Scapula fractures occur in approximately 1% of all frac- tures and constitute about 3% - 5% of all injuries of the shoulder joint (1-3). Ten to forty percent of these involves scapular neck, and out of these, only 10% are displaced and indicative of operative intervention (1, 4-7). The most common mechanism of injury for scapular fractures is a direct and high energy violent impact, which frequently affects the body of the scapula. This violent force, which gets transmitted from the upper extremity to the scapula, has usually high energy (2). On the basis of the position of the arm and intensity of the impact at the time of the trauma, fractures of the glenoid surface may occur. Scapu- lae are well-protected by the nearby musculature; hence, displaced intra-articular fractures of the glenoid are rare fractures (8-10). However, with the increasing incidence of high-energy trauma, these types of fractures are no more rare in poly-trauma patients (11-15). Most of the scapular fractures are commonly treated satisfactorily with nonop-
Results: After proper analysis and doing statistical comparison, we got p- value of 0.568 for functional outcome and 0.468 for anatomical outcome which is considered insignificant. (significance of p value determined as <0.05). But with regard to individual parameters in the scores, we got significantly better results in the values of volar tilt, radial inclination and intraarticular step off in volar locking compression plate than dynamic external fixator. Regarding complications, among Ex fix group, 3 patients had superficial pin tract infection, one patient had deep infection, one had malunion and one had pin bending complications and among LCP group one had screw penetration into joint space and one had secondary collapse of the fracture.
Many studies reviewing various methods of fixation look at radiographic parameters that affect outcome, however few if any have looked at surgeon grade or time to surgery as we have. In a large radiographic study, Mackenney et al. showed that age over 80 years; metaphyseal comminution and positive ulna variance were the main predictors of instability. This and poor radio-carpal alignment were shown to be associated with poor outcome . However this study did not look at results after fixation with a volar locking plate, which has specific design applications for use in osteo- porotic unstable fracture patterns. We chose not to assess radiographic parameters such as residual intra- articular step, correction of normal distal radial anat- omy and presence of post traumatic osteoarthritis as we were interested purely in patient centered outcome and these radiographic features have consistently been Table 3 Time to Fracture Union with varying fracture type
was checked in the C-arm in antero-posterior and lateral views (Fig. 1). Reduction was achieved via manual traction and closed reduction method in all cases. Sterile betadine dressing of the pin tract site was performed. A below- elbow plaster of Paris slab was applied in all patients for 1 week. The external fixator was removed in all patients after 8 weeks. No extra wire was used in any patient since we were able to achieve reduction in fracture by use of pins only.
Our study has been conducted in locally to assess the functional outcome of unstable distalradiusfracture in adults treated with palmer T-plate Osteosynthesis. Palmer T- plate can be the choice of implant for fixation of unstable distalradius fractures. Use palmer T- plate provides the best mode of anatomical reduction and in addition to this their buttress modes reduces and stabilize vertical shear intra-articular fractures through an antiglide effect . The purpose for conducting this study is to achieve a validated data by assessing the postoperative range of motion by the use of validated DASH score (Disability of Arm, Shoulder and Hand) and assessment of degree of flexion & extension at wrist post operatively. Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH & confirming its usefulness across the whole extremity [12,13]. A very strong correlation was noted between DASH & other scoring systems making it reliable in evaluating a subjective outcome. Range of flexion and extension which is most important function of wrist is evaluated.
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.
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 failure 4 . Volar plating has gained widespread use over the past decade 5 .
Differences between treatment groups were assessed on an intention to treat basis, with a normal approximation for the PRWE score at three, six, and 12 months. Preplanned subgroup analyses for PRWE were based on the stratification by intra-articular extension and age ≥50 or <50. A secondary analysis based on the type of fixation provided (per treatment analysis) was also preplanned. We anticipated using a multilevel model to account for both surgeon and centre effects, but as most of the surgeons (88%; 215/244) operated on fewer than three patients, we used mixed effects linear regression models with a single random effect to account for recruiting centre to analyse the primary and secondary outcome measures. An analogously structured logistic regression model was used to analyse complications. Tests were two sided and considered to
The management of distalradius fractures has undergone a lot of changes over the past years. Initially, universal cast treatment gave way to bridging external fixator, which in turn was replaced by dorsal buttress plating. Then palmar locked plate came into prominence. Outcome following treatment, especially in articular fractures depend upon anatomical reduction, restoration of articular congruency, stability of fixation and early mobilisation.
