Objectives: This study compared the clinical and radiological outcomes of two different methods for the treatment of distal radial intra-articular frac- tures. Patients and Methods: Forty-six patients with distalradiusintra-arti- cular fractures were divided into two groups. Group I included 24 patients with type C fracture treated by external fixator augmented by percutaneous K-wires. Group II included 22 patients with type C fracture treated by volar locked distal radial plate augmented by K-wires. Two patients had complex injuries necessitating double plating (sandwich). All patients were evaluated clinically by Mayo Wrist Score and radiologically by Sarmiento’s radiological score. Results: Both groups reported good personal satisfaction according to Mayo Wrist Score, and the results were not statistically different between the two groups. In Group I, 19 patients (79.2%) had excellent radiological out- come and five patients (20.9%) had good radiological outcome according to Sarmiento’s radiological score. In Group II, 20 patients (90.9%) had excellent outcome, and two (9.1%) had good radiological outcome; there was no or in- significant deformity. Conclusions: Complex distal radial fractures can be treated either by external fixation (ligamentotaxis) or by locked pre-contoured plating. The clinical outcome of plating and external fixator in our study did not show any statistically significant difference. The radiological outcome had no correlation with the clinical outcome.
The literature search identified three RCTs and six com- parative studies, which directly compared the results of the two methods of fixation. Basic demographic data of the included studies is summarized in Tables 1 and 2. All the studies were approved by the relevant ethics commit- tees and Institutional Review Board (IRB) of the individual institutions where they were performed and essential ethi- cal standards were followed. 13,14,16,18,22,30-33 Informed con-
Fractures of the distalradius are among the most common orthopaedic injuries, and impose a significant financial burden on healthcare . However, given the prevalence of distalradiusfractures, controversy remains concerning the best management. Although several surgical options are available, including percutaneous pinning, external fixa- tion, openreductioninternalfixation (ORIF) techniques, intramedullary fixation, as well as arthroscopic assisted reduction and fixation, the 2009 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) was unable to recommend for or against any one specific surgical method . Despite this lack of consensus, ORIF of distalradiusfractures has become increasingly popular in recent years, particularly in relation to the use of volar locking plates [3–5]. With the rise in cost-con- sciousness in our healthcare system, it is important to
In 1975 SARMIENTO introduced functional cast bracing to distalradiusfractures and immobilized the patient in supination. He modified the GARTLAND & WERLEY system of evaluation. The AO – ASIF group developed techniques of openreduction and internalfixation and external fixation. They applied their principles to distalradiusfractures like k wire pinning, plating and external fixators. They introduced AO minifixator for the distalradius.
This is a prospective study of a series of 26 patients with closed unstable comminuted intra-articular fracture distal end of the radius treated with two different methods of treatment to compare their anatomical and functional results. The external fixation group consisted of 12 patients and internalfixation group consisted of 14 patients. The anatomical and functional assessments were performed at six months and one year. The anatomical results at six months and one year showed that the internalfixation group was effective in maintaining the reduction compared to the external fixation group. The radial height, volar tilt and radial inclination were well maintained. However, the functional results at six months and one year showed no differences between these two types of fixation. The complication rate was higher in external fixation group.
erative methods (8, 9, 16, 17). However, in few selected intra- articular scapular fractures, the best outcome is usually ob- tained with openreduction and internalfixation (16, 17). They are often associated with poly-trauma, which takes the immediate attention away from scapula and hence other life threatening injuries are treated first (8, 9). Surgi- cal indications are there in the literature that include the unstable shoulder joint based on multiple disruptions of the superior shoulder suspensory complex (SSSC) (18-20), ‘medialization of glenoid’ (medial/lateral (M/L) displace- ment) by 10 - 25 mm (21, 22), angular deformity (21, 22), shortening > 25 mm as defined by Jones et al. (22) (a mea- sure of medialization of the glenoid), displaced fracture of the glenoid with intra-articular step-off or gap between 2 and 10 mm, and 20% - 30% involvement of the articular surface or instability of the glenohumeral joint(4, 7, 23-25). There are many published papers that describe different operative approaches and fixation techniques for scapula fractures (7, 24, 25). Ideberg’s classification (3) is the most
Being one of the most common skeletal injuries treated by Orthopaedic surgeons, Fractures of the distalradius constitute 17% of all the fractures evaluated in emergency room (Hagino Brown and Caesar, 2006). ency fracture in elderly patients associated with all of the risk factors for osteoporosis and has been linked to estrogen withdrawal and reduced bone mineral density in Mensforth and Latimer, 1989 O'Neill et al., A traumatic injury in younger males, where the injury is not as strongly related to gender, but related to high energy injuries (21% of all fractures) rather than to simple fall. As the consensus prevails, the vast majority of the distalradiusarticular injuries resulting in disruption of Lindau et al., 1997; The management of distalradiusfractures has undergone an extraordinary evolution over the preceding Saffar, 1995). OpenReduction and InternalFixation is an alternative but definitively valid treatment option for displaced intra-articular
