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The results of external fixation of the radius in the treatment of comminuted intraarticular fractures of the distal end
THE RESULTS OF EXTERNAL FIXATION OF THE RADIUS THE TREATMENT OF COMMINUTED INTRAARTICULAR FRACTURES OF THE DISTAL END
IN
M. BISHAY, X. AGUILERA,J. GRANT andD. R. DUNKERLEY From the Bath and Wessex Orthopaedic Research Unit, Wolfon Centre, Royal United Hospital NHS Trust, Bath, UK
14 unstable comminuted intraarticular fractures of the distal radius were treated by the use of the A/O mini-external fixator. The distal pins were inserted in the distal fragment, thus leaving the wrist joint free to mobilize. Clinical results were assessed at 3 to 12 months using the Sarmiento demerit point system. Nine were male and five female, with a mean age of 37 years. Ten fractures were closed and four were open. 11 patients (78.5%) had an excellent functional score and three (21.5%) had a good score. All patients had normal wrist morphology with an average radial length of 11 mm, radial angle of 23” and a mean volar angle of 12”. 12 patients had anatomical radio-carpal and radio-ulnar joints and two patients had a step less than 2 mm at the radio-carpal surface. This method has proved in our experience to be reliable in maintaining the position as well as allowing early functional recovery. Journal of Hand Surgery (British and European Volume, 1994) 19B: 378-383 Comminuted intraarticular fractures of the radius are difficult to manage. Manipulative reduction is possible but maintenance of the position in a cast is extremely difficult and is associated with a high rate of complications. Analysis of different treatment methods showed poor clinical results in 39% of young adults and late radiographs revealed post-traumatic arthritis in 65% (Knirk and Jupiter, 1986), usually associated with an unreduced die-punch fragment, (Green, 1975; Knirk and Jupiter, 1986). Biplane external fixators were used by Cooney et al (1979) but the recovery period was prolonged and the early results were poor in terms of hand function, although at 2 years both hand and wrist movement reached a good level. Clyburn ( 1987) devised a dynamic wrist fixator which allowed early movement and produced better earlier results. However, it required extension block in the early stage to prevent loss of the natural volar tilt. It also used the second metacarpal for location of the distal pins, causing tethering of the extensor tendons and limitation of flexion of the index finger (Vaughan et al, 1985; Schuind et al, 1989). We present the results of the use of the mini A0 external fixator in a series of comminuted intraarticular distal radial fractures in which the fixator was used without spanning the wrist joint, thus allowing early hand and wrist movement. Our functional results comprised 78.5% excellent and 21.2% good scoring. These compared favourably with published results of the same type of fractures in a similar group of patients. Frykman (1967) reported 79 to 87% poor function following plaster treatment. Szabo and Weber (1988) reported on 68 patients, treated by pin and plaster and 13 treated by external fixation with loss of palmar angulation in all patients despite many attempts at re-manipulation. This was also accompanied by a 50% complication rate in the pin and plaster group and 61% complication rate in the external fixator group.
Bradway et al (1989) reported the Mayo Clinic results of open reduction and internal fixation with 56% excellent results, 25% good and 19% fair. PATIENTS AND METHODS 14 patients were admitted to hospital with cornminuted intraarticular fractures of the distal radius. All were considered unstable by Cooney’s three criteria (Cooney, 1989): 1. Gross comminution 2. Intraarticular involvement (step off > 2 mm) 3. More than 25” dorsal or volar angulation. All fractures were Frykman’s type 7 and 8 with bi-articular involvement (Fig 1, Frykman, 1967). They were treated by the use of the A/O miniexternal fixator with 2.5 mm self-drilling, self-tapping pins (Fig 2) inserted under general or local anaesthesia. Operative method Under image intensifier control two pins are inserted into the distal fragments with attempts being made to reduce the die-punch fragment by levering this distally with the pins. Care must be taken to avoid transfixing the extensor or the abductor tendons. The direction of the distal pins depends on the degree and direction of displacement of the articular fragments. Two proximal pins are then inserted into the radial shaft followed by closed reduction of the fracture and construction of the external fixator with cross-bars to achieve stability. Where a large gap is noted at the fracture site, bone graft is introduced through a 1 cm dorsal incision and packed into the fracture site through the drill guide (Fig 3). A light dressing is then applied, and physiotherapy, with early mobilization of both the hand and the wrist, commences immediately post-operatively 378
319
EXTERNAL FIXATION OF THE RADIUS
Fig 1
Radiograph of the injured wrist with bi-articular involvement.
