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Volar plating of distal radius fracture: a retrospective analysis.

INTRODUCTION: From the earliest description of distal radius fracture by Abraham Colles (1) until now, the various methods of treatment of distal radius fracture have undergone remarkable changes and are still evolving. Although cast treatment gives good functional outcome in geriatric patients, (2,3) it has given way to operative methods for better outcome in high-demand younger patients. A multiple array of surgical techniques for fixation of distal radius fracture are available which include pins and plaster, spanning external fixator, percutaneous pinning and various types of plates and screws. (4) Volar plating of Barton fracture introduced by Ellis (5) continues to be a useful addition in the armamentarium for treatment of distal radius fractures. Many studies have shown the effectiveness of this technique in allowing early mobilization with restoration of radial length, radial inclination, articular congruity, and palmar tilt. (6,7,8,9) The purpose of this retrospective study is to analyse the functional and radiological outcomes of patient with isolated distal radius fracture treated with plating using a volar approach.

MATERIALS AND METHODS: Between January 2013 and March 2014, 24 patients with closed isolated distal radius fractures who underwent open reduction and internal fixation with plates and screws through standard volar approach at Chettinad Hospital & Research Institute were included in the study. All of these patients underwent the procedure within a week after the injury and were followed up for a minimum duration of one year. There were 17 men and 7 women. Mean age was 44 years (Range, 22-75 years). The fractures were classified based on the AO system. There were 4 A2, 12 B3, 5 C1, 3 C2 fracture types. The modes of injuries were motor vehicle accidents in 19 patients and fall on the outstretched hand in the remaining patients. Out of the 24 patients only one patient had a bilateral fracture. The fracture involved the right wrist in 12 patients and left wrist in 11 patients. All the fractures were screened with standard radiographs of the wrist which included anteroposterior and lateral projections and CT scan for intra-articular fractures.

The surgical procedure was performed under regional anaesthesia (Interscalene block). We used a standard volar approach for distal radius where the incision is made between flexor carpi radialis and radial artery. Deep dissection proceeds with reflection of the pronator quadratus using an L-shaped incision to expose the fracture line. The facture was reduced with longitudinal traction and digital pressure over the dorsal aspect. Temporary K-wires were used to maintain the reduction and to facilitate placement of a volar plate. Care was taken to avoid screws penetrating the radiocarpal joint and screw tips protruding excessively over the dorsal aspect. After checking the fracture reduction and the implants under image intensifier, the skin was closed using interrupted non-absorbable suture. The pronator quadratus was usually repaired before skin closure. Tourniquet was not used for the procedure. The limb was immobilised in a short arm plaster splint until suture removal on the tenth post-operative day. Active finger movements were initiated early followed by wrist mobilisation after three to four weeks.

At the time of the latest follow-up all the patient were evaluated both clinically and radiologically for final outcome. Antero-posterior and lateral radiographs were studied in terms of the following parameters which include volar tilt, radial inclination, radial length, and articular congruency. These films were compared with preoperative films and with previous follow-up films to assess the correction of the original deformity and to recognize any postoperative loss of reduction. The functional outcome of these patients were recorded and graded based on the modified clinical-scoring system of Green and O'Brien. (10)

RESULTS: Five patients at the end of one year had mild pain but they were able to return to their earlier jobs with unrestricted wrist movements and normal grip strength. These patients were grouped as excellent. Thirteen patients in addition to occasional pain had less than twenty five percent restriction of wrist movements compared to the opposite uninjured wrist but were able to return to their normal employment and hence given good rating. The wrist had mild pain in another five patients with reduced grip strength and restricted wrist movements more than fifty percent as compared to the normal side. These patients had to change job and showed a fair recovery of function. One patient developed surgical site infection which was managed with multiple debridements, plate removal with wrist spanning external fixator and finally ended up with stiff wrist and finger movements, occasional pain and paraesthesia along the course of median nerve which settled down with non-operative management and this patient got a poor outcome.

