Stable fixation of fractures of the distal radius can

Download (0)

Full text

(1)

M. Jakob, MD

P. Regazzoni, MD, Professor

University Hospital, Spitalstrasse 21, CH-4021 Basel, Switzerland. D. A. Rikli, MD,

Department of Traumatology, Kantonsspital, Buchserstrasse, CH-5001 Aarau, Switzerland.

Correspondence should be sent to Dr D. A. Rikli. ©2000 British Editorial Society of Bone and Joint Surgery 0301-620X/00/310099 $2.00

Fractures of the distal radius treated by

internal fixation and early function

A PROSPECTIVE STUDY OF 73 CONSECUTIVE PATIENTS

M. Jakob, D. A. Rikli, P. Regazzoni

From the Kantonsspital, Aarau, Switzerland

S

table fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50° to 70° apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients.

Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one.

Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

J Bone Joint Surg [Br] 2000;82-B:340-4.

Received 7 April 1999; Accepted after revision 13 July 1999

The management of fractures of the distal end of the radius continues to evolve; many reports show a close correlation between anatomical and functional results.1-24 Recently, it has been stressed that a fracture of the wrist should be treated on the same principles as any other fracture involv-ing a joint, that is, by anatomical reconstruction, stable fixation and early function.13,25 It is astonishing that these principles are rarely applied to fractures of the wrist, although they form one of the most common groups of injuries. In part, this may be due to an earlier lack of properly-designed implants and operative techniques,13but several new implants and techniques have now been described.19,26-28

We have developed a double-plating technique using 2.0 mm titanium implants based on the three-column con-cept of the distal radius and ulna and have reported 20 preliminary cases.19 We now describe a consecutive series of 74 fractures of the distal radius requiring surgery. They were studied prospectively, with special attention to techni-cal aspects and the specific complications seen in some early cases.

Patients and Methods

Between November 1994 and June 1997, we treated 76 consecutive patients with 77 fractures of the distal end of the radius, by open reduction and internal fixation using two 2.0 mm titanium plates.19 Three of these patients left the country and were lost to follow-up. We therefore report the results in 74 fractures in 73 patients, all reviewed at six weeks, six months and one year after operation.

There were 21 men and 52 women with a mean age of 60 years (20 to 86). The dominant wrist was fractured in 38 (52%) and 14 had an associated fracture in the same arm (1 clavicle, 3 humeri, 7 distal and 1 proximal ulna, 1 scaphoid and 1 metacarpal). Four patients (5.5%) had a contralateral fracture of the distal radius which was treated conserva-tively. Three (4%) had multiple injuries including closed head injuries.

Primary internal fixation was carried out in 52 patients (71%) and secondary fixation, after the failure of con-servative treatment in 21. Of the latter, 12 had been man-aged in plaster, 4 by percutaneous pins and plaster and 5 by external fixation.

According to the classification of Müller et al,29there were two simple extra-articular fractures (A2), 18 extra-articular fractures with metaphyseal comminution (A3), three partial articular fractures (1 B2, 2 B3), 11 simple articular fractures (C1) and 40 complex articular fractures (C2 and C3). The injuries were sustained in domestic falls (42%), in traffic accidents (38%), at work (12%) or at sport (8%).

The operations were carried out according to the tech-niques (Fig. 1) described previously.19 Metaphyseal defects were filled with cancellous autografts in eight wrists (11%) and with hydroxyapatite (Surgibone; Unilab Surgi-bone Inc, Mississauga, Canada) in 30 (41%). Four (5%) needed supplementary fixation with an external fixator for

(2)

four weeks because of persistent instability of the recon-structed articular surface. The other 70 (95%) started func-tional treatment soon after operation. Volar splinting was discontinued when the wound was healing satisfactorily

after one to two weeks. Load-bearing was allowed after six weeks.

Review at six weeks, six months and one year after operation included standard assessments of pain, functional disability, range of movement and grip strength (JAMAR Hand Dynamometer, Clifton, New Jersey). Standard postero-anterior and lateral radiographs of the fractured wrist were taken and compared with the postoperative views. We used a modification of the score of Stewart et al23 to rate the final anatomical result, and any post-traumatic arthritis was recor-ded using the scoring system of Knirk and Jupiter15

We used a paired Student t-test with two-tailed distribution for statistical evaluation.

Results

All 74 fractures united without infection (Fig. 2). At one year, 55 patients (75%) were free from pain, 11 (15%) had occasional pain during heavy work, five (7%) had constant pain with heavy work and two (3%) had occasional pain during the minor activities of daily living. Of the 73 patients, 71 (97%) had resumed their previous work and daily activities after a median 25.9 weeks (6 to 44), but two with multiple injuries had continued disability because of head injuries.