fragments in fractures with major joint involvement. Excessive distraction of the hardware, to obtain satisfactory reduction, can result in delayed union, nonunion, complex regional pain syndrome (CRPS) or digital stiffness [3, 4]. Despite the fact that randomized trials do not provide strong evidence regarding the type of surgical intervention that is the most appropriate treatment for fractures of the distalradius in adults, superior functional and radiological results of ORIF with respect to external fixation have been reported recently . Standard straight plates result in optimal diaphyseal stabilization but may be inadequate for fixing metaphyseal and epiphyseal fractures. When posi- tioned on the volar aspect of the radius, straight plates are too bulky and may create attritional damage to flexor tendons; they need to be bent to follow the radial volar inclination, and are not sufficiently wide to adequately fix the epiphysis and capture small articular pieces for such fractures. A new technique described by Ginn et al.  involves ‘‘bridging’’ the fracture using a standard 3.5 mm plate applied dorsally and fixed in distraction from the radius to the third metacarpal shaft distally. The distraction plate technique also uses the concept of ligamentotaxis and, like external fixation, is especially indicated for intra- articularfractures with small, comminuted fragments which may be difficult to manage with plates or other nonbridging methods; when distraction fails to obtain adequate reduction, the use of bone grafts, K-wires and supplementary screws are included in the procedure. The hardware is removed after radiographic evidence of con- solidation (mean time: 124 days) and wrist motion has been initiated. Excellent clinical and radiographical results are reported with this technique . Disadvantages of this method include the long period of immobilization of the wrist, the need for a second operation to remove the Fig. 3 Radioulnar synostosis at 9 months after osteosynthesis (Syn-
Recently surgical management has been widely recommended and performed to prevent disability. Several studies have shown convincingly that functional outcome is good when the anatomy is restored by obtaining good reduction of fracture fragments maintaining the angulations of the articular surface of radius and radial length, and to minimize those related complications as well. This study evaluates the surgical and functional outcomes of intra- articularfractures of distal end radius in a comparative study between closed reduction using external fixation and distraction osteosynthesis to align fragments versusopenreductioninternalfixation (ORIF) with buttress plating.
Fractures of the distal femur are complex injuries. They can produce significant long term disability. They account for 7% of all femoral fractures. If hip Fractures are excluded, 31% of femoral fractures involve distal portion. Although openreduction and internalfixation with plate and screws has Become a standard method of treatment for many types of fractures, the Management of comminuted, intraarticulardistal femoral fractures still remains Complex and challenging to the orthopaedic surgeon. Many of these fractures are the result of high energy trauma which generates severe soft tissue damage and articular and metaphyseal communition.
The goal of openreduction and plate fixation is to re- store articular congruity and axial alignment to prevent post-traumatic osteoarthritis. Additionally, open reduc- tion and plate fixation allows for early mobilisation and may theoretically lead to a more rapid recovery and bet- ter functional outcome [13, 14]. Especially in the young and working population, but also in the elderly patients, this could be an advantage. Moreover, redisplacement rates up to almost 60 % are encountered in patients treated with closed reduction and plaster immobilisation, especially in those with type C fractures [15–19]. How- ever, with nonsurgical treatment the standard risks for undergoing a surgical procedure and the risk of hard- ware removal, tendon rupture and neurovascular dam- age are avoided. Moreover, we know that especially patients over 65 years of age have a lower disutility for painful malunion . Though, plaster immobilisation is not without risks either. Pressure neuropathy of the superficial radial nerve, Complex Regional Pain Syn- drome and stiffness of the wrist can occur.
Abstract: Objective: We aimed to compare both functional and radiological outcomes of AO classification type C1 distal radial fractures managed using volar locking plates and percutaneous K-wire fixation. Materials and methods: In total, 15 patients were included in group 1, in which openreduction and internalfixation using volar locking plates were performed, whereas 15 patients were included in group 2, in which closed reduction and percutaneous K-wire fixation were utilized. In both groups, the functional outcomes were evaluated according to the Gartland-Werley scoring system. The Knirk and Jupiter scoring system was used to classify arthritic changes. Stewart’s radiological assessment criteria were used in angular assessments. Grip strength measurement was performed. Results: At the end of the follow-up, a significant difference was detected between the groups in volar tilt value (P<0.05) but not in radial inclination and radial length (P>0.05). Significant differences were detected in the Gartland-Werley score and the mean Knirk and Jupiter score between the two groups (P<0.05). No significant difference was found in the mean Stewart score between the groups (P>0.05). Conclusion: It was concluded that K-wire fixation seems insufficient in distalradiusfractures of the complex intra-articular type.
The ORCHID (OpenReduction and internalfixationversus Cast immobilization for Highly comminuted, Intra-articularfractures of the Distalradius) trial is a pragmatic, multi-center RCT that aims at evaluating dif- ferences in patient-centered outcomes between two major options (i.e., volar locked plating versus closed reduction and cast stabilization) for treating wrist frac- tures in an elderly population. 600 patients will be recruited at 15 hospitals of various levels of care and associated private practices throughout Germany. It is expected that 150 patients are recruited during the first year after the initiation of all centers, followed by recruitment of 300 and 150 patients in the subsequent years.