Fig 3
Fig 2
(a) Radiograph of an injured wrist showing impaction and bone loss. (b) Radiograph of the same wrist after external fixation and bone grafting.
Radiograph of the same wrist after external fixation.
Functional evaluation
(Fig 4). The patient is discharged the morning after surgery and attends out-patient physiotherapy. Check X-rays are performed in out-patients at 1,2 and 3 weeks post-operatively. The fixator is removed at 6 weeks in out-patients without anaesthesia and physiotherapy is continued until the patient regains full mobility. Assessment method
Clinical results were assessed between 3 and 12 months by an independent senior hand physiotherapist and by one of the authors.
Objective evaluation of the functional outcome was performed using the demerit point system of Sarmiento et al (1975). This system adds demerit points depending on several assessments, including those shown in Table 1. The grading of the results is shown in Table 2. Hand and wrist function were assessed using the active range of motion, hand grips and dexterity as indicators. The fist and pinch grip power were assessed using a Jamar digital hand dynamometer (Asimow Engineering; Los Angeles, California). Supination
THE JOURNAL OF HAND SURGERYVOL. 19BNo. 3 JUNE 1994
380
Fig 4
(a-d) Same patient as in Figure 3, 10 days following external fixation demonstrating the range of active movement.
Table l-The
demerit point system
Assessment
Demerit point
Residual deformity (dorsal and radial tilt) Subjective evaluation (pain and limitation of function) Objective evaluation (range of motion and strength) Complications (nerve damage, finger stiffness and arthritis)
Table 2-Grading
o-3 O-6 o-17 o-5
of results Grade
Excellent Good Fair Poor
Score
o-2 3-8 9-20 >21
power was assessed by simultaneous supination against the resistance of the examiner’s hands.
ing and radial angle (Van der Linden and Ericson, 1981). The intraarticular anatomy was assessed by the criteria of Knirk and Jupiter (1986). RESULTS 14 consecutive patients were included in this study. Nine were male and five female, with a mean age of 37 years (range 18-75). There were ten closed fractures and four open. In seven patients this was an isolated injury while seven had the distal radial fracture as part of multiple injuries. The fractures were caused by high velocity injuries: five patients were involved in road traffic accidents; eight fell from heights and one was injured in an explosion. We classified the fractures by Frykman’s method and also by the A0 classification. Details of the fracture types are shown in Table 3. Seven fractures were treated by primary external fixation, three of which required a bone graft. Seven patients received delayed fixation after a period of Table 3-Classification Frykman
Radiographic analysis At union both wrists were X-rayed. The extraarticular anatomy was assessed by the dorsal tilt, radial shorten-
of the fractures treated
VII VIII
AI0 5
c2
7
9
c3
7
EXTERNAL
381
FIXATION OF THE RADIUS
radio-ulnar joints (grade 0 incongruity), two patients had a step less than 2 mm at the radio-carpal surface. One of the latter also had an incongruous radio-ulnar joint due to a comminuted fracture of the ulnar head.
plaster treatment, the indications for external fixation being skin complications in one, median nerve compression in two and instability in four. Delay in external fixation varied between 10 to 17 days. 12 patients had general anaesthesia and the remaining two had local anaesthesia using haematoma block and subcutaneous infiltration with 1% plain lignocaine. One patient required K-wire stabilization of the distal radioulnar joint and one patient had two separate fixators for multiple open metacarpal fractures. The average hospital stay for an isolated injury was 20 hours but those who had multiple injuries required hospitalization for longer periods.
