Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 5  |  Page : 596-602  

Comparative analysis of external and internal fixation in lower radial articular fractures


1 Department of Orthopedics, Burdwan Medical College, Burdwan, India
2 Department of Orthopedics, RG Kar Medical College, Kolkata, India
3 Department of Physiology, Burdwan Medical College Burdwan, (Affiliated to West Bengal University of Health Sciences) West Bengal, India
4 Department of Pathology, Burdwan Medical College Burdwan, (Affiliated to West Bengal University of Health Sciences) West Bengal, India

Date of Web Publication10-Sep-2014

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713102, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.140420

Rights and Permissions
  Abstract 

Background: The treatment of distal radial articular fracture is still controversial despite continue refinement in the treatment. Objectives: The study was done to compare the functional as well as radiological outcome of treatment of distal radius by the external fixation frame and internal fixation by plating. Materials and Methods: This prospective study was conducted in a tertiary care hospital of eastern India on 40 patients with distal radial articular fractures after taking clearance from the Institutional Ethical committee and informed consent of the patients. All cases of distal radial articular fractures were randomly assigned by computerized methods to two different treatment protocols: a) external fixation application and b) internal fixation application. The fractures were classified with Fernandez and Jupiter classification. Results: In the present study excellent results were obtained in all Fernandez type I fractures both in external fixation and internal fixation group. Excellent to good results were obtained in all Fernandez type II fractures both in external fixation and internal fixation group. In external fixation group, out of six type II fracture four (66%) had excellent result and two (33%) had good result. In internal fixation group out of nine type II fracture five (55%) had excellent result and four (45%) had good result. Mixed results were obtained in all Fernandez type III fractures (16) both in external fixation and internal fixation group. In external fixation group, out of eight type III fracture 3(38%) had excellent result, four (50%) had good result and one (12%) had fair result. In internal fixation group out of eight type III fracture six (75%) had excellent result and two (25%) had good result. The results indicate that in type III fractures internal fixation is a better option. Fair to poor results were obtained in Fernandez type V (3) fractures both in external fixation and internal fixation group. Results may be improved by early bone grafting and possible external fixation and internal fixation (combined fixation). Out of thirteen patients with biplanar JESS, eight (61%) had excellent results compared to uniplanar UMAX in which out of seven, patients three (42%), had excellent results. Conclusions: External fixation and volar buttress plate produce almost equivalent functional results in distal radial articular fractures, with volar buttress plate having better anatomical results than external fixation in the present study. With careful assessment, good surgical technique and early mobilization, the distal radial articular fractures can be effectively managed with predictably good outcome using either external fixation or volar buttress plate. Volar buttress plate can be more effective in type III Fernandez fractures, while UMAX is a better option for Fernandez type II fractures.

Keywords: Distal radius fracture, treatment, internal versus external fixation


How to cite this article:
Ghosh S, Dutta S, Chaudhuri A, Datta S, Roy DS, Singh AK. Comparative analysis of external and internal fixation in lower radial articular fractures. Med J DY Patil Univ 2014;7:596-602

How to cite this URL:
Ghosh S, Dutta S, Chaudhuri A, Datta S, Roy DS, Singh AK. Comparative analysis of external and internal fixation in lower radial articular fractures. Med J DY Patil Univ [serial online] 2014 [cited 2020 May 27];7:596-602. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/596/140420


  Introduction Top


Almost 200 years have been passed since Colles (1814) described a fracture of distal end of radius and this fracture still remains one of the most challenging fractures. [1],[2],[3] Fracture of the distal end of radius represents the most common fracture of the upper extremity. There are three main peaks of fracture distribution; children aged 5-15, and males below 50 years of age and women over 40 years of age. The treatment of distal radial articular fracture is still controversial despite continue refinement in the treatment. Intra-articular fracture occur mainly in young individuals with good bone stock as a result of violent compression forces and are associated with substantial articular and periarticular tissue damage. If these fractures are allowed to collapse radial shortening, angulation and articular incongruity may cause permanent deformity and loss of function. The degree of disability after a distal radius fracture has been shown to correlate with the amount of residual deformity. The deformity has significant influence on the amount of motion. The traditional management with plaster of Paris cast immobilizes the wrist in flexed position, which is contrary to the functional position of the hand. This result delayed and incomplete rehabilitation in most of the cases. The patient looses significant strength and power and finds difficulty in day-to-day life activity. [1],[2],[3],[4]

Fractures of the distal end of radius really have become the focus of tremendous interest with remarkable changed area of fracture management. In the present study Fernandez and Jupiter classification was used to classify distal radius fracture. The study was done to compare the functional as well as radiological outcome of treatment of distal radius by the external fixation frame and internal fixation by plating.


