Prospective Study of Distal End Radius Fracture Volar Type Treated with Open Reduction Internal Fixation with Plating

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Prospective Study of Distal

End Radius Fracture Volar

Type Treated with Open

Reduction Internal Fixation

with Plating

INTRODUCTION

Distal radius fractures are the most frequent fractures in the upper extrem-ity. In adults they show a wide range of variation and are responsible for 10–20% of all skeletal fractures1. Volar displaced fractures of the distal end of radius include both intra-articular and extra-articular fractures i.e. Volar-Barton’s and Smith’s fractures. The main objective of the treatment is the re-establishment of anatomic integrity and functioning. There are several options for the same which include closed reduction and Kirschner (K) wires fixation with a plaster cast, external fixation (bridging or non-bridging, with or without K wires), and open reduction and internal fixation with plate and screws (non-locking or locking, pre-contoured plates). Y-locked plates are in the process of replacing conventional plates as they provide angular and axial stability and minimize the possibility of screw loosening and implant failure4. Volar plating has gained widespread use over the past decade5. The purpose of this study was to investigate the efficacy volar locking plate in the management of the intra-articular and extra articular volar fractures of distal end of radius of as well as to report the radiological and functional outcomes.

Prafulla G Herode*, Satish Uchale, Abhijeet Shroff, Vinod Nair, Amit Chaudhary

Department of Orthopaedics, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

 Address reprint requests to *Dr. Prafulla Govind Herode, Associate Professor, Department of Orthopaedics, Dr. D.Y. Patil Medical College, Hospital and Research centre, Pimpri, Pune 411108, India

E-mail: amitchaudhary.ds@gmail.com  Article citation: Herode PG, Uchale S,

Shroff A, Nair V, Chaudhary A. Prospective study of distal end radius fracture volar type treated with open reduction internal fixation with plating. J Pharm Biomed Sci 2016;06(02):134–138.

Available at www.jpbms.info Statement of originality of work: The manuscript has been read and approved by all the authors, the requirements for authorship have been met, and that each author believes that the manuscript represents honest and original work.

Sources of funding: None.

Competing interest / Conflict of interest:

The author(s) have no competing interests for financial support, publication of this research, patents, and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.

Disclaimer: Any views expressed in this paper are those of the authors and do not reflect the official policy or position of the Department of Defense.

NLM Title J Pharm Biomed Sci CODEN JPBSCT

2230-7885 ISSN No

ABSTRACT

Background Distal radius fractures are the most frequent fractures in the upper extremity. In adults they show a wide range of variation and are responsible for 10–20% of all skeletal fractures. The advent of fixed-angle locking plates has addressed inadequacies such as non-locked plates and has improved fracture healing. The purpose of this study was to investigate the efficacy volar locking plate in the management of the intra-articular and extra-articular volar fractures of distal end of radius of as well as to report the radiological and functional outcomes.

Aims and Objectives To study the role of locking plate in volar fractures of distal end radius.

Materials and Methods This prospective study comprised 25 patients. Fresh simple volar fracture (age >20 yrs) of lower end of radius presenting within a week of injury, who were treated with volar locking plate fixation at tertiary care teaching hospital was carried out from April 2012 to November 2014. Patients were evaluated for Stewart I radiological scoring system and Functional Patient Rated Wrist Evaluation (PRWE) scoring system. The radiological and functional outcomes were measured and analysed using the ANOVA chi square test.

Results According to Stewart score, in this study, 22 (88%) cases showed satisfactory anatomical results (good and excellent) hence volar fractures of distal radius is associated with satisfactory anatomical end result. Patient rated wrist evaluation scoring showed 22 patients with satisfactory functional results (good and excellent) considering pain and functional activities and 3 patients with unsatisfactory results (fair and poor).

Conclusion Open reduction and internal fixation with volar Locking plating has excellent functional outcome with minimal complications thus proving that it is a good modality of treatment for distal end radius fractures.