Early complication
One patient had irritation of the superficial radial nerve and two had superficial pin site infections. There were no vascular injuries, no tendon injuries and no deep infections. No late complications were found at 12 months. DISCUSSION
Comminuted intraarticular fractures of the distal radius have been classified by different systems. Gartland and Werley (1951) classified them as type 3 and Depalma (1952) followed the same classification. Lidstrom (1959) classed them as type 2E. Frykman (1967) devised his classification to take into account the prognostic value of the fracture typing. In our series all were Frykman’s types 7 and 8. In the A0 classification of fractures they were types C2 and C3. Whichever classification of distal radial fractures is used, they are characterized by bi-articular involvement of both radio-carpal and distal radio-ulnar joints, often with a depressed die-punch fragment. Due to the comminution and the impaction of the cancellous bone they are always associated with radial shortening and a residual tilt with a tendency to affect the congruity of the distal radio-ulnar joint. Many authors have demonstrated the direct relationship between restoration of the anatomy and the functional end result (Bacorn and Kurtzke, 1953; Melone, 1984; Szabo and Weber, 1988; Jenkins et al, 1988; Bradway et al, 1989; Jupiter, 1991).
Functional outcome
11 patients (78.5%) an had excellent functional score with no demerit points. Three (21.5%) had a good result with two demerit points. These were in the group that received secondary treatment. The range of motion, power-grip and pinch strength were expressed as a percentage of the normal opposite side. Details are shown in Table 4. Anatomical
outcome
All patients had excellent wrist morphology with no residual tilt or deviation at the distal radius. The average radial length was 11 mm (range 9 mm-15 mm), the average radial angle was 23” (range 15”-26”) and the mean volar angle was 12” (range 7”-19”). Details of the radiological outcome are shown in Table 5, (expressed as the difference from the uninjured side). Figures 5a and b demonstrate comparable radiographs of the injured and uninjured wrists at 12 months. 12 patients had anatomical radio-carpal as well as Table 4-Functional
outcome expressed as percentage of normal side 1
2
3
4
5
6
7
8
9
10
11
12
13
14
100 100 100 100 100 100 100 100 90 100
100 95 84 100 100 100 100 90 90 100
100 60 75 100 100 100 100 110 110 100
100 II 100 100 100 100 100 110 110 100
50 19 73 89 85 57 100 25 50 150
64 69 67 100 100 100 100 58 75 90
60 64 78 84 67 75 100 33 67 100
33 50 50 40 57 30 100 41 66 50
89 110 89 100 90 67 80 34 80 100
53 100 110 100 120 98 100 90 280 100
100 80 100 100 100 100 100 50 70 100
64 69 100 100 100 100 100 79 88 100
90 90 85 80 70 70 100 80 95 86
40 50 33 33 50 50 90 30 50 50
9
10
I1
12
13
14
1 0 0
-1
Patients Extension Flexion Supination Pronation Ulnar deviation Radial deviation Thumb flexion Power grip Pinch grip Supination power
Table S-Radiological
Patients Radial Radial Dorsal
length mm angle” angle”
outcome expressed as difference from the normal side
I
2
3
0 0 2
0 2 3
-8
4 3 5
-1 0 5
5
6
7
2 0 6
-2 -3
-3 8
1 4
8 0 0 -4
0 2 -3
3 -1 -1
2 1
0 2 -4
1 3 2
382
THE JOURNAL OF HAND SURGERY VOL. 19B No. 3 JUNE 1994
Different papers have described the use of external fixators using a ligamento-taxis effect between the radial shaft and the second metacarpal shaft, with different degrees of success. (Cooney et al, 1979; Vaughan et al, 1985; Prince and Warlock, 1988; Szabo and Weber, 1988; Kongsholm and Olerud, 1989; Schuind et al, 1989; Riss and Fruensgaard, 1989; Horesh et al, 1991; Fernandez et al, 1992). External fixation offers an attractive solution to the problem of the unstable fracture, producing a stable reduction that can be maintained until union. However, ligamento-taxis may result in stiffness of the wrist, and return of a functional range of motion may be delayed for up to 2 years (Cooney et al, 1979). Bradway et al (1989) suggested the use of the external fixator as a neutralization device used with open reconstruction and bone grafting. Open reduction and internal fixation is difficult in view of the gross comminution and the close proximity of the fracture to the wrist joint. The method described in this paper has the advantage of being only semi-invasive yet it enables accurate reduction by placing the distal pins in various components of the fracture, dependent on the degree and direction of displacement of the articular fragments (Melone, 1984). This method has proved in our experience to be reliable in maintaining the fixation as well as allowing early active movement. The anatomical and functional results represent an improvement on previous reports of similar fractures treated by external or internal fixation. There have been no major complications and pin track infection has not been a problem; the two cases where this developed settled with frequent dressings and did not require removal of the pins. We recommend this technique in the treatment of intraarticular fractures of the distal radius. Acknowledgment The authors would like to thank Mr Tutty and Mrs Woolhouse of the department of medical illustration for their help in producing the photographs, also Mrs Wiggins of the research department for her help with the manuscript.
