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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 31-43

Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study


Department of Orthopaedics, UPUMS, Saifai, Etawah, Uttar Pradesh, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Manish Raj
Department of Orthopaedics, UPUMS, Saifai, Etawah, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_11_19

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  Abstract 


Introduction: The purpose of the present study was to compare the results obtained by management of intra-articular fractures of distal end radius with closed reduction and external fixation versus open reduction and internal fixation with locking distal radius volar plate. Material and Method: The present study included 60 patients of distal intra-articular radius fractures. Patients were randomly divided into two groups: group I (close reduction and external fixator) and group II (open reduction and internal fixation with volar plating). Periodic clinical examination and x-ray review was carried out to find out functional outcome,range of motion, radiological outcome and complication. Patients were followed up for 6 month. Mean of all the quantitative variables was compared between two groups by unpaired 'T' test. Functional outcome was measured with Quick DASH score. Result: In present study palmer tilt,radial length and radial inclination was significantly greater in volar plate group.ulnar varience was more(-1.18mm) in volar plate group than external fixator group(-1.28mm). The mean QuickDASH scores and time to return to work were similar in patients treated with a locking plate and external fixator (QuickDASH score 2.4 ± 3.0 and 2.9 ± 5.4; 1.9 ± 0.5 months and 2.1 ± 0.7 months, respectively; P > 0.05).In present study Quick DASH score in ext fix group was 9.71 compaired to volar plating group 6.79 at the final followup. Complication rate were higher in close reduction and external fixation group as compared to open reduction and volar plating group. Conclusion: Open reduction and internal fixation with plate fixation had better functional outcome with less complication rate than close reduction and external fixation in management of intra-articular fractures distal end radius.

Keywords: Distal intra-articular radius fracture, close reduction and external fixator, open reduction and volar plate


How to cite this article:
Gill S, Raj M, Singh S, Rajpoot A, Mittal A, Yadav N. Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study. J Orthop Traumatol Rehabil 2019;11:31-43

How to cite this URL:
Gill S, Raj M, Singh S, Rajpoot A, Mittal A, Yadav N. Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Sep 17];11:31-43. Available from: http://www.jotr.in/text.asp?2019/11/1/31/264712




  Introduction Top


Fractures of the distal end of radius are a heterogeneous group of injuries with different fracture patterns. They were first described by Pouteeau (1783) and Colles (1814).

Fractures of the distal end of radius continue to be the most common skeletal injuries treated by orthopedic surgeons. In fact, these injuries are the most common fractures of the upper extremity and account for approximately 1/6th (17%) of all fractures seen and treated in emergency rooms.[1],[2],[3],[4] Many fractures of the distal aspect of the radius are relatively uncomplicated and are effectively treated by closed reduction (CR) and immobilization in plaster of Paris (POP) cast. However, vast majority of fractures of the distal end of radius are articular injuries that result in disruption of either radiocarpal joint or distal radioulnar joint or both.[5],[6] Intra-articular fractures are inherently unstable, are difficult to reduce anatomically and immobilize in POP cast, and are associated with high rate of complications.[7] For an optimal result, there must be an accurate restoration of skeletal anatomy and supervised rehabilitation by a skilled physiotherapist. Preservation of the articular congruity is the principle prerequisite for successful recovery.[6],[8],[9],[10] The best method of obtaining and maintaining an accurate restoration of articular anatomy, however, remains a topic of considerable controversy.[6]

Colles,[6],[11],[12],[13] in reference to fractures of the distal aspect of the radius, stated, “One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain; the deformity, however, will remain undiminished throughout life.”

Most orthopedic surgeons today would agree that a patient with a malunited fracture of the distal end of the radius who “enjoys perfect freedom in all motions, and is exempt from pain,” is the exception, not the rule. The goal of a treating surgeon should then be to restore the functional anatomy by a method that does not compromise hand function.

