|Year : 2022 | Volume
| Issue : 3 | Page : 132-137
Functional outcome of distal end radius fractures managed with variable-angle locking plates: A prospective study
Manikandan Kumarasamy, K Naveen Kumar, AA Akashdeep, KP Uma Anand
Department of Orthopedics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
|Date of Submission||24-Jan-2022|
|Date of Decision||12-Mar-2022|
|Date of Acceptance||16-Mar-2022|
|Date of Web Publication||1-Sep-2022|
Department of Orthopedics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry
Source of Support: None, Conflict of Interest: None
Introduction: Management of distal end radius intraarticular fractures is difficult to manage and these fractures account for 10% of all fractures. Multiple treatment options ranging from conservative to internal fixation, of which volar plate fixation has emerged as an effective method of internal fixation in comparison with other fixed-angle locking plates as they ensure proper restoration of the articular surfaces and anatomical alignment. Materials and Methods: A hospital-based prospective study was conducted on 14 patients with distal end radius fractures admitted in our hospital from January 2019 to December 2019. Patients with distal end radius fractures treated with variable-angle locking plate were included and were followed-up minimum of 6 months. The results were analyzed based on radiological parameters and Mayo Wrist Score (MWS). Results: Of 14 patients, 11 were male patients and three were female patients. Seven patients had right-sided fracture whereas remaining seven patients had left-sided fractures. All 14 patients were treated with variable-angle locking plate. Among 14 patients, 12 patients achieved union by 12 weeks, only two patients achieved union by 24 weeks. Ten patients had excellent results while four patients had a good outcome based on MWS. All patients in our study had painless union without any complications. Conclusion: The use of variable-angle locking plates in distal end radius fractures helps to maintain perfect anatomical reduction, early mobilization, and better postoperative outcome.
Keywords: Distal radioulnar joint, distal radius fracture, Mayo Wrist Score, variable-angle volar locking plate, Volar Barton's fracture
|How to cite this article:|
Kumarasamy M, Kumar K N, Akashdeep A A, Uma Anand K P. Functional outcome of distal end radius fractures managed with variable-angle locking plates: A prospective study. J Orthop Dis Traumatol 2022;5:132-7
|How to cite this URL:|
Kumarasamy M, Kumar K N, Akashdeep A A, Uma Anand K P. Functional outcome of distal end radius fractures managed with variable-angle locking plates: A prospective study. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Dec 3];5:132-7. Available from: https://jodt.org/text.asp?2022/5/3/132/355248
| Introduction|| |
Fracture of the distal end of radius represents the most common fractures of the upper extremity accounting for 16% of all fractures treated by orthopedic surgeons. The global burden of these fractures increased tremendously in the recent past. Incidence of this injury appears to be both gender-and age-specific. While males sustain this injury at a younger age following high-energy trauma such as road traffic accident or fall from height, females sustain this injury due to increasing age and menopause following low-energy trauma resulting in osteoporotic fractures.,
The majority of these fractures are usually displaced. In early days, closed reduction and cast immobilization were the only mainstay of treatment for all these fractures but malunion, subluxation/dislocation of distal radio ulnar joint from redisplacement or collapse of fracture within the cast resulted in poor functional and cosmetic outcomes. In more complex fractures of distal radius, patients may not achieve complete freedom of movement in the wrist and forearm in addition to the decreased grip and pain that might continue for several months.