We compared the range of movement with that of the uninjured side in the 68 patients with unilateral fractures (Table I). There were statistically significant improvements in dorsiflexion, palmar flexion, supination and pronation between six weeks and six months (p < 0.001) and in dorsiflexion and palmar flexion between six months and one year (p < 0.05). The grip strengths in the same 68 patients are shown in Table II, revealing statistically sig-nificant increases in grip strength between six months and one year (p < 0.01).

Fig. 1

Diagram of internal fixation by double buttressing. The implants are placed at an angle of 50° to 70° to each other.

Table I. Range of movement (percentage of uninjured side) after operation in 68 patients Percentage of uninjured side

Time after operation 10 to 20 20 to 40 40 to 60 60 to 80 80 to 100

Six weeks Dorsiflexion 2 10 18 16 22 Palmar flexion 11 27 12 18 Ulnar deviation 4 10 16 38 Radial deviation 2 7 12 20 27 Supination 4 7 7 16 34 Pronation 3 3 12 50 Six months Dorsiflexiion 1 4 7 16 40 Palmar flexion 1 4 12 18 33 Ulnar deviation 1 1 10 12 44 Radial deviation 1 1 10 15 41 Supination 2 1 2 7 56 Pronation 1 1 4 62 One year Dorsiflexion 1 1 3 11 52 Palmar flexion 1 3 6 18 40 Ulnar deviation 3 13 52 Radial deviation 6 8 54 Supination 1 5 62 Pronation 1 4 63

(3)

The final anatomical results according to the classifica-tion of Stewart et al23 were excellent in 90%, good in 8% and fair in 2%. A more detailed analysis showed a mean loss of radial length of 1 mm (0 to 4) and a mean increase in palmar tilt of 1.7° (0 to 14) at six weeks (both p < 0.001). There was no later loss of reduction, no loss of radial angle and no residual intra-articular incongruity.

As regards degenerative changes15 one wrist showed grade-III osteoarthritis, one grade II and three grade I (7% in total). The patient with grade-III changes needed a Bowers hemiarthroplasty for distal radioulnar arthritis and ulnar impingement; the other four had no symptoms.

Complications occurred in 16 wrists (21.6%). Four patients (5.5%) developed extensor tendinitis which settled

after removal of the implants in three and spontaneously in one. In five of our early cases (7% of the whole series), ruptures of the extensor tendon required removal of the

Fig. 2a Fig. 2b

Fig. 2c Fig. 2d

Radiographs showing a and b) an intra-articular fracture of the distal radius with a displaced dorsiulnar fragment and c, and d) six months after surgery. There is no osteoarthritis, no pain and an excellent range of move-ment. The plates are in the correct position.

Table II. Grip strength (percentage of uninjured side) after operation in

68 patients

Percentage of uninjured side

40 to 59 60 to 79 80 to 99 > 100 Dominant side (34) Six months 5 9 12 8 One year 2 3 9 20 Non-dominant side (34) Six months 10 9 7 8 One year 2 6 9 17

(4)

implant and repair of the tendon at one to six months. These five ruptures were caused by dorsiulnar T-plates which had been cut at operation to form L-plates. Although the cut edge had been smoothed with a file, it caused attrition rupture. Since we abandoned this technique we have had no further cases of rupture of the tendon.

There were four secondary displacements (5.5%) during the first six weeks after operation. Three were due to technical error in that the radial plate had been placed too dorsal, parallel to the dorsiulnar plate. In this position, the plate does not buttress the radial column, allowing second-ary dislocation of the radial styloid fragment. These three patients required reoperation to reposition the dorsiradial plate. The further course was uneventful and the final results were good. One patient needed an additional palmar buttress plate for a very comminuted fracture.

We saw no cases of secondary carpal tunnel syndrome, but four patients (5.5%) developed acute algodystrophy (2 mild; 2 severe). This resolved completely in three after treatment with calcitonin and physiotherapy, but one patient still had moderate pain during daily activities at one year.

The implants were removed from 17 wrists (23%), three for irritation of the extensor tendon and five for ruptures of the tendon caused by cut plates. In four wrists the plates had been placed on the dorsal rim for very short distal fragments and were restricting dorsiflexion; removal of the implant allowed significant improvement of movement. Five patients requested that the plates and screws be taken out despite lack of symptoms.

The final result was considered to be excellent by 83%, good by 14% and fair by 3% of the patients.