With the changing mode of injury (MOI), fracture of the distal end radius occurring in younger patients, increasing functional demands of the patients, better understanding of the fracture pattern, advances in biomechanics of the wrist, and availability of treatment-oriented classification system, it seems we have to look beyond the conventional teaching that they all do well ultimately.

Over the past 20 years, more sophisticated internal techniques and external fixation techniques and devices for the treatment of displaced fractures of the distal end of the radius have been developed.[10],[14],[15] The use of percutaneous pin fixation, Kapandji's intrafocal pinning ext fix devices that permit distraction and palmar translation, low profile internal fixation plates, arthroscopically assisted reduction, and bone grafting techniques including bone-graft substitutes, all have contributed to improved fracture stability and outcome.

The ultimate goal is to restore the anatomical articular congruity of the distal radius and provide the patients with the most functional and comfortable wrist.

Aims and objectives

The main aim of this prospective study is to compare the results obtained by the management of intra-articular fractures of distal end radius by CR with ext fix as compared to open reduction and internal fixation (ORIF) with locking distal radius volar plate in terms of:

  • Functional outcome
  • Radiological outcome
  • Range of movement
  • Complication.


Gartland and Werley (1951)

  • Group I – Simple Colles fracture
  • Group 2 – Comminuted Colles fracture, undisplaced intra-articular fragment
  • Group 3 – Comminuted Colles fracture, displaced intra-articular fragment.


Melone (1986)

  • Type 1 – Undisplaced, minimal comminution, stable
  • Type 2 – Unstable, displacement of medial complex, moderate-to-severe comminution
  • Type 3 – Displacement of medial complex as a unit plus an anterior spike
  • Type 4 – Wide separation or rotation of the dorsal fragment and palmar fragment rotation.


Fernandez (1987)

  • Type 1 – Bending: One cortex of the metaphysis fails because of tensile stress; opposite cortex with some comminution
  • Type 2 – Shearing: Fracture of the joint surface
  • Type 3 – Compression: Fracture of the joint surface with impaction of subchondral and metaphyseal bone, intra-articular comminution
  • Type 4 – Avulsion: Fracture of the ligament attachments of the ulnar and radial styloid process, radiocarpal fracture-dislocation
  • Type 5 – Combination: High-velocity injuries.


Cooney (1990) universal classification

  • Type I – Extra-articular, undisplaced
  • Type 2 – Extra-articular, displaced
  • Type 3 – Intra-articular, undisplaced
  • Type 4 – Intra-articular, displaced.


Modified AO

  • Type A – Extra-articular
  • Type B – Partial articular


    • B1 – Radial styloid fracture
    • B2 – Dorsal rim fracture
    • B3 – Volar rim fracture
    • B4 – Die-punch fracture


  • Type C – Complete articular.


Management principles and treatment alternatives

The aim of treatment of a fracture of the distal radius is to achieve and maintain acceptable reduction until healing occurs, followed by rehabilitation of the wrist to restore grip strength and motion and to minimize the risk of secondary osteoarthritis and avoid complications. To achieve this, an orthopedic surgeon has an arsenal of different methods to choose from conservative to surgical. These include:

  1. CR and cast immobilization
  2. CR and percutaneous pinning
  3. Intrafocal pinning (Kapandji's method)
  4. CR and ext fix with or without K-wire
  5. Limited open reduction
  6. ORIF with or without grafting
  7. Fragment-specific systems with low profile plates and wires
  8. Newer alternatives are also present such as:


  • Arthroscopically assisted reduction
  • Micronail
  • Combined internal fixation and ext fix
  • In situ screw placement
  • CR and percutaneous injection of a paste that forms a carbonated apatite
  • Use of bone cement
  • Low-intensity pulsed ultrasound.


Criteria for acceptable reduction (Melone) are as follows:

  • 2 mm articular incongruity
  • <10° loss of radial inclination
  • <2 mm volar or dorsal translation
  • <10° residual dorsal tilt (between 15° dorsal tilt and 20° volar tilt)
  • <5 mm radial shortening.