In cases of unstable or displaced fractures, numerous surgical interventions such as percutaneous pinning, closed reduction and external fixation, external fixation and percutaneous pinning, open reduction and fixation with pins, and internal fixation with either dorsal or volar plates are commonly tried. Many studies have suggested that open reduction and internal fixation techniques yield better patient outcomes in terms of better anatomical reduction, restoration of articular congruity, and early stability compared to the external fixation techniques.,,
Volar plate fixation has recently emerged as an effective method of internal fixation of unstable distal radius fractures in comparison with the conventional fixed-angle locking plates owing to the factors such as variable fracture patterns, plate geometry, and positioning. Variable-angle volar locking plate (VAVLP) is considered a better tool in managing the displacements which is frequently associated with distal end radius fractures as they ensure proper restoration of anatomic alignment, prevention of residual articular incongruence, and operative flexibility and targeted fixation.,, Nevertheless, the functional outcome of distal end radius fractures managed with variable-angle locking plates has not been extensively studied [Figure 1]. Hence, we have undertaken this study to assess the clinical and radiological outcomes of VAVLP fixation for distal radius fractures.
- To assess the clinical and radiological outcomes of VAVLP for fixation of distal end radius fractures
- To assess the complications associated with distal end radius fractures which are managed surgically with VAVLP.
| Materials and Methods|| |
It is a hospital-based prospective study conducted on patients who presented to casualty and the outpatient Department of Orthopaedics in Medical College and Hospital after obtaining permission from the Institutional Ethics Committee from January to December 2019. Based on the previous inflow of patients, the sample size was estimated to be 20. Universal sampling technique was adopted in this study. Our study included all patients of age 18 years and above with Type B and Type C (AO classification) distal end radius fractures, which are oblique, transverse, comminuted, and intraarticular fractures not more than 1 week old. Patients with nonosteoporotic pathological fractures, fractures with neurovascular deficit, and patients unfit for surgery were excluded from the study. The study participants were clinically examined and evaluated with anteroposterior and lateral view radiographs of the wrist [Figure 1]. Any features suggestive of distal radius fracture were noted. Clinical and radiological findings were correlated. Totally 14 patients were included in the study during the study. All Type B and C fractures were planned for surgery, after obtaining informed written consent from the patient. Preoperative radiological assessment using Lafontaine et al. criteria for instability was done. Once fit, the patient was taken for surgery. Standard operative procedures were followed and a senior orthopedic surgeon performed the surgery.
After patient preparation, the fracture site was reached using modified Henry's approach. The fracture fragments were then reduced and internal fixation using VAVLP which is stainless steel implant from NEBULA company, were used under fluoroscopic guidance [Figure 2]. The site was then washed thoroughly and the skin was closed in layers. Sterile dressing was then applied and the wrist was immobilized with either Plaster of Paris splint or a wrist immobilizer splint.
Postoperatively, the patient's operated limb was kept under elevation and dressing was done on postoperative days (POD) 2, 5, and 8. Sutures were removed on POD 11 routinely unless contraindicated. Wrist mobilization was usually commenced on the 5th day. Both active and passive mobilizations were encouraged. Postsurgery, the patient was on regular follow-up at 4, 8, 12, and 24 weeks. During each follow-up, the patient was evaluated clinically using Mayo Wrist Score (MWS) and Visual Analog Score for pain. Serial X rays were taken at 4, 8, 12, and 24 weeks to assess the radiological signs of union.
Guidelines for acceptable reduction of distal radius fractures include:
- Radial shortening <5 mm at the distal radioulnar joint (DRUJ) compared with the contralateral side
- Radial inclination on PA view >15°
- Sagittal tilt on the lateral view between 15° dorsal tilt and 20° volar tilt
- Intraarticular step-off or gap <2 mm of the radiocarpal joint
- Articular incongruity <2 mm of the sigmoid notch or the distal radius.
The results were entered and analyzed statistically using Epi Info software version 126.96.36.199 and software SPSS version 24.0 (IBM, India) was used for analysis. Frequencies and percentages were used for the nominal variables such as age, gender, mode of trauma, side involved, comorbidities, smoking, and outcome of surgery. The association of age, type of injury, time to union, and comorbidities were compared with the outcome of surgery using Chi-square test.
| Results|| |
Among the 14 cases studied, three were <30 years while the rest were more than 30 years and there were 11 male patients (78.6%) and three female patients. Half of the study population had right-sided fractures while the rest had left-sided fractures.