The latest follow-up radiographs showed a mean palmar tilt of 5[degrees](Range, 5[degrees]- 12[degrees] dorsal to palmar), radial inclination averaged 18[degrees](Range, 13[degrees] to 23[degrees]), mean radial shortening 1.5 mm (Range, 0-3mm), and articular congruity averaged 1mm.

The average duration of follow-up of these patients is eighteen months (Range, twelve-twenty four months). The mean time to radiological fracture healing was seven weeks (Range, six-eight weeks). None of the patient had tendon related problems.

DISCUSSION: The treatment of fracture distal end of radius with the use of plating through a volar approach has been shown to give a good functional as well as a radiological outcome based on the results of various studies. (6,11,12,13) Volar plating is simpler to perform due to relatively spacious flat volar anatomy of distal end of radius and it allows early restoration of wrist and finger movements. With proper placement of the distal screws late collapse and loss of palmar tilt can be minimised (6). The use of low-profile volar plate, correct screw length along with repair of the pronator quadratus to brachiradialis aponeurosis lowers the incidence of late frictional tear of the flexor as well as the extensor tendons. (11,14)

The results of this retrospective study are comparable with those reported by various authors in terms of early functional recovery and acceptable radiological parameters. (3,6,11) The modified Green and O'Brien Score showed 5(21 Percent) excellent, 13(54 Percent) good, 5(21 Percent) fair, and 1(4 Percent) poor results at the latest follow-up. Arora, et al (3) reported 31(27%) excellent, 54(47%) good, 23(20%) fair, and 6(5%) poor results in their multicenter study. Similarly, Drobetz et al (6) had excellent in 23(46%), good in 11(22%), moderate in 12(24%) and poor in 4(8%) patients.

Except for one patient who developed surgical site infection that necessitated plate removal and conversion to a bridging external fixator, almost all of the patients included in this study had good relief of pain and were able to return to productive jobs.

The limitations of this study are small sample size and short duration of follow-up which may explain the absence of post-traumatic osteoarthritic changes in patients with intra-articular fractures as seen in studies with longer duration of follow-up. (15)

Volar plating is not the recommended for certain fractures of distal end of radius especially the B2 and C3 types. (6,12,13)

Based on the results of this study and after reviewing relevant literatures, it was found that with proper selection of fracture types and using accurate surgical techniques, volar plating continues to be an useful method for treatment of fracture distal end of radius with minimal complications and at the same time allows the patient an early return to normal life.

CASE 1:

CASE 2

DOI: 10.14260/jemds/2015/1318

BIBLIOGRAPHY:

(1.) Colles, Abraham. "On the fracture of the carpal extremity of the radius." The New England Journal of Medicine, Surgery and Collateral Branches of Science 3.4 (1814): 368-372.

(2.) Egol, K. A., et al. "Distal radial fractures in the elderly: operative compared with non-operative treatment." The Journal of Bone & Joint Surgery 92.9 (2010): 1851-1857.

(3.) Arora, Rohit, et al. "A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: non-operative treatment versus volar locking plating." Journal of orthopaedic trauma 23.4 (2009): 237-242.

(4.) Wolfe, S.W. Green's Operative Hand Surgery. 6th ed. Philadelphia: Churchill Livingstone, 2010, Print.

(5.) Ellis J. "Smith's and Barton's fractures: a method of treatment". The Journal of Bone & Joint Surgery Br 47 (1965): 724-727.

(6.) Drobetz, H., and E. Kutscha-Lissberg. "Osteosynthesis of distal radial fractures with a volar locking screw plate system." International orthopaedics 27.1 (2003): 1-6.

(7.) Rozental, Tamara D., and Philip E. Blazar. "Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius." The Journal of hand surgery 31.3 (2006): 359-365.

(8.) Chung, Kevin C., et al. "Treatment of unstable distal radial fractures with the volar locking plating system." The Journal of Bone & Joint Surgery 88.12 (2006): 2687-2694.

