevant findings were recorded  as per protocol presented to and  approved by institutional research and ethics committee.

Observations


Initially in first part of study  36 patients with 39 across wrist fixators were enrolled . Final  follow up was done on 32 patients with 35 across wrist fixators : 3 had bilateral  involvement .

Age range was 18 to 67 years  : 25 males , 07 females  . Mean age was 41.43 ± 13.8 yrs . Male female ratio 3.5 : 1 . Majority 9 patients were between 41 and 50 yrs [28.12% ] , followed by 8 between 21 and 30 [ 25% ], together accounting for more than half of fractures as well as patients .

The commonest mode of injury was road traffic accidents [ n = 20 , 62.5%  ], followed by fall from height [ n = 08 , 25% ] . Assault , industrial accident , fall at ground level and other mode caused distal radius injuries in 1 each .

Majority 26 were open fractures [ 74.3 %] , 9 closed [25.7%] . Majority 11/35  fractures [31.4%]  were Frykman   type VIII , followed by type III [17%] . Maximum number of fractures [20 out of 35]  were  AO 23 type C – complete articular [ 57.1% ]  by  AO classification.

Majority of patients [25/32 ] were operated within the first week of presentation . Mean time  for external fixation following injuries was 4.09 days. 17 fixators were applied  across right wrists in 14 males and 3 females , 18 fixators  across left wrists in 14 males and 4 females . 3 males had bilateral across wrist fixation . A total number of 213 Schanz screws were inserted in 35 across wrist frames . 17 fixators had 8 screws each , 15 had 4 screws each , 2 with 6 pins each and 1 with 5 pins . 13 fractures were additionally stabilized with K wires  before external fixation.

All 35 fixators were of static type , rigid frame configuration . None was dynamized . None was degraded / descaled prior to removal.

Result & Analysis


32 adults with 35 distal radius fractures managed with 35 across wrist external fixators were followed up for an average period of 85.9 weeks [1.65yrs] : range 15  – 290 weeks .

Pin tract infection [PTI]  was observed in 4 out of 213 pins : 2 pins  with grade 2 infection and 1 pin each with grade 1 and 3 infection [ pin wise infection 1.8 % ]. It was seen in 4 patients out of 32 [ patient wise PTI 12.5% ],  in 4 of 35 across wrist fixators [ fixator wise PTI 11.42 % ] .

2 fixators had loosening of 1 pin each due to infection . Reflex sympathetic dystrophy was seen in a patient who was operated 10  days after injury . 1 Schanz pin was found broken  during a follow up . In a patient with neglected perilunate subluxation  avascular necrosis of lunate bone was recorded as a late complication .

During or after fixation none had metacarpal fracture , radial nerve neuropathy , post reduction swelling , compartment syndrome . No patient had  carpal tunnel syndrome , tendinous adhesion in flexor compartment , rupture of extensor pollicis longus , shoulder hand syndrome , fixator intolerance during follow up period  .

34 of 35 fractures [ ≥97%] united within 8 weeks . Maximum [68.6%] united by 6 weeks . Average union time was  6.25 ± 0.72 weeks  . One compound  fracture in a female patient with associated hypothyroidism resulted into non union [2.9%] .  Malunion was observed in 2 fractures [5.75%] ; both AO 23 complete articular type : one 23 C2 and one 23 C3 / both Frykman type VIII . Post fixator removal both had radial deviation of hand  and prominence of ulnar styloid.

Discussion


In  contradistinction to earlier popular belief of distal radius injuries being  prevalent  among elderly and females recent literature shows an increased preponderance of these  fractures in younger males [12 ,10] .One of the bimodal peaks in young males is attributable  to involvement of two wheeler riders in increasing number of road traffic accidents [ RTA’s ]  during the last decade . In the present study it contributed to and caused   most of the compound fractures too .

2 [5.75%] malunions  seen in patients with greater impaction and complete articular  comminution  caused by fall from height were  comparable with over 6% - 8% in other studies [15 ,1] . Studies reported from nil to solitary non union in 13 and 24 cases [2 ,13 ,16 ,1]. One non union was recorded among 35 fractures [2.9%] in spite of 75% compound injuries in the present series .