Complications

The reported complication rates of distal radius fracture in the literature vary from 6% to 80%.

Immediate complications

  1. Nerve injuries > median nerve > radial nerve > ulnar nerve
  2. Open injuries
  3. Skin injuries – More common in elderly and especially during manipulation due to edematous fragile skin
  4. Compartment syndrome – One of the rare complications.


Early complication (<6 weeks)

  1. Cast issues – Swelling
  2. Distal radioulnar subluxation or dislocation – Especially in volar or dorsal Barton's fractures
  3. Infection
  4. Tendon rupture – Extensor pollicis tendon is the most commonly ruptured incidence in 3% within a mean of 7 weeks.


Late complications (>6 weeks)

  1. Nerve complication and complex regional pain syndrome
  2. Arthritis
  3. Nonunion/delayed union-nonunion is rare. 0.2% reported nonunion in Bacon and Kurtzke study of 2000 distal end radius
  4. Malunion
  5. Tendon complication.


Complications related to external fixation

  1. Pin-tract infection, pin breakage, pin loosening
  2. Fracture through pin sites
  3. Iatrogenic nerve and tendon injury
  4. Complications related to overdistraction.



  Materials and Methods Top


Source of data

The present study was conducted on patients presented with intra-articular distal end radius fractures, who were either managed with close reduction with external fixation or open reduction and distal radius locking plate was done.

Type of study

This was an interventional prospective randomized control trial study.

Study area

The study was conducted at UPUMS, Saifai, Etawah.

Study period

The study carried out over 1 year from January 2017 to August 2018.

Method of collection of data

Sample size

Cases satisfying the inclusion and exclusion criteria admitted in the Department of Orthopaedics, UPUMS, Saifai, Etawah, from January 2017 to July 2018 included. We started the study with 61 patients but one was lost during follow-up. Sixty patients studied in which 33 patients were treated with volar plate and 27 patients were treated with ext fix.

The sampling method to be applied for collection of cases consists of:

  1. All patient's attended to by the Department of Orthopaedics at the UPUMS, Saifai, Etawah, who fulfill the inclusion and exclusion criteria
  2. Detailed history-taking and clinical examination as per the pro forma
  3. Investigations after taking written informed consent
  4. Mode of sustenance of the injury
  5. Severity of the fracture
  6. To assess the outcome of the treatment by follow-up of the patient at 2, 4, and 6 months.


Inclusion criteria

All cases will be selected on the basis of:

  1. Clinical signs and symptoms
  2. Radiological findings confirming intra-articular fracture of distal end radius, Frykmann and AO classification
  3. Patients who are medically fit and willing for surgery
  4. Patients between age group of 20–70 years of both sexes.


Exclusion criteria

  1. Patients below 20 and above 70 years of age
  2. Distal end radius fracture associated with other injuries around the wrist joint
  3. Pathological fractures
  4. Distal end radius fracture associated with neurovascular deficit
  5. There is evidence that the patient will be unable to adhere to trial procedures or complete questionnaires.


Method of randomization

  • Simple randomization by alternative case selection.


Management protocol

Emergency management

  • General supportive measures
  • Examination of associated injury
  • Management of wound if any and application of appropriate POP slab
  • Limb elevation and active finger movements
  • Analgesics for pain
  • X-ray of the affected limb.


Definitive management

Preoperative

  • Informed consent to be taken
  • Clinical examination: Routine protocol for examination of the wrist joint will be followed
  • Radiological examination: X-ray wrist joint anterioposterior (AP) and lateral view for the assessment of:


    • Radioulnar angulation
    • Volar angulation
    • Radial length
    • Radial shift
    • Associated ulnar styloid fracture
    • Distal radioulnar joint dissociation


  • Preoperative investigations: Only routine investigations will be conducted on the patients to assess fitness for anesthesia and surgery
  • Routine hematological investigations including haemoglobin level, total leukocyte count, erythrocyte sedimentation rate, random blood sugar level, renal function tests, and liver function tests were done
  • Other investigations: X-ray of the chest, electrocardiography, computed tomographic scan of the wrist where appropriate
  • Anesthesia used: Regional anesthesia (local anesthesia/brachial block) as per requirement.