(9.) Constantine, Kostas J., Mark C. Clawson, and Peter J. Stern. "Volar neutralization plate fixation of dorsally displaced distal radius fractures." Orthopedics 25.2 (2002): 125-128.

(10.) Bradway, John K., Peter C. Amadio, and William P. Cooney. "Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius." The Journal of Bone & Joint Surgery 71.6 (1989): 839-847.

(11.) Orbay, Jorge L., and Diego L. Fernandez. "Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report." The Journal of hand surgery 27.2 (2002): 205-215.

(12.) Wright, Thomas W., Mary Beth Horodyski, and Dean W. Smith. "Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation." The Journal of hand surgery 30.2 (2005): 289-299.

(13.) Ruch, David S., and Anastasios Papadonikolakis. "Volar versus dorsal plating in the management of intra-articular distal radius fractures." The Journal of hand surgery 31.1 (2006): 9-16.

(14.) Bell, J. S. P., R. Wollstein, and N. D. Citron. "Rupture of flexor pollicis longus tendon A COMPLICATION OF VOLAR PLATING OF THE DISTAL RADIUS." Journal of Bone & Joint Surgery, British Volume 80.2 (1998): 225-226.

(15.) Knirk, Jerry L., and JESSE B. Jupiter. "Intra-articular fractures of the distal end of the radius in young adults." The Journal of Bone & Joint Surgery 68.5 (1986): 647-659.

Victor Moirangthem [1], Bharat Kumar R. J [2], Vijayanand R. R [3], Narayana Reddy M [4]

AUTHORS:

[1.] Victor Moirangthem

[2.] Bharat Kumar R. J.

[3.] Vijayanand R. R.

[4.] Narayana Reddy M.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Orthopaedics, Chettinad Hospital & Research Institute.

[2.] Assistant Professor, Department of Orthopaedics, Chettinad Hospital & Research Institute.

[3.] Senior Resident, Department of Orthopaedics, Chettinad Hospital & Research Institute.

FINANCIAL OR OTHER COMPETING INTERESTS: None

[4.] Professor & HOD, Department of Orthopaedics, Chettinad Hospital & Research Institute.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Victor Moirangthem, 3B, Staff Villas, Chettinad Hospital & Research Institute, Rajiv Gandhi Salai, Kelambakkam-603103, Kanchipuram, Tamilnadu.

E-mail: victormoirangthem@gmail.com

Date of Submission: 08/06/2015.

Date of Peer Review: 09/06/2015.

Date of Acceptance: 22/06/2015.

Date of Publishing: 26/06/2015.

Table 1

Patient Demographic Profile

Case   Age (years)    Gender          Mode of Injury

1           48         Male      Motor vehicular accident
2           75         Male     Fall on outstretched hand
3           40         Male      Motor vehicular accident
4           25         Male      Motor vehicular accident
5           29         Male      Motor vehicular accident
6           51         Male      Motor vehicular accident
7           30         Male      Motor vehicular accident
8           63        Female    Fall on outstretched hand
9           28         Male      Motor vehicular accident
10          30         Male      Motor vehicular accident
11          48        Female     Motor vehicular accident
12          32         Male      Motor vehicular accident
13          74        Female    Fall on outstretched hand
14          49        Female     Motor vehicular accident
15          45        Female     Motor vehicular accident
16          60         Male      Motor vehicular accident
17          56        Female    Fall on outstretched hand
18          22         Male      Motor vehicular accident
19          39         Male      Motor vehicular accident
20          58         Male      Motor vehicular accident
21          62        Female    Fall on outstretched hand
22          40         Male      Motor vehicular accident
23          32         Male      Motor vehicular accident
24          30         Male      Motor vehicular accident

Case   Laterality    AO type

1         Right         A2
2         Left          C1
3         Right         B3
4         Right         A2
5         Both          B3
6         Left          B3
7         Left          B3
8         Right         A2
9         Left          C2
10        Right         C1
11        Right         C2
12        Left          B3
13        Left          B3
14        Left          C1
15        Right         A2
16        Right         C1
17        Right         B3
18        Left          B3
19        Left          C1
20        Right         B3
21        Left          B3
22        Right         C2
23        Left          B3
24        Right         B3