Discussion

The indications for operation were articular involvement with a step or gap in the joint surface of more than 2 mm and/or instability due to metaphyseal comminution. Two young patients with A2 fractures lacked these indications, but requested surgery rather than plaster to allow early function.

More than two-thirds of the fractures were intra-articular. We recognise that extra-articular injuries have a better prognosis, but felt that a consecutive series of fractures requiring surgery would give the best account of our prac-tice. The technique using two 2.0 mm titanium plates, based on the three-column concept of the distal radius and ulna, has previously been described in detail.19

Our overall results compare favourably with other reported series of such fractures treated by opera-tion.3,5-7,18,26-28,30,31 All our patients, except for two with associated head injuries, returned to their previous work and activities within 25.9 weeks.

We believe that the good results in terms of range of movement, grip strength and pain were due to the restora-tion of the joints and the extra-articular anatomy. The anatomical results according to the score of Stewart et al23

were excellent or good in 98%. The mean loss of radial length of 1 mm or less, and an increase in palmar tilt of 1.7° are tolerable, not leading to clinically significant ulnar impingement. Despite this, we are now developing a new 2.0 mm titanium T-plate with locked distal screws. This is being used in a pilot series in the hope that loss of radial length and increase in palmar tilt can be completely avoi-ded in the future.

Biomechanical testing of our double-plating technique on cadaver radii has shown superior initial stiffness in comparison with other methods.32 It must be stressed, however, that buttressing of the intermediate as well as the radial styloid column is essential, with the plates placed at an angle of 50° to 70°. Correct placement of the dorsiradial plate deep to the wrist extensors to support the radial styloid is crucial. All four secondary displacements were due to failure by the surgeon to appreciate this.

In five early cases, ruptures of the extensor tendon were due to attrition by distally cut plates. We stopped cutting plates and then had no more such ruptures. Irritation of the tendon occurred in 5%, comparing favourably with the 23% reported for the Pi-plate.27 We believe that this is due to the small size of the implants and our use of a strictly subperiosteal approach, which leaves the tendon sheathes of the second and third compartments intact. We also cover the extensor pollicis longus tendon with a flap of extensor retinaculum so that no tendon is in direct contact with the implants.

Recent reports have described associated tears of the triangular radioulnar ligament in up to 53% and of the scapholunate ligament in up to 21% of extra- and intra-articular fractures of the distal radius.33-35 It has been suggested that these injuries were responsible for poor results unless they were diagnosed and treated early, but their clinical significance is not entirely clear. We believe that minor tears of the intercarpal ligaments do not lead to significant instability and heal without further treatment, provided that the anatomy of the joint, including the distal radioulnar joint, is meticulously restored and undue traction with external fixation devices is avoided. We have not addressed this issue by MRI studies, arthrography, arthro-scopy or stress radiographs. We concentrated on the clinical evaluation of a relatively new technique of internal fixation, and found no instability of the carpal or distal radioulnar joints in our clinical and radiological evaluation. Our fol-low-up of one year is probably too short to make a defini-tive statement, and we believe that this ligament problem deserves further clinical and biomechanical investigation.

When open reduction of dorsal displaced fractures of the radius is indicated to restore congruency and extra-articular anatomy, we recommend our double-plating method. This is reliable in providing stable internal fixation and allowing early function, but it is a demanding technique, requiring careful attention to detail.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

(5)

References

1. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of

conservative treatment of fractures of the distal radius. Clin Orthop 1986;206:202-10.

2. Aro HT, Koivunen T. Minor axial shortening of the radius affects

outcome of Colles' fracture treatment. J Hand Surgery 1991;16-A: 392-8.

3. Axelrod T, Paley D, Green J, McMurtry RY. Limited open reduction of

the lunate facet in comminuted intraarticular fractures of the distal radius.

J Hand Surg Am 1988;13:372-7.

4. Bacorn RW, Kurtzke JF. Colles' fracture: a study of two thousand cases

from the New York State Workmen's Compensation Board. J Bone Joint

Surg [Am] 1953;35-A:643-58.

5. Bradway JK, Amadio PC, Cooney WP. Open reduction and internal

fixation of displaced, comminuted intra-articular fractures of the distal end of the radius. J Bone Joint Surg [Am] 1989;71-A:839-47.

6. Catalano LW, Cole RJ, Gelbermann RH, et al. Displaced intra-articular

fractures of the distal aspect of the radius: long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg [Am] 1997;79-A:1290-302.

7. Fernandez DL. Correction of post-traumatic wrist deformity in adults by

osteotomy, bone-grafting and internal fixation. J Bone Joint Surg [Am] 1982;64-A:1164-78.