The mode of trauma was road traffic accidents for 64.3% of all cases. The rest 35.7% of cases were due to self-fall. Among the 14 cases, 50% of the cases were classified as Type B while the rest were Type C according to AO fracture classification.
[Table 1] summarizes the findings of the study participants.
|Table 1: Summary of pre-, intra-, and postoperative findings in the study cases|
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Preoperative radiological criteria postulated by Lafontaine et al. were used to assess the stability of fractures at presentation. In this study, five patients (35.7%) had a score of 3, 8 (57.1%) had a score of 4 and 1 (7.2%) had a score of 5. Intraoperatively, none of the patients in this study required neither bone grafting nor K-wiring and there were no intraoperative complications. Various postoperative parameters were considered for this study including the routine procedures followed such as POD mobilization and days to suture removal. 10 (71.4%) patients had their operated wrists mobilized on POD 5 while 4 (28.6%) of the patients were mobilized on POD 8. Sutures were removed on POD 11 for all the patients except 1 for whom sutures were removed on POD 14.
Parameters such as fracture reduction, time to union, pain at the fracture site, and MWS were assessed for all patients during follow-up at 4, 8, 12, and 24 weeks.
The mean radial shortening is 3 mm, mean radial inclination is 18°, and mean intraarticular step is 1 mm.
Twelve patients (85.7%) had radiological signs of union by 12 weeks while two patients (14.3%) had union by 24 weeks. All patients had acceptable reductions [Figure 3].
Among 14 patients who were included in the study, 10 patients had excellent results (MWS – 90) while four had a good outcome (MWS -80) at 24 weeks [Table 2] and [Figure 4].
| Discussion|| |
Distal radius fractures account for 20% of all fractures and have a bimodal age distribution, with the adolescent/young adult and elderly populations being the most affected. Unstable fractures of the distal end of radius have an inherent capacity for the loss of reduction or shortening or both. Anatomical articular reduction greatly reduces the incidence of posttraumatic osteoarthritis and the quality of reduction relates directly to the final outcome.
The mainstay of treatment for nondisplaced, stable fractures remains closed reduction, and cast immobilization without contributing to hand swelling and stiffness.
Rikli and Regazzoni assessed the long-term results of external fixation on distal radius fracture in a retrospective follow-up study done on patients with distal radius fractures treated with external fixation and found that the functional and radiological assessment indicated excellent to good results in more than 80% of patients.
Nevertheless, with a higher infection rate and postoperative stiffness associated with external fixators, open reduction, and internal fixation is preferred in the treatment of fractures of the distal end of the radius, despite the extensive surgical exposure of both metaphyseal and articular components.,
Studies have stated that internal fixation with the use of a volar plate for distal radial fractures promoted painless union., The long-term gain in quality-adjusted life-years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. In our study, we have assessed the clinical and radiological outcomes of distal end radius fractures which are managed surgically with variable-angle locking plate.
Internal fixation using the dorsal approach is indicated for dorsally or radially displaced fractures as there is direct exposure, easy reduction, and plate fixation on the compression side of most distal radius fractures thus the plate provides a buttress against collapse and less risk of neurovascular injury., However, there were increasing reports of the incongruity of DRUJ and extensor tendon ruptures due to prominent hardware.,,,
In this study, we have employed volar approach using the modified Henry's approach which facilitated a good view of the fracture site, restoration of radial length, inclination, and radial tilt. Furthermore, avoidance of dorsal dissection helps preserve the vascular supply to comminuted distal fragments as perfusion of the distal fragment occurs mainly through a dorsal vascular retinaculum that remains undisturbed during the volar approach. Because the volar compartment of the wrist has a great cross-sectional space and the implant is separated from the flexor tendons by the pronator quadratus, the incidence of flexor tendon complications is lessened. Regardless of the direction of the displacement of the distal fragment (dorsal, volar, radial, or impaction), volar plating of both articular and extraarticular fractures is an effective internal fixation method that may reduce some of the soft tissue complications associated with dorsal plating.