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MATERIALS AND METHODS

This prospective study compromised 25 patients (age >20 years) of fresh simple volar fracture of lower end of radius i.e. AO types A 2.3, B 3.1, B 3.2, B 3.3 pre-senting within a week of injury, who were treated with volar locking plate fixation. Study was conducted in the Department of Orthopaedic, in a tertiary care teaching hospital from April 2013 to November 2015.

The maximum follow up was for 24 months and min-imum was 6 months with average follow up of 10 months. All the patients were treated as indoor patient. A written informed consent was obtained before surgery.

All the patients were selected on the basis of patients having distal end radius fracture with volar displace-ment without neurovascular injury. The exclusion cri-teria were age <20 years, pathological fractures and patients medically unfit for surgery. Surgery was indi-cated in cases where volar tilt was greater than 20°, dorsal tilt was greater than 10°, articular step-off was greater than 2 mm, radial shortening was greater than 5 mm, and radial inclination was less than 15° in conformity with the instability criteria proposed by David L. Nelson, of the International distal radius fracture study group. Fractures were classified according to the AO classifi-cation. Patients were discharged usually on the 3rd day, unless they had associated injuries. Patients were followed up at the end of 1 week, 4 weeks & 8 weeks, 3 months, 6 months and 12 months. Clinical and radiographic assessment were performed at every visit.

AP and lateral X-rays were taken on follow-up and compared with opposite wrist X-rays (control). Patients were instructed about the exercises of the elbow, digits and shoulders. At the end of the first week, patients were encouraged to exercise and move wrists and hand freely.

At end of sixth week, radiographs were taken and active motion of the wrists consisting of wrist move-ments, supination, pronation, finger grip were started. Patients were evaluated for Stewart I radiological scor-ing system6,7(Table 1) and Functional Patient Rated Wrist Evaluation (PRWE) scoring system7–9(Table 2). The radiological and functional outcome measures were

analyzed using the ANOVA chi-square test. The mean follow up was 6 months (range 0–12 months) for out-come measurement of volar locking plate fixation.

Operative procedure

Open reduction and internal fixation with anatomical restoration of wrist joint by using various size plates and screw.

RESULTS

Out of 25 patients, 16 (64%) were males and 9 (36%) were females. The youngest patient in the series was of 21 years and the oldest was of 83 years. In this study 60% of the total patient had a fracture involving their right hand (dominant). Majority of the injuries (48%) were due to fall on outstretched hand, followed by those due to road traffic accident (44%), and the remaining (8%) due to fall from the height. Out of the 25 patients maximum number of patients (12) had been classified in B3.2 by the AO classification. Maximum number of patients stayed for duration of 1 to 3 days in the hospital i.e. 16 out of 25 patients. The average results of move-ments after 8 months in the present study were 68.4° palmar flexion, 70.2° dorsiflexion, 18.6° radial devi-ation, 32° ulnar devidevi-ation, 74.2° pronation and 76.6° supination (Table 2). The complications observed were postoperative stiffness in 2 (8%) patients and regional pain syndrome in 1 (4%) patient. Union occurred in all cases.

Radiological outcome by Stewart I scoring system showed good (68%) to excellent (20%) results. Fair and poor results were seen in 1% and 8% of the patients respectively; cause being inability to maintain volar angle, radial angle and radial length in highly com-minuted or unstable volar fracture of the distal radius. Functional outcome by patient rated wrist evaluation scoring system showed good and excellent grading in a majority of patients i.e. in 60% and 28% respectively, along with fair and poor results in 4% and 8% of the patients, respectively (Table 3). The final radiological and functional end results were 88% (22) satisfactory

Table 1 Stewart I scoring system assessment of

anatomical result (modified from Ref 6). Final volar

angle (degrees)

Loss of radial length

(mm)

Loss of radial angle

(degrees)

Score for each measurement

Neutral Under 3 0–4 0

1–10 3–6 5–9 1

11–14 7–11 10–14 2

≥15 ≥12 ≥15 4

Anatomical grade obtained by addition of the three scores for each result: excellent 0 good 1–3; fair 4–6; and poor 7–12.