References
Fig 5
(a-b) Radiographs of both wrists of the same patient as in Figure 3 at 12 months review. *The injured right side demonstrate an ulnar nlus variant as a conseauence of 2 mm radial shortening. This remained asymptomati; although it may lead to future impingement.
Frykman (1967) reported that treatment by manipulation and plaster of his type 7 and 8 fractures gave poor results and impaired mobility in 79% and 87% respectively. Szabo and Weber (1988) reported a 50% complication rate in treatment by pin and plaster. They also showed that treatment by distraction can restore radial length and alignment but may increase intraarticular displacement. ‘,
BACORN, R. W. and KURTZKE, J. F. (1953). Colles’ fracture: A study of 2000 cases from the New York State Workmen’s Compensation Board. Journal of Bone and Joint Surgery, 35A: 3: 643-659. BRADWAY, J. K., AMADIO, P. C. and COONEY, W. P. (1989). Open reduction and internal fixation of displaced, comminuted intrarticular fractures of the distal end of the radius. Journal of Bone and Joint Surgery, 71A: 6: 839-847. CLYBURN, T. A. (1987). Dynamic external fixation for cornminuted intraarticular fractures of the distal end of the radius. Journal of Bone and Joint Surgeky, 69A: 2: 248-254. COONEq, W. P. (1989). Editorial: Management of Colles’ fractures. Journal of H&d Surgery, 14B: 2: 137-139. COONEY, W. P., LINSCHEID, R. L. and DOBYNS, J. H. (1979). External uin fikation for unstable Colles’ fractures. Journal of Bone and Joint surgery,61A: 6: 840-845 DEPALMA, A. F. (1952). Comminuted fractures of the distal end of the radius treated by ulnar pinning. Journal of Bone and Joint Surgery, 34A: 3: 651-662. FERNANDEh, A., LEON, H., NIN, F. and MASLIAH, R. (1992). A simple external fix tion frame for the treatment of distal radius fractures. A 0 / ASIF Dialoa&ue, 5: 2: 5-8. FRYKMAN, C. ~~9&7).Fjractures of the distal radius including sequelae, should-
EXTERNAL
FIXATION
383
OF THE RADIUS
er-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthopaedica Scandinavica, Suppl. 108. GARTLAND, J. J. and WERLEY, C. W. (1951). Evaluation of healed Colles’ fractures. Journal of Bone and Joint Surgery, 33A: 4: 895-907. GREEN, D. P. (1975). Pins and plaster treatment of comminuted fractures of the distal end of the radius. Journal of Bone and Joint Surgery, 57A: 3: 3044310. HORESH, Z., VOLPIN, G., HOERER, D. and STEIN, H. (1991). The surgical treatment of severe comminuted intraarticular fractures of the distal radius with the small A0 external fixation device. Clinical Orthopaedics and Related Research, 263: 147-153. JENKINS, N. H., JONES, D. G. and MINTOWT-CZYZ, W. J. (1988). External fixation and recovery of function following fractures of the distal radius in young adults. Injury, 19: 235-238. JUPITER, .I. B. (1991). Current concepts review: Fractures of the distal end of the radius. Journal of Bone and Joint Surgery, 73A: 3: 461-469. KNIRK, J. L. and JUPITER, J. B. (1986). Intraarticular fractures of the distal end of the radius in young adults. Journal of Bone and Joint Surgery, 68A: 5: 647-659. KONGSHOLM, J. and OLERUD, C. (1989). Plaster cast versus external fixation for unstable intraarticular Colles’ fractures. Clinical Orthopaedics and Related Research, 241: 57-65. LIDSTROM, A. (1959). Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthopaedica Scandinavica (suppl) 41.