The literature available on variable-angle locking plates for radius fracture is scarce.
Kumar et al. concluded that there is no significant difference in distal end radius fractures managed with either locking or nonlocking plates in the clinical or subjective outcome but locking mechanism offers a better maintenance in radiological parameters. Variable angle plates offer better postoperative axial loading when compared to fixed-angle plates.,,,
Our study used standard configuration volar locking variable angle plates which offered good maintenance of articular congruity.,, The patients in our study did not require bone grafting or K-wiring and there were no intraoperative complications. This is consistent with the findings of Gogna et al., that volar locking plates have better-maintained radial length and the congruency of the articular indicating better outcome with low complications.
Khatri et al. concluded that variable-angle locking plates engaged the fracture fragments better with good bi-cortical purchase with satisfactory use of additional techniques such as K-wires in comminuted fractures.
However, in our study, we have not used any additional K-wires or bone grafts to augment fixation as variable angle plates were enough to achieve adequate reduction.
In our study, we achieved early mobilization of the wrists for 10 patients on the 5th POD while four patients were mobilized on the 8th POD.
Twelve of 14 patients achieved radiological signs of union by 12 weeks while the other two patients achieved union by 24 weeks. This was in agreement with findings of a previous study, which stated that locking mechanism offers a better radiological outcome. The participants of our study who were treated surgically with internal fixation using variable-angle locking plate had almost painless union. The postoperative MWS were found to be excellent for majority of the patients. This was in consensus with the reports of Karl M Koenig et al. in 2009, who stated that the use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union.
| Conclusion|| |
In our study, we observed that the distal end radius fractures managed with variable-angle locking plates were associated with ample anatomical reduction and early mobilization of the wrists offering better postoperative functionality.
Limitation of our study
We had studied only fresh fractures and open fractures were not included in the study. More sample size and longer follow-up durations would have better consolidated our findings and correlated with the quality of life of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ruch DS, MeQueen MM. Distal radius and ulna fractures. In: Rockwood and Green's Fractures in Adults. 7th
ed., Vol. 1. Philadelphia, Lippincott Williams and Wilkins, 2009. p. 829-77.
Hagino H, Yamamoto K, Ohshiro H, Nakamura T, Kishimoto H, Nose T. Changing incidence of hip, distal radius, and proximal humerus fractrures in Tottori Prefecture. Bone 1999;24:265-70.
Zemel NP. The prevention and treatment of complications from fractures of the distal radius and ulna. Hand Clin 1987;3:1-11.
Franceschi F, Franceschetti E, Paciotti M, Cancilleri F, Maffulli N, Denaro V. Volar locking plates versus K-wire/pin fixation for the treatment of distal radial fractures: A systematic review and quantitative synthesis. Br Med Bull 2015;115:91-110.
Pradhan RL, Lakhey S, Pandey BK, Manandhar RR, Rijal KP, Sharma S. External and internal fixation for comminuted intra-articular fractures of distal radius. Kathmandu Univ Med J (KUMJ) 2009;7:369-73.
Dias JJ, Wray CC, Jones JM, Gregg PJ. The value of early mobilisation in the treatment of Colles' fractures. J Bone Joint Surg Br 1987;69:463-7.
Missakian ML, Cooney WP, Amadio PC, Glidewell HL. Open reduction and internal fixation for distal radius fractures. J Hand Surg Am 1992;17:745-55.
Levin SM, Nelson CO, Botts JD, Teplitz GA, Kwon Y, Serra-Hsu F. Biomechanical evaluation of volar locking plates for distal radius fractures. Hand (N Y) 2008;3:55-60.
Colles A. On the fracture of the carpal extremity of the radius. Edinb Med Surg J 1814;8:15-27.
Nakamura T, Del Pinal F, Mathoulin C, Nakamura T. Anatomy and biomechnics of the distal radioulnar joint (DRUJ). J Bone Joint Surg 2012;64A:15-23.