  Materials and Methods Top


This prospective study was conducted in a tertiary care hospital of eastern India on 40 patients with distal radial articular fractures after taking clearance from the Institutional Ethical committee and informed consent of the patients. All cases of distal radial articular fractures who presented to the department of orthopedic surgery in a time span of 1 year were randomly assigned by a computerized method to two different treatment protocols: a) external fixation application and b) internal fixation application. The fractures were classified with Fernandez and Jupiter classification [5] on the basis of finding of A/P and lateral radiograph of the wrist including hand [Figure 1].
Figure 1: Pre-Operative X-ray

Click here to view


The criteria of inclusion were: All patients aged 18-65 years with displaced Type II, III and V fractures less than 7 days old or type I fractures not reduced according to the acceptable criteria were included.

The exclusion criteria were open fractures, Fernandez type IV fractures, type I fractures well reduced with closed reduction, associated neurovascular injury, associated life threatening injuries, fractures more than 7 days old.

Treatment: Thorough clinical assessment for arterial/neural injuries was made and anteroposterior and lateral view of wrist was taken. After admission initial fracture reduction was done to reduce pain and swelling and patient was kept on below elbow POP slab. Patients were randomly allocated using computerized randomization method into two groups.

Group A: Group A consisted of 20 patients who had been treated with Universal Mini External Fixator (UMAX) or Joshi's External Stabilization System (JESS). [6],[7] All cases were operated under regional anesthesia [Figure 2] and [Figure 3].
Figure 2: Post-Operative X-ray of plating

Click here to view
Figure 3: Pre-operative and Post-Operative X-ray of JESS

Click here to view


Technique: After antiseptic draping and dressing closed reduction was first done using a so-called ''hand shake grip'' to distract the fracture while counter traction was applied proximal to elbow by the assistant. The surgeon's contralateral thumb was used to restore the normal volar tilt, radial tilt and radial height. The reduction was then evaluated in AP and lateral plane under image intensifier. Once radial length, volar tilt, articular congruity and inclination had been restored, at least up to the acceptable level, the UMAX/JESS frame was applied according. Supplemental K-wires using power drill were required in three cases in which the above reduction criteria was not fulfilled. These K-wires were inserted through the radial styloid process and dorsal ulnar surface of radius under image guidance.

Pin Placement

Forearm pin: Two 3.5 mm Schanz pin/2.5 mm K-wires were inserted under direct vision through both cortices into the shaft of the radius proximal to the fracture site, keeping the arm in midprone position. Care was taken to avoid the interval between the Extersor Carpi Radialis Longus (ECRL) and brachioradialis in which radial sensory nerve runs. Instead the interval between Extensor Carpi Radialis Longus (ECRL) and Brevis (ECRB) were identified and ECRL was retracted palmarly and ECRB dorsally to expose the radial shaft by making 2 small (1-2 cm) incisions along the radial border of the forearm in the area of planned pin placement.

Adding percutaneous pins to provide additional stability is one of the earliest forms of internal fixation. For the larger segments, 0.62-inch Kirschner wires (K-wires) may be used, while 0.45-inch K-wires may be used to fix the intermediate column and for subchondral fragment support. The radial styloid is pinned to the proximal shaft in a reduced position. Once the lateral cortex is reconstituted, the intermediate column (lunate facet) is pinned from dorsal ulnar to proximal radial. Finally, the central impaction fragments can be supported using subchondral transverse wires.

In UMAX, Schanz pins were placed after drilling with 2.5 mm drill bit according to AO principle. In JESS, forearm was fixed in both radial and ulnar side to stabilize both radial and ulnar column.

Metacarpal pin: The distal pins/K-wires were inserted primarily into the radial surface of the index metacarpal; the first pin was placed into the metaphyseodiaphyseal junction involving the second and third metacarpal, the more distal pin/K-wire was directed by the configuration of the fixator clamps. In JESS frame, we used 1.5-1.8 mm K-wire in the ulnar aspect of fifth metacarpal involving fourth and fifth metacarpal.