Operative management

  • CR and application of ext fix/ORIF with distal radius locking volar plate.


Close reduction external fixation

  • After brachial plexus block and sterile draping under fluoroscopic guidance, two Schanz pins applied trough second and third metacarpal and two Schanz pins applied over the radius with correct localization by ext fix
  • Ext fix fitted in the Schanz pin and then reduction done by applying traction and screw of ext fix tighten
  • Additional injury such as radial styloid fracture and distal ulno radial joint (DRUJ) injury were fixed with K-wire.


Distal radius locking volar plate

  • After brachial plexus block, an incision given which is centered longitudinally open flexor carpi radialis
  • Palmer cutaneous branch of median nerve and superficial branch of radial artery identified and protracted and anterior and posterior sheath of flexor carpi radialis (FCR) incised and space of Parona is developed. Pronator quadrates fascia incised at its radial and ulnar border and retracted ulnarly [Figure 1]
  • After manual reduction of fracture segment under fluoroscopic guidance, percutaneous pin applied for the hold of reduction. Then, plate applied and distal and proximal locking done and closure done in layers
  • Additional injury such as radial styloid fracture and DURJ injury were fixed with K-wire.
Figure 1: Surgical exposure of distal end of radius

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Postoperative

  • Analgesics and antibiotics
  • Postoperative rehabilitation program.


Follow-up

All the patients were followed up at 2 months, 4 months, and 6 months.

  1. Functional evaluation was done according to QuickDASH (QD) score at 2 months, 4 months, and 6 months.



  QuickDASH Top


This score rate the abilty of patients to perform different activity and graded them into different category.

A QD score may not be calculated if there is >1 missing item.

2. Range of movement was assessed at 2, 4, and 6 months (palmar flexion, dorsiflexion, ulnar deviation, radial deviation, pronation, and supination)

3. Radiographic evaluation was done at immediate postoperative period and 2, 4, and 6 months for the evaluation of radiographic parameters as mentioned below Volar tilt, radial inclination, ulnar variance, and radial height on each film was measured and recorded in either degrees or millimeters. Methods for making measurement was based on those described by Mann et al.[16] Volar tilt was measured on a lateral radiograph by determining the angle formed between the long axis of the radius and a line drawn along the articular surface.[17],[18] Normal volar tilt was taken as 11° ± 5°.[19] Radial inclination was measured on a posterioanterior (PA) radiograph by determining the angle formed between the long axis of the radius and a line drawn from the distal tip of the radial styloid to the ulnar corner of the lunate fossa.[20] Normal radial inclination was considered as 22° ± 3°. Ulnar variance was measured on a PA radiograph using the method of perpendiculars. The long axis of the radius was identified and a line was drawn perpendicular to this, extending through the ulnar-most corner of the lunate fossa. The distance between this line and the distal-most point of the ulnar dome was recorded as the ulnar variance, where a positive number will denote ulnar positive and a negative number will denote ulnar negative. Normal ulnar variance was taken as 0.7 ± 1.5 mm.[21],[22],[23],[24] Radial height was determined by finding the long axis of the radius and then extending a line perpendicular to it at the tip of the radial styloid on a PA radiograph. The distance between this line and the distal-most point of the ulnar dome was recorded. Normal radial height was taken as 14 ± 1 mm.[25] Accepted functional range for each measurement, excluding radial height, based on functional outcomes from the literature was defined as <20° dorsal angulation, >10° radial inclination, <5 mm ulnar variance, and <2 mm step off.[7],[16],[18],[26],[27],[28],[29],[30],[31],[32],[33]

4. Complication was watched for during the entire study period.


  Result Top


  • Our primary outcome measure was QD score, and the secondary outcome measure was range of movements, radiographic outcome, and complications
  • Mean of all the quantitative variables was compared between two groups by unpaired “t” test.