Conclusion


With ever growing number of road traffic accidents , specially keeping in view the increasing number of 2/3/4 wheelers on roads , compound comminuted  fractures of distal radius  pose a significant challenge to orthopaedic acumen. External fixators play a much needed  dual role in salvaging the situation by helping in management of fractures as well as soft tissue injuries  . Proper pre operative planning , intra and post operative precautions and fixator care  minimize complications .

Over the decades external fixation of distal radius  injuries has been yielding satisfactory , acceptable and comparable  long term results . Ease of applicability , relatively  shorter learning  curve , and financial considerations make it a preferred modality in an orthopaedic surgeon’s  options . 

References


1. Anderson JT , Lucas GL , Buhr BR : Complications of treating distal radius fractures with external fixation – a community experience : Iowa Ortho J : 2004 : 24 : 53 – 9

2. Edwards GE : Intra articular fractures of distal part of radius treated with small AO external fixator : J Bone Joint Surg Am : 1991 : 73 : 1241 - 50

3. Frykman G : Fractures of distal radius : a clinical and experimental study : Acta Ortho  Scand : 1967 : 108 :1 :[suppl]

4. Garcia RJ , Oda T , Shauver MJ , Chung KC : A systematic review of outcomes and complications of treating distal radius fractures in elderly : J Hand Surg Am : 2011 : 36 [5] : 824 - 835

5. Handoll HH , Vaghela MV , Madhok R : Percutaneous pinning for treating distal radius fractures in adults : Coch Data Syst Rev : 2007 : 3 : CD 006080

6. Kotwal PP , Garg B : Fractures of distal radius : current concepts : Punjab J of  Ortho : 2008 : 1 : 34 – 41

7. Kulshreshtha P , Roy T , Audige L : Dynamic versus static external fixation of distal radius fractures : a randomized study : Indian J Ortho : 2011 : 45 [6] :527 - 34

8. Mader K , Pennig D : The treatment of severely comminuted  intra articular fractures of distal radius : Strat Traum Limb Recon : 2006 :1 : 2 – 17

9. Mam M K , Prabhakar S , Prakash JS , Bali K :  Functional outcome following treatment of Colles’ fracture: A comparative study of closed reduction and plaster cast application versus Kirschner wire fixation :  WebmedCentral TRAUMA 2011 :2(1) : WMC001472

10. Nagi ON ,Dhillon MS , Aggarwal S , Deogaonkar KJ   : External fixators for intraarticular distal radius fractures : Indian J Ortho : 2004 :38 [1] : 19 -22

11.Prakash JS , Luther A ,Deodhar M : Modified radical mastectomy and wound drainage : WebmedCentral General Surgery : 2015: 6 [3]:WMC004822

12. Raju P , Kini SG : Loss of correction in unstable comminuted distal radius fractures with external fixation and bone grafting – a long term follow up study  : J Ortho Surg Res : 2011 : Pubmed PMID : 21600030 : Pubmed central  PMCID  : PMC3118123

13. Rikli DA , Kupfer K , Bodoky A : Long term results of external fixation of distal radius fractures : J Trauma : 1998 : 44 [6] : 970 - 76

14. Shin EK , Jupiter JB : Current concepts in management of distal radius fractures : Acta Chir Ortho Traumatol Cech : 2007 : 74 [4] : 233 – 46

15. Vigler M , Coert JH , Kaminsky AJ , Gilbert RS , Hausman MR : Treatment of distal radius fractures with external fixation , limited open reduction and dorsal autologous cancellous  onlay bone grafting : Hand Microsurg : 2012 : 1 [1]: 10 – 16

16. Weber SC , Szabo RM : Severely comminuted distal radius fracture as an unsolved problem : complications associated with external fixation and pins and plaster techniques : J Hand Surg Am : 1986 :11 : 157 – 165

17. Zlowodzki  M, Prakash JS , Aggarwal NK : External Fixation of Complex Femoral Fractures : International  Orthopedics :  2007 : 31 [3]: 409- 413

Source(s) of Funding


Self funded

Competing Interests


None

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1 review posted so far

Across wrist external fixation for distal radius fractures in adults
Posted by Dr. Mohit K Patralekh on 15 Apr 2016 12:44:11 PM GMT Reviewed by Author Invited Reviewers

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