While using supplemental K-wires the first K-wire was inserted through the tip of the radial styloid process just dorsal to the first extensor compartment, in anatomical snuff box proximal to the radial artery, aiming to cross the fracture site in both plane under image intensifier control that require about 45° angle with the long axis of the radius on the posteroanterior and 10° dorsally on the lateral view. Both the K-wires were advanced to just penetrate the cortex of the proximal fragment. The UMAX/JESS frame was applied to the proximal and distal pins and distraction/fixator applied to achieve reduction and again checked under image intensifier. Out of 20 patients in this group, we used uniplanar UMAX without hinge at wrist in seven (7) cases, biplanar JESS without hinge at wrist in eleven (11) cases and biplanar JESS with hinge at wrist in two (2) cases.

Group B: Group B patients were treated with volar buttress plate. All cases were operated under regional anesthesia.

Technique: After antiseptic draping and dressing closed reduction was first done using a so called ''hand shake grip'' to distract the fracture. Reduction is checked under image intensifier. The wrist was opened through volar approach -The volar surface of distal radius was accessed through the interval between flexor carpi radialis (FCR) tendon and radial artery. A longitudinal incision was made along the forearm, starting from distal radial crease overlying the FCR tendon. After dissection through subcutaneous tissue, the FCR tendon sheath was readily visible. The radial artery with its venae comitantes, which lie immediately radial to the FCR tendon, were identified and tagged. The FCR sheath was opened, avoiding the palmar cutaneous branch of median nerve, just ulnar to FCR tendon. The tendon retracted to the ulnar side to reveal the floor of the tendon sheath and protect the median nerve and its palmar cutaneous branch. The floor of the tendon sheath was incised longitudinally to expose the distal end of pronator quadratus muscle. More proximally, flexor digitorumsuperficialis (FDS) to the index finger and flexor pollicislongus (FPL) tendons were encounted overlying the pronator quadratus muscle. The flexor digitorumsuperficialis (FDS) was swept ulnarly and the flexor pollicislongus (FPL) was mobilized radially for better visualization of the pronator quadratus. Then the pronator quadratus muscle was elevated subperiosteally to expose distal end of radius with articular surface, capsule and the carpus. Intra-articular fragments were reduced under vision. The palmar surface of distal radius is flat so a flat implant on to the plamer surface of distal radius was applied to correct any malrotation of the fracture fragments. Sometimes they were temporary fixed with K-wires. The reduction was then evaluated in AP and lateral plane under image intensifier. A 3.5 mm volar buttress plate was placed and seen under image intensifier. Then the plate was fixed with 3.5 mm screws. Wound was closed in layers. A compressive bandage and POP slab was done.

Post Operative Management

Group A

Meticulous pin site care was taken under regular cleaning with 70% alcohol (spirit). Pin site infection and pin site loosening were assessed continuously. Skiagrams were taken at first postoperative day, 6 weeks and 10 weeks to assess progression of union and maintenance of alignment. The Fixator was kept in place between 6-8 weeks.

Group B

All patients were kept in compressive bandage and POP slab for 10-14days. Patients were instructed for active finger and shoulder movement in that period. Dressing was changed at 48 h. Stitches were removed on 12-14 days. Then gradual range of motion exercise of wrist started. X-rays were taken at first postoperative day, 6 weeks and 10 weeks to assess progression of union. Patients were discharged from hospital after stitch removal.

Shoulder exercises of Codman type, six pack hand exercise and were started from the second postoperative day in both groups of patients.

Follow Up

Patients of group A and B were followed up at 3, 6, 9 weeks and 3 months. Patients were evaluated both clinically and radiologically.

Measurement was done on the basis of Van der Linden and Ericson method. Dorsal tilt was expressed as the number of degrees from neutral position and taken as negative. Volar tilt was taken as positive. Malunion was defined as more than 15 deg of residual tilt or >3 mm radial shortening compared to the opposite normal wrist.