There was a significant difference in the final outcome in both the study groups, assessed using The Modified Green O‟Brien System. However, we preferred using the external fixator application in the treatment of intra-articularfractures of the distalradius (Frykman Type VII and VIII). Although openreduction and internalfixation has advantages such as direct visualization and manipulation of the fracture segments, stable fixation and the possibility of immediate postoperative motion but we preferred the use of external fixator since it provides continuity of reduction under fluoroscopic control, improved reduction by ligamentotaxis, 15 and the ability to protect the reduction until
In the volar locked plating technique, the skin was incised longitudinally along the course of the flexor carpi radialis (FCR) tendon. The FCR sheath was opened and the tendon retracted to the radial side to expose the ulnar corner of the distalradius (this can be extended into a carpal tunnel release). The FCR tendon was also retracted to the ulnar side to expose the radial styloid and scaphoid fossa. Great care was taken to avoid pressure on the median nerve. Underneath the FCR sheath lies the flexor pollicis longus (FPL) tendon. This was retracted ulnarly revealing the pronator quadratus (PQ) muscle. The PQ muscle was elevated from its radial origin and reflected ulnarly to expose the distalradius. If the fracture was very distal, it was not necessary to completely elevate this muscle. The palmar extrinsic radiocarpal ligaments should not be detached from the radius to expose the joint surface as this
Human mandible is shown to exhibit numerous complex combination of movements and torsion patterns, which must be considered when evaluating the stability of the osteosynthesis device 77 . Also miniature osteosynthesis devices become essential for stabilization of subcondylar fractures because of the usually small size of condylar fragments. It is also mandatory to place these plates along “Ideal line of osteosynthesis’’ for dictating predictable outcome. Champy et al 1976 6 experimentally located these strain lines in the mandibular body, symphysis and angle region. Later Meyer et al 7 proposed ideal lines of osteosynthesis in condylar region.
Abstract: Background: Although operative fixation with a volar locking plate is becoming increasingly popular for treatment of distalradiusfractures, it is not clear whether it is superior to other conventional treatment methods such as percutaneous fixation with Kirschner wires. The present meta-analysis compared the effects of internalfixation with volar locking plates and percutaneous fixation for the treatment of distalradiusfractures. Methods: A literature search was performed without language restrictions and all randomized controlled studies comparing the effects of volar locking plates and percutaneous fixation for the treatment of distal radial fractures were included. Data of function scores, range of motion, grip strength, radiographic results, and complications were pooled and analyzed with a standard meta-analytical method. Results: Seven studies in seven publications were included. Pooled data indicated that there were no significant differences in Patient-Related Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores between the two treatment methods postoperatively. Fixation with volar locking plates took significantly longer than percutaneous fixation. There was a significant differ- ence in supination and grip strength favoring volar locking plate fixation at 3 and 6 months but not at ≥12 months, postoperatively. The final complication rates were similar in the two treatment groups. Conclusion: In the manage- ment of distalradiusfractures, volar locking plate and percutaneous fixation yielded similar outcomes, while the former had the advantage of supination and grip strength in the early stage postoperatively. Percutaneous fixation was quicker to perform than volar locking plate fixation.
satisfactory results in 37 patients with a minimum follow up interval of 6 months. Less dramatic results were reported by a variety of authors when the plafond fractures studied included larger numbers of high energy injuries. Bourne et al 2 studied 42 patients with tibial plafond fractures, 62% of whom were victims of high-energy trauma. Of the 16 Ruedi type III fractures treated by openreduction and internalfixation, only 44% had satisfactory result. The majority of these fractures were complicated by nonunion (25%), infection (13%) and arthrodesis (32%).
The FCE rate for internalfixation of leg fractures varies from 0.34 per 10,000 residents in Doncaster to 1.11 in Nottingham. The Trent average is 0.7 FCEs per 10,000 residents. For a typical district of 500,000 adult residents, this equates to an average of 35 internal fixations of the lower leg per annum, ranging from 17 to 56. In terms of lower leg fracture workload for this group of patients, the proportion of workload classified to internalfixation ranges from 13.8% in Doncaster to 27.4% in Nottingham. Performing a chi-square independence test to test the null hypothesis that the rate of internal fixations performed does not vary across Trent districts, leads to a rejection of the Null Hypothesis at the 1% level. In other words, there is strong statistical evidence that the rate of internal fixations for lower leg fractures varies across the Region. Whilst casemix could be an issue, there is no reason to believe that the casemix of fractures should vary greatly between Districts other than for age and occupational factors.
In the reported cases, the cancellous screws were passed from the non-articular area. Their direction was oblique, from front to back and from medial to lateral, fixing the trochlea to the capitulum. Alterna- tively, Herbert screws were inserted into the articular surface buried beneath the cartilage; their direction was perpendicular to the fracture line, securing the frag- ment of the trochlea to the posterior wall with maximum compression. We opted for this type of osteosynthesis be- cause it is more stable from a biomechanical point of view.