The fibular component also bifurcates in a similar fashion into anterior and posterior tubercles, anterior being more prominent and forma a convex triangle and forms an ideal counterpart for the concave tibial lateral surface. This medial aspect of distal fibula is the cristae incisurae fibularis. The anterior tubercle of the fibula is called the WAGSTAFFE TUBERCLE.
Duration of Surgery: In our study the average duration of surgery for Group 1 (External Fixator + K-wires) was 47.00±10.20 minutes, whereas in Group 2 (Plating) was 61.00±9.51 with significant p-value of < 0.001. In a study conducted by Shukla et al. mean surgery time was 35.1±2.5 mins in the external fixation group and 56.5± 2.7 mins in the volar platefixation group. Duration of Hospital Stay: In our study 14 (23%) patients were discharged after 3 days of hospital stay, 45 (75%) were discharged in 4-6 days, 7 (14%) and 1 (1.7%) in >6 days from the time of admission. Average duration of stay being 3.94 days. Average duration of the stay for the External Fixator group being 3.63 days, whereas with the plating group 4.23 days. Duration of hospital stay proved to be significant with a p-value of 0.028. Time to Fracture Union: In our study the average time to fracture union for the External Fixator group was 10.10±2.2 weeks, whereas for the Plating group it was 9.76±2.4 weeks, with a p- value of 0.592, which was not significant. This corresponds to a study done by Oliveira et al.
This is to certify that this dissertation titled “COMPARATIVE STUDY ON THE ANALYSIS OF FUNCTIONAL OUTCOME IN DISTALRADIUSARTICULAR FRACTURES TREATED BY CLOSED REDUCTION THROUGH BRIDGING EXTERNAL FIXATOR AUGMENTED WITH K-WIRES AND VOLAR-LOCKING PLATING” is a bonafide record of work done by DR. KEERTHY CHANDRA BASSETTY, during the period of his postgraduate study from July 2012 to September 2014 under guidance and supervision in the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai- 600003, in partial fulfillment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr. M.G.R. Medical University to be held in April 2015.
Distalradius fractures are among the most common fractures of the musculoskeletal system. Functional out- come usually correlates well with maintenance of the radiographic reduction and the bony healing. In com- minuted fractures of the distalradius, the use of bone grafts (autogenous, allograft, or in synthetic form) increases the structural stability at the fracture site and promotes bony union . Following widespread use of volar locked plating systems, however, routine use of the bone grafts, particularly in the acute setting is believed to be unnecessary, even in comminuted fractures, since these fixation systems provide significant stability at the fracture site [2-4]. In fact volar locking plate failure due to nonunion of the distalradius is rare with limited number of reports in the English literature [5-7]. In this study, we report a case of nonunion of the distalradius leading to failure of the hardware on an obese patient.
Specimens were thawed at room temperature on the day of testing. Skin and soft tissues were removed, and the wrist capsule and interosseous membrane, triangular disc, and the capsule of the distal radioulnar joint were left intact. A standardized 3-part intra-articular and severe comminuted fracture was simulated as reported previously with some modification [7,9]. Briefly, a 1-cm transverse gap was made at a point 2-cm proximal to the articular surface of the lunate fossa. A second sagital split osteotomy was performed between the scaphoid and lunate fossa under protection of the wrist and distal radioulnar joints, creating an unstable intra-articularfracture with both radial- and unlar-side fracture frag- ments. In addition, polymethyl methacrylate was mounted on the metacarpal bones of each specimen to simulate axial loading of the distalradius across the intact wrist at full extension (Figure 1). Specimens were then fixed with the Acu-Loc® volar plate system (Acumed, Hillsboro, OR). Two locking screws were used to fix the ulnar fragment and 2 more to fix the radial fragment, while 2 locking screws and one cortical screw were used to fix the proximal fragment. In addition, the radial fragment was fixed with (+) or without (-) 2 lock- ing screws targeting the radial styloid (Figure 2).