Table 2 Range of movement (6 months post

operatively).

Movements Normal range in degree after 6 months Average result in degrees

Palmar flexion 35–75 68.4

Dorsal flexion 45–85 70.2

Radial deviation 15–30 18.6

Ulnar deviation 20–50 32

Pronation 70–90 74.2

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(good and excellent) and 12% (3) unsatisfactory (fair and poor).

The PRWE scoring or the patient rated wrist evalu-ation is the most sensitive and reproducible instrument for evaluating the outcome in patients with the distal radius fracture. The PRWE is a 15 itemed questionnaire designed to measure the wrist pain and disability in daily living activity. The PRWE allows the patient to rate their level of wrist pain and disability from 0 to 10 for each item.

DISCUSSION

The advent of fixed-angle locking plates has addressed inadequacies such as non locked plates and has improved fracture healing. Formerly, minimal motion at joint or sufficient bone density enough to withstand the applied physiologic load was required to achieve a rigid fixation construct with a non-locked plate. These limiting factors required prolonged cast immobilisation even after sur-gical fixation. In osteoporotic bone, the screws stand a chance of loosening because of the minimal axial stress. The locking plate introduced stability at the screw plate interface creating a four times stronger “single beam construct”, which allowed motion between the screws and plate. Locked plates decrease the potential for tog-gling of the screws in the cortex, hence making them ideal for osteoporotic and extra-articular fractures10. The present study included 25 patients (16 males, 9 females; mean age 43 years; range 21–83 years). Out of our 25 cases, the majority that is 7 (28%) patients lie in the age group of 51–60 years. The male to female ratio

is 16 (64%):9 (36%). The study of Kiliç et al11. (2009) included 27 patients (15 males, 12 females; mean age 45 years; range 18–77 years) who were treated with volar locking plate fixation for unstable distal radius fractures. The P value (ANOVA) was insignificant (0.7662). Right side was involved the most in our study, accounting to a total of 60% (15 cases). In this study of 24 patients, Murakami12 (2007) reported 55% of the fractures to be that of the right side. The P value was insignifi-cant (0.9015). Out of 25 cases, maximum number of patients had an injury due to fall (on outstretched hand and from height) and road traffic accident; 14 (56%) and 11 (44%), respectively. In a study by Aggarwal and Nagi (2004)13 of 16 cases, the injury was caused by motor vehicle accidents in 13 (81%) cases and by a fall in 3 (19%). The P value was considering significant (0.0417). Maximum number of patients (48%) have been classified in B3.2 by the AO classification in our study; 12(48%). In the study of Aggarwal and Nagi13 (2004), from January 1997 to July 2003, a total of 16 cases of volar Barton’s fracture treated by the same tech-nique, were studied. All cases were type-B3 fractures: 10 were of the B3.3 subtype, 4 of the B3.2 subtype, and 2 of the B3.1 subtype. In the study of Kiliç et al11. (2009) of 27 patients, 3 fractures were of B2 (11.1%), 2 of B3 (7.4%) and C1 (7.4%) each, 14 of C2 (51.9%) and 6 were that of C3 (22.2%), as per the AO classification. In our study, the average hospital stay for 16 patients (64%) was 1–3 days. The remaining 9 (36%) patients stayed for longer periods, due to associated injuries. In the study of Rampoldi and Marsico 14 (2007), the duration ranged from 2 to 9 days (mean = 2.3 days). The Stewart scoring was based on a radiograph of the normal wrist (the control film) and serial radiographs of the injured wrist. In the present study, we had the following results at the end of 6 months, comparing with a control film (Normal wrist): Mean volar angle: 9.48°, loss of radial length: 1.56 mm, and loss of radial angle: 1.52°. In the comparative study of Stewart HD6 (1984) (plas-ter cast group), the mean volar or dorsal angle was 9.9°, loss of radial length was 1.8 mm and loss of radial angle was 1.7° at the end of the study. In Kiliç et al.’s11 (2009) study, the mean radial tilt angle was 6.2° volar ward (range dorsal 10°–volar 14°) on the healthy side and 3° volar ward (range dorsal 10°–volar 18°) on the operated side, the mean loss of radial length on the operated side was 1.3 mm (range 0–5 mm), and that for the healthy side was 26.8° (range 22°–30°) while the mean radial angle for the operated side was 24.8° (range 20°–28°). The mean loss was 2°. The range of movements after 6 months in present study was comparable to the results of the above series; the average results in the present stud-ies were: 68.4° palmar flexion, 70.2° dorsiflexion, 18.6° radial deviation, 32° ulnar deviation, 74.2° pronation and 76.6° supination. In the prospective study of Kiliç et al11. (2009), the functional results of the patients at the end-point visit were: mean flexion angle 5SO (range 0°–70°), mean extension angle 40° (range 35°–70°),