Table 2

Modified Clinical-Scoring System of Green and O'Brien

Category                 Score                  Findings
                       (Points)

Pain (25 points)          25                      None
                          20                Mild, occasional
                          15               Moderate, tolerable
                           0              Severe or intolerable

Functional status         25         Returned to regular employment
(25 points)               20              Restricted employment
                          15           Able to work but unemployed
                           0         Unable to work because of pain

Range of motion                           Percentage of normal
(25 points)               25                       100
                          15                      75-99
                          10                      50-74
                           5                      25-49
                           0                      0-24
                                    Dorsiflexion-plantar flexion arc
                                           (injured hand only)
                          25              120[degrees] or more
                          15            91[degrees]-119[degrees]
                          10             61[degrees]-90[degrees]
                           5             31[degrees]-60[degrees]
                           0               30[degrees] or less

Grip Strength                             Percentage of normal
(25 points)               25                       100
                         15 10                 75-99 50-74
                           5                      25-49
                           0                      0-24

Final result
Excellent               90-100
Good                     80-89
Fair                     65-79
Poor                      <65

Table 3

Final Clinical Score as given in the modified Clinical-Scoring System
of Green and O'Brien

Case     Pain     Functional    Wrist      Grip       Final
         Score      Status       ROM     Strength    Result

1         20          25         25         25         95
2         20          25         15         25         85
3         20          25         15         25         85
4         20          25         25         25         95
5         20          25         15         25         85
6         20          25         15         25         85
7         20          25         15         25         85
8         20          25         25         25         95
9         20          20         10         15         65
10        20          25         15         25         85
11        20          20         10         15         65
12        20          25         15         25         85
13        20          25         15         25         85
14        20          20         10         15         65
15        20          25         25         25         95
16        20          20         10         15         65
17        20          25         15         25         85
18        20          25         15         25         85
19        20          20         10         15         65
20        20          25         15         25         85
21        20          25         15         25         85
22        15          15         10         10         50
23        20          25         25         25         95
24        20          25         15         25         85

Table 4

Final Radiological measurements

Case         Palmar             Radial         Radial      Articular
          Tilt(Degrees)      Inclination     Shortening    Congruity
                              (Degrees)         (mm)          (mm)

1      10[degrees] palmar    23[degrees]         0             0
2       5[degrees] palmar    18[degrees]         0             0
3       8[degrees] palmar    20[degrees]         0             1
4      10[degrees] palmar    22[degrees]         0             0
5       8[degrees] palmar    18[degrees]         1             1
6       5[degrees] palmar    20[degrees]         0             0
7       5[degrees] palmar    18[degrees]         1             1
8      10[degrees] palmar    22[degrees]         0             0
9       3[degrees] dorsal    14[degrees]         1             1
10      8[degrees] palmar    16[degrees]         0             1
11      3[degrees] dorsal    18[degrees]         1             0
12      5[degrees] palmar    18[degrees]         1             0
13      8[degrees] palmar    20[degrees]         0             1
14      3[degrees] dorsal    16[degrees]         1             0
15     12[degrees] palmar    20[degrees]         0             0
16     0[degrees] neutral    18[degrees]         1             0
17      5[degrees] palmar    20[degrees]         0             1
18      5[degrees] palmar    18[degrees]         1             0
19     0[degrees] neutral    18[degrees]         1             1
20      5[degrees] palmar    20[degrees]         0             0
21      5[degrees] palmar    18[degrees]         0             0
22      5[degrees] dorsal    13[degrees]         3             1
23     12[degrees] palmar    22[degrees]         0             0
24      5[degrees] palmar    20[degrees]         0             0
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Title Annotation:ORIGINAL ARTICLE
Author:Moirangthem, Victor; Bharat, Kumar R.J.; Vijayanand, R.R.; Narayana, Reddy M.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 29, 2015
Words:2574
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