8. Frykman G. Fracture of the distal radius including sequelae - shoulder

hand-finger syndrome, disturbance in the distal radioulnar joint and impairment of nerve function: a clinical and experimental study. Acta

Orthop Scand (Suppl) 1967;108:1-155.

9. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures.

J Bone Joint Surg [Am] 1951;33-A:895-907.

10. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL.

Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg [Am] 1996; 78-A:357-65.

11. Hagert CG. Distal radius fracture and the distal radioulnar joint:

anatom-ical considerations. Handchir Mikrochir Plast Chir 1994;26: 22-6.

12. Howard PW, Steward HD, Hind RE, Burke FD. External fixation or

plaster for severely displaced comminuted Colles' fractures? J Bone Joint

Surg [Br] 1989;71-B:68-73.

13. Jupiter JB. Current concepts review. Fractures of the distal end of the

radius. J Bone Joint Surg [Am] 1991;73-A:461-9.

14. Kihara H, Palmer AK, Werner FW, Short W, Fortino M. The

stabilising mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg 1995;20-A:930.

15. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the

radius in young adults. J Bone Joint Surg [Am] 1986;68-A:647-59.

16. Lidstrom A. Fractures of the distal end of the radius: a clinical and

statistical study of end results. Acta Orthop Scand 1959:Suppl 41.

17. McQueen M, Caspers J. Colles' fracture: does the anatomical result

affect the final function? J Bone Joint Surg [Br] 1988;70-B:649-51.

18. Melone CP Jr. Open treatment for displaced articular fractures of the

distal radius. Clin Orthop 1986;202:103-11.

19. Rikli D, Regazzoni P. Fractures of the distal end of the radius treated by

internal fixation and early function: a preliminary report of 20 cases.

J Bone Joint Surg [Br] 1996;78-B:588-92.

20. Rikli D, Küpfer K, Bodoky A. Long-term results of the external fixation

of distal radius fractures. J Trauma 1998;44:970-6.

21. Scheck M. Long-term follow-up of treatment of comminuted fractures of

the distal end of the radius by transfixation with Kirschner wires and cast.

J Bone Joint Surg [Am] 1962;44-A:337-51.

22. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical

study of distal radial fractures. J Hand Surg [Am] 1987;12-A:529-34.

23. Stewart HD, Innes AR, Burke FD. Factors affecting the outcome of

Colles' fracture: an anatomical and functional study. Injury 1985;16:289-95.

24. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional

outcome of displaced intraarticular distal radius fractures. J Hand Surg

Am 1994;19:325-40.

25. Palmer AK. Fractures of the distal radius. In: Green DP, ed. Operative

hand surgery. Vol. 1. 3rd edition. New York, etc: Churchill Livingstone,

1993:929-71.

26. Carter PR, Frederick HA, Laseter GF. Open reduction and internal

fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg 1998;23-A:300-7.

27. Ring D, Jupiter JB, Brennwald J, Büchler U, Hastings H. Prospective

multicenter trial of a plate for dorsal fixation of distal radius fractures.

J Hand Surg 1997;22-A:777-84.

28. Zimmermann R, Gabl M, Pechlaner S, et al. Distal, metaphyseal

compression fractures of the radius: results of open reposition, stable defect replacement with cortico-cancellous iliac crest bone and plate osteosynthesis. Unfallchirurg 1998;101:762-8.

29. Müller ME, Nazarian S, Koch P, Schatzker J. Comprehensive

classifi-cation of fractures of long bones. Berlin, etc: Springer, 1990.

30. Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular

fractures of the distal end of the radius with plates. J Bone Joint Surg

[Am] 1997;79-A:1303-12.

31. Jupiter JB, Lipton H. The operative treatment of intraarticular fractures

of the distal radius. Clin Orthop 1993;292:48-61.

32. Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P. Biomechanical

evaluation of different fixation techniques at the distal end of the radius.

J Hand Surg 2000; in press.

33. Mudgal C, Hastings H. Scapho-lunate diastasis in fractures of the distal

radius: pathomechanics and treatment options. J Hand Surg 1993;18-B:725-9.

34. Peicha G, Fellinger M, Seibert FG, Grechenig W, Schippinger G.

Scapho-lunar ligament injuries in acute wrist trauma: arthroscopic diag-nosis and minimally invasive surgery. Unfallchirurg 1997; 100:430-7.

35. Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis

of intra-articular soft tissue injuries associated with distal radial fractures.

Figure

Updating...

References