Table 3 Radiological outcome (Stewart I score) and

functional outcome by PRWE scoring system (pain scoring A and functional scoring B) combined.

Range of

Score Grading patientsNo of Percentage %

Radiological outcome

0 Excellent 5 20

1–3 Good 17 68

4–6 Fair 1 04

7–12 Poor 2 08

Functional outcome

0–20 Excellent 7 28

21–40 Good 15 60

41–60 Fair 1 4

61–80 Poor 2 8

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mean radial deviation 18° (range 10°–26°), mean pro-nation 86° (range 0°–90°) and the mean supipro-nation 83°(range 0°–90°). Kasapinova and Kamiloski7 (2011) had an average movement of 53. SO palmar flexion, 61.7° dorsiflexion, 30.6° radial deviation, 38.8° ulnar devia-tion, ‘67.7° pronation and 67° supination. Murakami et al. (2007)11, in their study had an average movement of 55° palmar flexion, 61° dorsiflexion and 23° radial deviation, 35° ulnar deviation, 6°pronation and 87° supination. We observed complications in three patients. In the study of Kiliç et al11. (2009), two patients (7.4%) had an articular malalignment due to insufficient fix-ation, while one patient (3.7%) had complaints about pain and irritation related to prominent screws in the early phase. In the study of Aggarwal and Nagi13 (2004), a total of 3 (18.75%) cases had complications. Mild radiocarpal osteoarthrosis was seen in two patients, though it did not affect their functional outcome, while Sudeck’s atrophy was seen in a non cooperative patient which affected the functional result (graded as fair). In a retrospective study of volar plate fixation of intra-articu-lar distal radius fractures by Tarallo et al.5 the complica-tion rate was <5%, including loss of reduccomplica-tion in two patients. In another retrospective study by Tarallo et al.5 (2013) of 303 patients, complications were seen in 18 patients (5.9%). They noted tendon impairments in a majority of patients. According to the Stewart score, in this study, 22 (88%) cases showed satisfactory ana-tomical results (good and excellent). Kasapinova and Kamiloski7 (2011) showed satisfactory result in 76.6% of the cases, while Kiliç11 (2009) reported 88.9% sat-isfactory results. PRWE score showed similar functional results with good and excellent scores in 22 patients in our study. Kasapinova and Kamiloski (2011)7 showed satisfactory result in 76.6% of the cases, while Kiliç11 (2009) reported 92.3% satisfactory results. Observing the Stewart scoring and the PRWE scoring system, the final outcome of the treatment was graded as excellent, good, fair and poor. The maximum number of patients showed good and excellent results (Table 4), thus con-firming the volar locking plate treatment to be a good method of treatment for volar fracture of the distal end radius fractures. The overall results obtained in this study were comparable with the above series - Taralloet al. (2013)5, Fok et al.(2013)15, Kasapinova and Kamiloski (2011)7, Kiliç11 (2009), Aggarwal and Nagi13 (2004), and Stewart et al (1984)6. We believe that our study would provide additional knowledge and experience about the treatment of volar distal radius fractures. A small study group and short follow up duration are the limitations of our study.