The subjective, objective and radiographic findings were quantified by the demerit system of Gartland and Werley as modified by Sarmiento et al. The outcome of each fracture was graded as excellent, good, fair and poor. Demerit point system was used to evaluate end result of healed distal radius fractures [Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8] and [Figure 9].
Figure 4: Follow up picture of functional outcome of plating

Click here to view
Figure 5: Follow up picture of functional outcome of plating

Click here to view
Figure 6: Follow up picture of functional outcome of JESS

Click here to view
Figure 7: Follow up picture of functional outcome of JESS

Click here to view
Figure 8: Follow up X-ray of case treated with external fixation

Click here to view
Figure 9: Follow up X-ray of case treated with internal fixation

Click here to view



  Results Top


Mean follow up period for patients randomly allocated to group A in this study was 63.4 weeks with a range of 53 weeks to 78 weeks and follow up in group B was 58.5 weeks with a range of 20 weeks to 72 weeks. The mean age in group A patients was 42.7 years with a range of 20 to 64 year. The mean age in group B patients were 38 years with a range of 18 to 60 years and most of the patients are in the age group of 31-50 years. The mean operative-injury interval in group A was 3.4 days with a range of 1 to 6 days. The mean operative-injury interval in group B was 3.2 days with a range of 1 to 6 days. There were 8 females in group A while 9 females in group B. There were 12 males in group A while 11 males in group B.

The mean range of motion in group A patients at the most recent follow up was 73.2 degrees palmar flexion (range 50-80 degrees) ,67.2 degrees dorsiflexion (range 46-70 degrees), 70.2 degrees of supination (range 64-80 degrees), 72.4 degrees of pronation (range 62-86 degrees), 23.6 degree of ulnar deviation (range 12-28 degrees), 12 degree of radial deviation (range 8-16 degrees). Combined dorsiflexion - palmarflexion arc more than 120 degrees was achieved in 16(80%) out of 20 patients. The mean range of motion in group B patients at the most recent follow up was 67.4 degrees palmar flexion (range 54-76 degrees), 60.2 degrees dorsiflexion (range 54-70 degrees), 74.6 degrees of supination (range 68-82 degrees), 75.2 degrees of pronation(range 64-86 degrees), 20 degree of ulnar deviation(range 10-26 degrees), 12.4 degree of radial deviation (range 6-14 degrees). Combined dorsiflexion - palmarflexion arc more than 120 degrees was achieved in 19 (95%) out of 20 patients. In both groups dorsiflexion was more restricted than palmar flexion.

At the most recent follow up examination according to modified Sarmiento Gartland and Werley (Demerit point system) in group A (n = 20) 11 (55%) wrists were graded as excellent, 7 (35%) wrists were graded as good, 1 (5%) wrists were graded as fair, 1 (5%)wrists were graded as poor. Out of 11 excellent results 8 had biplanar fixator and 3 had uniplanar fixation. In group B (n = 20) 12 (60%) wrists were graded as excellent, 6 (30%) wrists were graded as good, 2 (10%) wrists were graded as fair, no wrists were graded as poor.

In Group A the distal radial articular fracture was reduced to neutral to less than 15 degree volar tilt in all patients except two. Overall mean volar tilt was 4.8 degree and range of-2.5 to 8.5 degree. In Group B all patients achieved volar tilt between neutral to 15 degree. Overall mean volar tilt was 6.34 degree and range of 2-10.5 degree. The significance of difference in means in to groups was statistically significant with P-value <0.05. In Group A the mean radial inclination at the recent follow up was 18.35 degrees with a range between 16-21 degrees. In Group B the mean radial inclination at the recent follow up was 21.55 degrees with a range between 20-23 degrees. The significance of difference in means in to groups was statistically significant with P-value <0.05. In Group A the mean radial length at the recent follow up was 8.67 mm with a range between 7.4-9.9 mm. In Group B the mean radial length at the recent follow up was 11.51 mm with a range between 10.8-12 mm. The significance of difference in means in to groups was statistically significant with P-value <0.05. In Group A the mean ulnar variance at the recent follow up was -1.05 with a range between-0.9 to-1.2. In Group B the mean ulnar variance at the recent follow up was +0.41 with a range between-0.05 to +1.6. The significance of difference in means in to groups was statistically significant with P-value <0.05. The overall postoperative complication in Group A was 25%. Two had pin tract infection, which was treated by oral antibiotics. No case required fixator removal or change of pins. One patient had hypoaesthesia along the sensory distribution of radial nerve but recovered spontaneously after 6 months. Two patients lost reduction during first 6 months of their follow up. The overall postoperative complication in Group B was 30%. Two had tendon irritation, which was improved with physiotherapy. One case required implant failure required removal of plate at 3 months. One patient had hypoaesthesia along the distribution of the palmar cutaneous branch of median nerve but recovered spontaneously after 3 months. Two cases lost the reduction due to postoperative collapse.