MELONE, C. P. (1984). Articular fractures of the distal radius. Orthopedic Clinics of North America, 15: 2: 217-236. PRINCE, H. and WORLOCK, P. (1988). The small A0 external fixator in the treatment of unstable distal forearm fractures. Journal of Hand Surgery, 13B: 3: 294-297. RIIS, .I. and FRUENSGAARD, S. (1989). Treatment of unstable Colles’ fractures by external fixation. Journal of Hand Surgery, 14B: 2: 145-148. SARMIENTO, A., PRATT, G. W., BERRY, N. C. and SINCLAIR, W. F. (1975). Colles’ fractures. Functional bracing in supination. Journal of Bone and Joint Surgery, S7A: 3: 311-317. SCHUIND, F., DONKERWOLCKE, M., RASQUIN, C. and BURNY, F. (1989). External fixation of fractures of the distal radius: A study of 225 cases. Journal of Hand Surgery, 14A: 2(2): 405-407. SZABO, R. M. and WEBER, S. C. (1988). Cornminuted intraarticular fractures of the distal radius. Clinical Orthopaedics and Related Research, 230: 39-48. VAN DER LINDEN, W. and ERICSON, R. (1981). Colles’ fracture: How should its displacement be measured and how should it be immobilized? Journal of Bone and Joint Surgery, 63A: 8: 1285-1288. VAUGHAN, P. A., LUI, S. M., HARRINGTON, I. J. and MAISTRELLI, G. L. (1985). Treatment of unstable fractures of the distal radius by external fixation. Journal of Bone and Joint Surgery, 67B: 3: 385-389.
Accepted: 2 February 1994 M. Bishay FRCS. W&son Centre, Royal United Hospital Q 1994 The British
Society
for Surgery
of the Hand
NHS
Trust,
Bath BAl
3NG,
UK.
IN
M. BISHAY, X. AGUILERA,J. GRANT andD. R. DUNKERLEY From the Bath and Wessex Orthopaedic Research Unit, Wolfon Centre, Royal United Hospital NHS Trust, Bath, UK
14 unstable comminuted intraarticular fractures of the distal radius were treated by the use of the A/O mini-external fixator. The distal pins were inserted in the distal fragment, thus leaving the wrist joint free to mobilize. Clinical results were assessed at 3 to 12 months using the Sarmiento demerit point system. Nine were male and five female, with a mean age of 37 years. Ten fractures were closed and four were open. 11 patients (78.5%) had an excellent functional score and three (21.5%) had a good score. All patients had normal wrist morphology with an average radial length of 11 mm, radial angle of 23” and a mean volar angle of 12”. 12 patients had anatomical radio-carpal and radio-ulnar joints and two patients had a step less than 2 mm at the radio-carpal surface. This method has proved in our experience to be reliable in maintaining the position as well as allowing early functional recovery. Journal of Hand Surgery (British and European Volume, 1994) 19B: 378-383 Comminuted intraarticular fractures of the radius are difficult to manage. Manipulative reduction is possible but maintenance of the position in a cast is extremely difficult and is associated with a high rate of complications. Analysis of different treatment methods showed poor clinical results in 39% of young adults and late radiographs revealed post-traumatic arthritis in 65% (Knirk and Jupiter, 1986), usually associated with an unreduced die-punch fragment, (Green, 1975; Knirk and Jupiter, 1986). Biplane external fixators were used by Cooney et al (1979) but the recovery period was prolonged and the early results were poor in terms of hand function, although at 2 years both hand and wrist movement reached a good level. Clyburn ( 1987) devised a dynamic wrist fixator which allowed early movement and produced better earlier results. However, it required extension block in the early stage to prevent loss of the natural volar tilt. It also used the second metacarpal for location of the distal pins, causing tethering of the extensor tendons and limitation of flexion of the index finger (Vaughan et al, 1985; Schuind et al, 1989). We present the results of the use of the mini A0 external fixator in a series of comminuted intraarticular distal radial fractures in which the fixator was used without spanning the wrist joint, thus allowing early hand and wrist movement. Our functional results comprised 78.5% excellent and 21.2% good scoring. These compared favourably with published results of the same type of fractures in a similar group of patients. Frykman (1967) reported 79 to 87% poor function following plaster treatment. Szabo and Weber (1988) reported on 68 patients, treated by pin and plaster and 13 treated by external fixation with loss of palmar angulation in all patients despite many attempts at re-manipulation. This was also accompanied by a 50% complication rate in the pin and plaster group and 61% complication rate in the external fixator group.