Mean age in our study was 38.5 years with maximum patients in age group of 18-50 years (80%) which comparable with other studies (21) . Males predominated our study with 27 male patients and 13 female patients .The increased incidence of male sex in distal end radius can be attributed to an over whelming large proportion of male patients and high outdoor activities and the female population largely work indoors (21). Right hand was slightly more involved than left hand. RTA and fall from height was mode of trauma in 85% cases. Around 62.5 % of the study population had type III or type IV fracture according to Frykman’s classification. Similar results
Fixation with the 3.5 mm Medial Distal tibial LCP has many similarities to the traditional platefixation methods, with a few important improvements. The technical innovation of locking screws provides the ability to create a fixed angle construct while using familiar AO plating techniques. Locking capability is important for fixed angle constructs in osteopenic bone or multifragmentary fractures where screw purchase is compromised. These screws do not rely on plate to bone compression to resist patient load, but function similarly to multiple, small, angled blade plates. The fixation of this implant can be done in both MIPPO or routine open reduction technique.
Several factors have already been reported to predict the outcome of the volar plating system for the DRF. Age, AO classification, distal radial ulnar joint injury, ulnar styloid fracture and initial displacement are pre- dictive of reduction loss and knowing that these factors are predictive can aid in early decision-making as to the method of treatment [10, 11]. Age, sex and size of dorsal cortex comminution can be used to predict the late dor- sal tilt angulation of distalarticular surface of radius at the end of the immobilization . An increase in ar- ticular cavity depth and anteroposterior distance of the lunate fossa should be avoided when performing platefixation to improve results following distalintra-articularradius fractures . Flexor pollicis longus tendon rup- ture is a common complication leading to worse func- tional outcome after VLP for DRF. Selvan DR et al.  found that the risk of flexor pollicis longus tendon rup- ture decreased if the radial tilt was close to normal values after fracture reduction and the closer the distal end of the plate is to the joint, the risk of pollicis longus tendon ruptures increased. Kitay A et al.  also re- ported that plate position associated with attritional flexor tendon rupture following DRF with VLP. The rup- ture risk increased when plate prominence was greater than 2.0 mm volar to the critical line or plate position was within 3.0 mm of the volar rim.
Pooling the data from four RCTs [9–11, 13], our meta- analysis found that grip strength was significantly better in patients with VLP fixation at 3 and 6 months postop- eratively, with no significant difference at 12 months postoperatively. We found range of wrist flexion and su- pination to be significantly better in patients with VLP fixation at 3 and 6 months, again with no significant dif- ference, compared to patients with K-wire fixation, at 12 months. There were no differences for other ROMs of the wrist between the two patient groups. In our ana- lysis, we presumed that patient-reported function and satisfaction, as recorded by the DASH, was partially re- lated to objective assessments of wrist and hand function (i.e. ROM and grip strength) following DDDRF, which could explain statistical differences in grip strength be- tween the two patient groups over the early postopera- tive period. But the ROMs of the wrist and grip strength between the two patient groups are also similar at 1 year. Even extension and pronation do not show any difference
The primary function of the intermediate column is load transmission and the medial or the ulnar column serves as an axis for forearm and wrist rotation as well as a post for secondary load transmission. Close reduction and cast immobilization has been the mainstay of treatment of these fractures but malunion of fracture and subluxation/ dislocation of distal radioulnar joint and radiocarpal joint resulting in poor functional and cosmetic results is the usual outcome.
After eight weeks of postoperative care, a CT scan of the operated forearm was acquired to verify consoli- dation. As described in a previous publication , the residual malalignment error was measured by comparing the planned model with the postoperative result in 3D. Additionally, the postoperative plate and screw position was compared to the position in the 3D planning. Only if the distal part of the postopera- tive radius was present in the postoperative CT scan, axial alignment of the postoperative bone model with the model of the malunion was performed as follows: After superimposing, using the Iterative Closest Point (ICP) sur- face registration algorithm , the exact visual alignment of the cortical cross-section, on the proximal end of both models, was conducted by displaying the postoperative bone model in transparency mode (Fig. 3). The residual malalignment error was measured by calculating the rela- tive transformation between the distalradius parts in