Fernandez DL. Jupiter JB. Fractures of the distal radius. J Hand Surg Am 1995;12:26-52.
Johnathan VP, Jolhener SM. Barton's fracture description and classification. J Bone Joint Surg 1996;16:256-62.
Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20:208-10.
Conti Mica MA, Bindra R, Moran SL. Anatomic considerations when performing the modified Henry approach for exposure of distal radius fractures. J Orthop 2017;14:104-7.
Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd
, Linscheid RL. Scaphoid malunion. J Hand Surg Am 1989;14:679-87.
Cooney WP. Fractures of the distal radius. A modern treatment-based classification. Orthop Clin North Am 1993;24:211-6.
Rikli DA, 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;78:588-92.
Nakata RY, Chand Y, Matiko JD, Frykman GK, Wood VE. External fixators for wrist fractures: A biomechanical and clinical study. J Hand Surg Am 1985;10:845-51.
Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intra carpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78:357-65.
Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-28.
Arora R, Lutz M, Fritz D, Zimmermann R, Oberladstätter J, Gabl M. Palmar locking plate for treatment of unstable dorsal dislocated distal radius fractures. Arch Orthop Trauma Surg 2005;125:399-404.
Weber ER. A rational approach for the recognition and treatment of Colles' fracture. Hand Clin 1987;3:13-21.
Ruch DS. Fractures of the distal radius and ulna. J Hand Surg Am 2006;5:29-32.
Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956-60.
Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: A comparative study. J Hand Surg Am 2011;36:1135-41.
Ring D, Jupiter JB, Brennwald J, Büchler U, Hastings H 2nd
. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg Am 1997;22:777-84.
Resnick D. Internal derangements of joints. J Bone Joint Surg 2002;12:124-8.
Leung F, Zhu L, Ho H, Lu WW, Chow SP. Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate – A biomechanical study in a cadaveric model. J Hand Surg Br 2003;28:263-6.
Wong KK, Chan KW, Kwok TK, Mak KH. Volar fixation of dorsally displaced distal radial fracture using locking compression plate. J Orthop Surg (Hong Kong) 2005;13:153-7.
Kumar S, Chopra RK, Sehrawat S, Lakra A. Comparison of treatment of unstable intra articular fractures of distal radius with locking plate versus non-locking plate fixation. J Clin Orthop Trauma 2014;5:74-8.
Martineau D, Shorez J, Beran C, Dass AG, Atkinson P. Biomechanical performance of variable and fixed angle locked volar plates for the dorsally comminuted distal radius. Iowa Orthop J 2014;34:123-8.
Kim JH, Lee HJ, Kim J, Kim MB, Rhee SH, Gong HS, et al.
Korean type distal radius anatomical volar plate system: A preliminary report. Clin Orthop Surg 2014;6:258-66.
Shin EK, Jupiter JB. Current concepts in the management of distal radius fractures. Acta Chir Orthop Traumatol Cech 2007;74:233-46.
Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: Choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093-110.
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am 2011;36:824-35.e2.
McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg Am 2001;26:916-22.
Cooney WP 2nd
, Dobyns JK, Linscheid RL. Complications of Colles' fractures. J Bone Joint Surg Am 1980;62:613-9.
Gogna P, Selhi HS, Singla R, Devgan A, Magu NK, Mahindra P, et al.
Dorsally comminuted fractures of the distal end of the radius: Osteosynthesis with volar fixed angle locking plates. ISRN Orthop 2013;2013:131757.
Khatri K, Sharma V, Farooque K, Tiwari V. Surgical treatment of unstable distal radius fractures with a volar variable-angle locking plate: Clinical and radiological outcomes. Arch Trauma Res 2016;5:e25174.
Koenig KM, Davis GC, Grove MR, Tosteson AN, Koval KJ. Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? J Bone Joint Surg Am 2009;91:2086-93.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]