Bradway et al (1989) reported the Mayo Clinic results of open reduction and internal fixation with 56% excellent results, 25% good and 19% fair. PATIENTS AND METHODS 14 patients were admitted to hospital with cornminuted intraarticular fractures of the distal radius. All were considered unstable by Cooney’s three criteria (Cooney, 1989): 1. Gross comminution 2. Intraarticular involvement (step off > 2 mm) 3. More than 25” dorsal or volar angulation. All fractures were Frykman’s type 7 and 8 with bi-articular involvement (Fig 1, Frykman, 1967). They were treated by the use of the A/O miniexternal fixator with 2.5 mm self-drilling, self-tapping pins (Fig 2) inserted under general or local anaesthesia. Operative method Under image intensifier control two pins are inserted into the distal fragments with attempts being made to reduce the die-punch fragment by levering this distally with the pins. Care must be taken to avoid transfixing the extensor or the abductor tendons. The direction of the distal pins depends on the degree and direction of displacement of the articular fragments. Two proximal pins are then inserted into the radial shaft followed by closed reduction of the fracture and construction of the external fixator with cross-bars to achieve stability. Where a large gap is noted at the fracture site, bone graft is introduced through a 1 cm dorsal incision and packed into the fracture site through the drill guide (Fig 3). A light dressing is then applied, and physiotherapy, with early mobilization of both the hand and the wrist, commences immediately post-operatively 378
319
EXTERNAL FIXATION OF THE RADIUS
Fig 1
Radiograph of the injured wrist with bi-articular involvement.
Fig 3
Fig 2
(a) Radiograph of an injured wrist showing impaction and bone loss. (b) Radiograph of the same wrist after external fixation and bone grafting.
Radiograph of the same wrist after external fixation.
Functional evaluation
(Fig 4). The patient is discharged the morning after surgery and attends out-patient physiotherapy. Check X-rays are performed in out-patients at 1,2 and 3 weeks post-operatively. The fixator is removed at 6 weeks in out-patients without anaesthesia and physiotherapy is continued until the patient regains full mobility. Assessment method
Clinical results were assessed between 3 and 12 months by an independent senior hand physiotherapist and by one of the authors.
Objective evaluation of the functional outcome was performed using the demerit point system of Sarmiento et al (1975). This system adds demerit points depending on several assessments, including those shown in Table 1. The grading of the results is shown in Table 2. Hand and wrist function were assessed using the active range of motion, hand grips and dexterity as indicators. The fist and pinch grip power were assessed using a Jamar digital hand dynamometer (Asimow Engineering; Los Angeles, California). Supination
THE JOURNAL OF HAND SURGERYVOL. 19BNo. 3 JUNE 1994
380
Fig 4
(a-d) Same patient as in Figure 3, 10 days following external fixation demonstrating the range of active movement.
Table l-The
demerit point system
Assessment
Demerit point
Residual deformity (dorsal and radial tilt) Subjective evaluation (pain and limitation of function) Objective evaluation (range of motion and strength) Complications (nerve damage, finger stiffness and arthritis)
Table 2-Grading
o-3 O-6 o-17 o-5
of results Grade
Excellent Good Fair Poor
Score
o-2 3-8 9-20 >21
power was assessed by simultaneous supination against the resistance of the examiner’s hands.
ing and radial angle (Van der Linden and Ericson, 1981). The intraarticular anatomy was assessed by the criteria of Knirk and Jupiter (1986). RESULTS 14 consecutive patients were included in this study. Nine were male and five female, with a mean age of 37 years (range 18-75). There were ten closed fractures and four open. In seven patients this was an isolated injury while seven had the distal radial fracture as part of multiple injuries. The fractures were caused by high velocity injuries: five patients were involved in road traffic accidents; eight fell from heights and one was injured in an explosion. We classified the fractures by Frykman’s method and also by the A0 classification. Details of the fracture types are shown in Table 3. Seven fractures were treated by primary external fixation, three of which required a bone graft. Seven patients received delayed fixation after a period of Table 3-Classification Frykman
Radiographic analysis At union both wrists were X-rayed. The extraarticular anatomy was assessed by the dorsal tilt, radial shorten-
of the fractures treated
VII VIII
AI0 5
c2
7
9
c3
7
EXTERNAL
381
FIXATION OF THE RADIUS
radio-ulnar joints (grade 0 incongruity), two patients had a step less than 2 mm at the radio-carpal surface. One of the latter also had an incongruous radio-ulnar joint due to a comminuted fracture of the ulnar head.