  Observation Top


The present study was conducted in the Department of Orthopaedics, UPUMS, Saifai, with the objective to compare the results obtained by management of intra-articular fractures of distal end radius by CR with ext fix as compared to ORIF with locking distal radius volar plate.

[Table 1] show the age distribution. About half of the patients of external fixation group (51.8%) and 30.3% of ORIF group were between 41 and 50 years of age. However, 30% of Ext. fix group and 24.24% of ORIF group were <30 years of age and 39.39% of ORIF group patient were of 30–40 years of age.
Table 1: Age distribution

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[Table 2] show the distribution of gender between the groups. Majority of the patients in both Ext. fix group (85.2%) and ORIF group (72.7%) were males.
Table 2: Distribution of gender between the groups

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[Table 3] show the comparison of side between the groups. 44.4% of Ext. fix group and 48.5% of ORIF group had left-sided fracture. More than half (55.6%) of Ext. fix group and (51.5%) ORIF group had right-sided fracture.
Table 3: Comparison of side between the groups

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[Table 4] show the comparison of MOI between the groups. 42.4% of ORIF group patient sustained injury through fall on outstretched hand. More than half (63%) of Ext. fix group and (57.6%) ORIF group patients sustained injury through road traffic accident.
Table 4: Comparison of mode of injury between the groups

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[Table 5] show the comparison of AO class between the groups. More than half of the patients in both Ext. fix group (59.3%) and ORIF group (54.5%) were from C2 AO class. However, 25.9% of Ext. fix group and 30.3% of ORIF group were from C1 AO class. 14.8% of Ext. fix group and 15.2% of ORIF group were from C3 AO class.
Table 5: Comparison on the basis of AO classification between the groups

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[Table 6] show the comparison of type of injury between the groups. Among majority of the patients in both Ext. fix group (92.5%) and ORIF group (93.9%) had close injury. 6% of patients treated with ORIF with plate had open injury of Gustilo Anderson Grade 1 and 7.4% of the patients treated with ext fix had open injury of Gustilo Anderson Grade 2.
Table 6: Comparison of type of injury between the groups

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[Table 7] show the comparison of QD score between the groups across the time periods. QD score was significantly higher in Ext. fix group (22.25) compared to ORIF group (17.90) at 2 months (P = 0.0001), 14.20/12.35 at 4 months (P = 0.0002), and 9.71/6.79 at 6 months (P = 0.0001).
Table 7: Comparison of quickDASH score between the groups across the time periods

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[Table 8] show the comparison of range of motion (ROM) between the groups at 2 months. Palmar flexion was found to be significantly (P = 0.0001) higher in ORIF group (70.15 ± 1.43) than that in Ext. fix group (60.30 ± 4.01) at 2 months [Figure 2]. Dorsiflexion was also found to be significantly (P = 0.0001) higher in ORIF group (62.36 ± 1.90) than that in Ext. fix group (58.19 ± 4.67) at 2 months. Supination (75.15/68.07) and pronation (71.91/66.89) were significantly (P = 0.0001) higher in ORIF group than that in Ext. fix group at 2 months. Radial deviation was significantly (P = 0.003) higher in ORIF group (19.09 ± 1.10) than that in Ext. fix group (18.00 ± 1.64) at 2 months [Figure 3]. Ulnar deviation was found to be significantly (P = 0.0001) higher in ORIF group (20.12 ± 1.31) than that in Ext. fix group (18.30 ± 1.29) at 2 months.
Table 8: Comparison of range of motion between the groups at 2 months

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Figure 2: Clinical range of motion in volar plating case at final follow-up

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Figure 3: Clinical range of motion in external fixator case at final follow-up