Distal end radius with volar displacement can be treated conservatively or surgically depending on the type of fracture and the surgeons opinion, the question of whether surgery or conservative treatment should be used for wrist fracture remains controversial.

Surgical treatment involves reduction of fractured parts and fixation using proper plates and screws. This operative

technique aims to provide anatomical restorations and immediate stability, which facilitates earlier mobilisa-tion. However, all surgeries carries the risk of compli-cations such as wound infections, implant or fixation failure, resurgery etc.

With early mobilisation and post operative physio-therapy, these adverse effects may be prevented. If surgi-cal treatment can protect or accelerate the bone healing process by securely stabilising the fracture, it can also reduce recovery time. This may not be the case for older people with osteoporosis because the porosity of their bones may increase the risk of fixation failure and thus preclude early mobilisation.

CONCLUSION

We suggest that stabilizing the fracture fragments with volar locking plate and screws is an effective method to maintain the reduction till union and prevent collapse of the fracture fragments, even when the fracture is grossly comminuted/intra-articular/unstable and/or the bone is osteoporotic. More studies with larger sample size and long term follow-up need to be done to throw more light on the associated complication and their prevention.

REFERENCES

1. Pardini AG Jr. “Fraturas da extremidade distal do rádio lna.” em Traumatismos da mão. 3 Edição. Rio de Janeiro, Medsi; 2000. pp. 419–456.

2. Broos PL, Sermon A. From unstable internal fixation to biolog-ical osteosynthesis. A historbiolog-ical overview of operative fracture treatment. Acta Chir Belg. 2004;104:396–400.

3. Perren SM. Evolution of the internal fixation of long bone frac-tures. The scientific basis of biological intimal fixation: choosing a new balance between stability and biology. J Bone Joint Surg (Br). 2002;84(8):1093–110.

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5. Tarallo L, Mugnai R, Zambianchi F, Adani R, Catani F. Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events. J Orthop Trauma. 2013;27(12):740–5.

6. Stewart HD, Innes AR, Burke FD. Functional cast bracing for Colles’ fracture. A comparison between cast-bracing and con-ventional plaster casts. J Bone Joint Surg Br. 1984;66:749–753.

Table 4 Final outcome of the LCP system in volar

fracture by Stewart I score and PRWE scoring system combined.

Final result No. of patients Percentage

Excellent 5 20

Good 17 68

Fair 1 4

Poor 2 8

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7. Kasapinova K, Kamiloski V. Outcome evaluation in patients with distal radius fracture. Prilozi. 2011;32:231–46.

8. MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH. Responsiveness of the short form-36, disability of the arm, shoul-der, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture. J Hand Surg Am. 2000;25:330–40. 9. MacDermid Joy C. The Patient-Rated Wrist Evaluation (PRWE)

User Manual. Canada: McMaster University. 2007.

10. Levin SM, Nelson CO, Botts JD, Teplitz GA, Kwon Y, Serra-Hsu F. Biomechanical evaluation of volar locking plates for distal radius fractures. Hand (NY). 2008;3(1):55–60.

11. Kiliç A, Kabukçuoğlu Y, Ozkaya U, Gül M, Sökücü S, Ozdoğan U. Volar locking plate fixation of unstable distal radius fractures. Acta Orthop Traumatol Turc. 2009;43(4):303–8.

12. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci. 2007;12(2):134–40.

13. Aggarwal AK, Nagi ON. Open reduction and internal fixation of volar Barton’s fractures: a prospective study. J Orthop Surg (Hong Kong). 2004;12(2):230–4.

14. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures. Acta Orthop Belg. 2007;73:714–9.

15. Fok MW, Klausmeyer MA, Fernandez DL, Orbay JL, Bergada AL. Volar plate fixation of intra-articular distal radius fractures: a ret-rospective study. J Wrist Surg. 2013;2(3):247–254.

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