plaster treatment, the indications for external fixation being skin complications in one, median nerve compression in two and instability in four. Delay in external fixation varied between 10 to 17 days. 12 patients had general anaesthesia and the remaining two had local anaesthesia using haematoma block and subcutaneous infiltration with 1% plain lignocaine. One patient required K-wire stabilization of the distal radioulnar joint and one patient had two separate fixators for multiple open metacarpal fractures. The average hospital stay for an isolated injury was 20 hours but those who had multiple injuries required hospitalization for longer periods.
Early complication
One patient had irritation of the superficial radial nerve and two had superficial pin site infections. There were no vascular injuries, no tendon injuries and no deep infections. No late complications were found at 12 months. DISCUSSION
Comminuted intraarticular fractures of the distal radius have been classified by different systems. Gartland and Werley (1951) classified them as type 3 and Depalma (1952) followed the same classification. Lidstrom (1959) classed them as type 2E. Frykman (1967) devised his classification to take into account the prognostic value of the fracture typing. In our series all were Frykman’s types 7 and 8. In the A0 classification of fractures they were types C2 and C3. Whichever classification of distal radial fractures is used, they are characterized by bi-articular involvement of both radio-carpal and distal radio-ulnar joints, often with a depressed die-punch fragment. Due to the comminution and the impaction of the cancellous bone they are always associated with radial shortening and a residual tilt with a tendency to affect the congruity of the distal radio-ulnar joint. Many authors have demonstrated the direct relationship between restoration of the anatomy and the functional end result (Bacorn and Kurtzke, 1953; Melone, 1984; Szabo and Weber, 1988; Jenkins et al, 1988; Bradway et al, 1989; Jupiter, 1991).
Functional outcome
11 patients (78.5%) an had excellent functional score with no demerit points. Three (21.5%) had a good result with two demerit points. These were in the group that received secondary treatment. The range of motion, power-grip and pinch strength were expressed as a percentage of the normal opposite side. Details are shown in Table 4. Anatomical
outcome
All patients had excellent wrist morphology with no residual tilt or deviation at the distal radius. The average radial length was 11 mm (range 9 mm-15 mm), the average radial angle was 23” (range 15”-26”) and the mean volar angle was 12” (range 7”-19”). Details of the radiological outcome are shown in Table 5, (expressed as the difference from the uninjured side). Figures 5a and b demonstrate comparable radiographs of the injured and uninjured wrists at 12 months. 12 patients had anatomical radio-carpal as well as Table 4-Functional
outcome expressed as percentage of normal side 1
2
3
4
5
6
7
8
9
10
11
12
13
14
100 100 100 100 100 100 100 100 90 100
100 95 84 100 100 100 100 90 90 100
100 60 75 100 100 100 100 110 110 100
100 II 100 100 100 100 100 110 110 100
50 19 73 89 85 57 100 25 50 150
64 69 67 100 100 100 100 58 75 90
60 64 78 84 67 75 100 33 67 100
33 50 50 40 57 30 100 41 66 50
89 110 89 100 90 67 80 34 80 100
53 100 110 100 120 98 100 90 280 100
100 80 100 100 100 100 100 50 70 100
64 69 100 100 100 100 100 79 88 100
90 90 85 80 70 70 100 80 95 86
40 50 33 33 50 50 90 30 50 50
9
10
I1
12
13
14
1 0 0
-1
Patients Extension Flexion Supination Pronation Ulnar deviation Radial deviation Thumb flexion Power grip Pinch grip Supination power
Table S-Radiological
Patients Radial Radial Dorsal
length mm angle” angle”
outcome expressed as difference from the normal side
I
2
3
0 0 2
0 2 3
-8
4 3 5
-1 0 5
5
6
7
2 0 6
-2 -3
-3 8
1 4
8 0 0 -4
0 2 -3
3 -1 -1
2 1
0 2 -4
1 3 2
382
THE JOURNAL OF HAND SURGERY VOL. 19B No. 3 JUNE 1994