  Discussion Top


In the present study excellent results were obtained in all Fernandez type I fractures both in external fixation and internal fixation group. Excellent to good results were obtained in all Fernandez type II fractures both in external fixation and internal fixation group. In external fixation group, out of six type II fracture four (66%) had excellent result and two (33%) had good result. In internal fixation group out of nine type II fracture five (55%) had excellent result and four (45%) had good result. Mixed results were obtained in all Fernandez type III fractures (16) both in external fixation and internal fixation group. In external fixation group, out of eight type III fracture three (38%) had excellent result, four (50%) had good result and one (12%) had fair result. In internal fixation group out of eight type III fracture six (75%) had excellent result and two (25%) had good result. The results indicate that in type III fractures internal fixation is a better option. Fair to poor results were obtained in Fernandez type V (3) fractures both in external fixation and internal fixation group. Results may be improved by early bone grafting and possible external fixation and internal fixation (combined fixation). Out of thirteen patients with biplanar JESS, eight (61%) had excellent results compared to uniplanar UMAX in which out of seven, patients three (42%), had excellent results. This finding suggests that biplanar external fixation may be a better modality than uniplanar external fixation.

A prospective study of 55 patients evaluating the rate of functional improvement after treatment with volar locking plates demonstrated similar rates of recovery between elderly patients and younger patients. [8] A retrospective analysis of 24 distal radius fractures in patients treated with a volar fixed-angle plate showed good results with no significant loss of reduction. [9]

In another cohort of 20 patients aged treated with internal fixation following failed conservative management, 17 had a return to preoperative functional levels. [10] At an average follow-up of 38 months, there were 7 excellent, 11 good, and 2 fair results.

A randomized controlled trial compared external fixation with conservative management for redisplaced fractures and patients in the external fixation group showed a significantly better anatomical result. [11] A recent retrospective trial compared functional outcomes in patients treated with external fixation with those treated with conservative management and demonstrated significantly better results. [12]


  Conclusion Top


External fixation and volar buttress plate produces almost equivalent functional results in distal radial articular fractures, with volar buttress plate having better anatomical results than external fixation in the present study. Though there were complications associated with both external fixation and volar buttress plate but the benefits outweigh various potential problems and complications. With careful assessment, good surgical technique and early mobilization, the distal radial articular fractures can be effectively managed with predictably good outcome using either external fixation or volar buttress plate. Volar buttress plate can be more effective in type III Fernandez fractures, while UMAX is a better option for Fernandez type II fractures.

 
  References Top

1.Smith DW, Henry MH. Volar fixed-angle plating of the distal radius. J Am Acad Orthop Surg 2005;13:28-36.  Back to cited text no. 1
    
2.Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am 2007;32:962-70.   Back to cited text no. 2
    
3.Blakeney WG. Stabilization and treatment of Colles′ fractures in elderly patients. Clin Interv Aging 2010;5:337-44.  Back to cited text no. 3
[PUBMED]    
4.Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable Colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma 2009;23:237-42.  Back to cited text no. 4
    
5.Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg Am 1997;22:563-71.  Back to cited text no. 5
    
6.Ghosh S, Ghosh D, Datta S, Chaudhuri A, Roy DS, Chowdhury A. External fixation by Joshi′s external stabilizing system in cases of proximal humerus fractures in elderly subjects. J Sci Soc 2013;40:99-102.  Back to cited text no. 6
  Medknow Journal  
7.Gupta AK, Gupta M, Sengar G, Nath R. Functional outcome of closed fractures of proximal humerus managed by Joshi′s external stabilizing system. Indian J Orthop 2012;46:216-20.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Chung KC, Squitieri L, Kim HM. Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years. J Hand Surg Am 2008;33:809-19.   Back to cited text no. 8
    
9.Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am 2004;29:96-102.   Back to cited text no. 9
    
10.Jupiter JB, Ring D, Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg Am 2002;27:714-23.   Back to cited text no. 10
    
11.Roumen RM, Hesp WL, Bruggink ED. Unstable Colles′ fractures in elderly patients. A randomised trial of external fixation for redisplacement. J Bone Joint Surg Br 1991;73:307-11.   Back to cited text no. 11
    
12.Aktekin CN, Altay M, Gursoy K, Aktekin LA, Ozturk AM, Tabak AY. Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 2010;35:736-42.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed1757    
    Printed25    
    Emailed0    
    PDF Downloaded228    
    Comments [Add]    

Recommend this journal