Different papers have described the use of external fixators using a ligamento-taxis effect between the radial shaft and the second metacarpal shaft, with different degrees of success. (Cooney et al, 1979; Vaughan et al, 1985; Prince and Warlock, 1988; Szabo and Weber, 1988; Kongsholm and Olerud, 1989; Schuind et al, 1989; Riss and Fruensgaard, 1989; Horesh et al, 1991; Fernandez et al, 1992). External fixation offers an attractive solution to the problem of the unstable fracture, producing a stable reduction that can be maintained until union. However, ligamento-taxis may result in stiffness of the wrist, and return of a functional range of motion may be delayed for up to 2 years (Cooney et al, 1979). Bradway et al (1989) suggested the use of the external fixator as a neutralization device used with open reconstruction and bone grafting. Open reduction and internal fixation is difficult in view of the gross comminution and the close proximity of the fracture to the wrist joint. The method described in this paper has the advantage of being only semi-invasive yet it enables accurate reduction by placing the distal pins in various components of the fracture, dependent on the degree and direction of displacement of the articular fragments (Melone, 1984). This method has proved in our experience to be reliable in maintaining the fixation as well as allowing early active movement. The anatomical and functional results represent an improvement on previous reports of similar fractures treated by external or internal fixation. There have been no major complications and pin track infection has not been a problem; the two cases where this developed settled with frequent dressings and did not require removal of the pins. We recommend this technique in the treatment of intraarticular fractures of the distal radius. Acknowledgment The authors would like to thank Mr Tutty and Mrs Woolhouse of the department of medical illustration for their help in producing the photographs, also Mrs Wiggins of the research department for her help with the manuscript.
References
Fig 5
(a-b) Radiographs of both wrists of the same patient as in Figure 3 at 12 months review. *The injured right side demonstrate an ulnar nlus variant as a conseauence of 2 mm radial shortening. This remained asymptomati; although it may lead to future impingement.
Frykman (1967) reported that treatment by manipulation and plaster of his type 7 and 8 fractures gave poor results and impaired mobility in 79% and 87% respectively. Szabo and Weber (1988) reported a 50% complication rate in treatment by pin and plaster. They also showed that treatment by distraction can restore radial length and alignment but may increase intraarticular displacement. ‘,
BACORN, R. W. and KURTZKE, J. F. (1953). Colles’ fracture: A study of 2000 cases from the New York State Workmen’s Compensation Board. Journal of Bone and Joint Surgery, 35A: 3: 643-659. BRADWAY, J. K., AMADIO, P. C. and COONEY, W. P. (1989). Open reduction and internal fixation of displaced, comminuted intrarticular fractures of the distal end of the radius. Journal of Bone and Joint Surgery, 71A: 6: 839-847. CLYBURN, T. A. (1987). Dynamic external fixation for cornminuted intraarticular fractures of the distal end of the radius. Journal of Bone and Joint Surgeky, 69A: 2: 248-254. COONEq, W. P. (1989). Editorial: Management of Colles’ fractures. Journal of H&d Surgery, 14B: 2: 137-139. COONEY, W. P., LINSCHEID, R. L. and DOBYNS, J. H. (1979). External uin fikation for unstable Colles’ fractures. Journal of Bone and Joint surgery,61A: 6: 840-845 DEPALMA, A. F. (1952). Comminuted fractures of the distal end of the radius treated by ulnar pinning. Journal of Bone and Joint Surgery, 34A: 3: 651-662. FERNANDEh, A., LEON, H., NIN, F. and MASLIAH, R. (1992). A simple external fix tion frame for the treatment of distal radius fractures. A 0 / ASIF Dialoa&ue, 5: 2: 5-8. FRYKMAN, C. ~~9&7).Fjractures of the distal radius including sequelae, should-
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Accepted: 2 February 1994 M. Bishay FRCS. W&son Centre, Royal United Hospital Q 1994 The British
Society
for Surgery
of the Hand
NHS
Trust,
Bath BAl
3NG,
UK.