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[Table 9] show the comparison of ROM between the groups at 4 months. Palmar flexion was found to be significantly (P = 0.0001) higher in ORIF group (74.06 ± 1.87) than that in Ext. fix group (66.07 ± 4.64) at 4 months. Dorsiflexion was also found to be significantly (P = 0.002) higher in ORIF group (65.06 ± 1.76) than that in Ext. fix group (62.00 ± 5.04) at 4 months.
Table 9: Comparison of range of motion between the groups at 4 months

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Supination (78.82/70.07) and pronation (76.12/68.07) were significantly (P = 0.0001) higher in ORIF group than that in Ext. fix group at 4 months. Radial deviation was significantly (P = 0.008) higher in ORIF group (20.94 ± 1.70) than that in Ext. fix group (19.30 ± 1.70) at 4 months. Ulnar deviation was found to be significantly (P = 0.0001) higher in ORIF group (22.09 ± 1.18) than that in Ext. fix group (20.78 ± 1.42) at 4 months.

[Table 10] show the comparison of ROM between the groups at 6 months. Palmar flexion was found to be significantly (P = 0.0001) higher in ORIF group (78.00 ± 2.01) than that in Ext. fix group (70.07 ± 4.64) at 6 months. Dorsiflexion was also found to be significantly (P = 0.02) higher in ORIF group (67.00 ± 1.85) than that in Ext. fix group (64.89 ± 4.86) at 6 months. Supination (80.12/71.22) and pronation (77.58/70.30) were significantly (P = 0.0001) higher in ORIF group than that in Ext. fix group at 6 months. Radial deviation was significantly (P = 0.001) higher in ORIF group (21.79 ± 2.11) than that in Ext. fix group (20.04 ± 1.80) at 6 months. Ulnar deviation was found to be significantly (P = 0.0001) higher in ORIF group (23.03 ± 1.07) than that in Ext. fix group (21.81 ± 1.71) at 6 months.
Table 10: Comparison of range of motion between the groups at 6 months

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[Table 11] show the comparison of radiological evaluation between the groups at 2 months [Figure 4]. Volvar tilt was found to be significantly (P = 0.02) higher in ORIF group (11.30 ± 1.38) than that in Ext. fix group (10.63 ± 0.56) at 2 months. Radial inclination was also found to be significantly (P = 0.0001) higher in ORIF group (23.03 ± 1.10) than that in Ext. fix group (21.96 ± 0.43) at 2 months [Figure 5]. Radial length was significantly (P = 0.0001) higher in ORIF group (12.81 ± 0.32) than that in Ext. fix group (12.30 ± 0.44) at 2 months. Ulnar variance in Ext. fix group was −1.30 and ORIF group was −1.30 at 2 months, but the result was statistically nonsignificant.
Table 11: Comparison of radiological evaluation between the groups at 2 months

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Figure 4: (a) Preoperative radiograph of DER fracture. (b) Follow-up radiograph at 4 weeks after volar plating. (c) Follow-up radiograph at 12 weeks after volar plating

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Figure 5: (a) Preoperative radiograph of DER fracture. (b) Follow-up radiograph at after external fixation. (c) Follow-up radiograph at 12 weeks after external fixation removal

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[Table 12] show the comparison of radiological evaluation between the groups at 4 months. Volvar tilt was found to be significantly (P = 0.0001) higher in ORIF group (12.06 ± 0.99) than that in Ext. fix group (11.06 ± 0.48) at 4 months. Radial inclination was also found to be significantly (P = 0.001) higher in ORIF group (22.97 ± 1.21) than that in Ext. fix group (22.07 ± 0.47) at 4 months. Radial length was significantly (P = 0.001) higher in ORIF group (12.70 ± 0.35) than that in Ext. fix group (12.24 ± 0.46) at 4 months. Ulnar variance in Ext. fix group was −1.29 and ORIF group was −1.28 at 4 months, but the result was statistically nonsignificant.
Table 12: Comparison of radiological evaluation between the groups at 4 months

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[Table 13] show the comparison of radiological evaluation between the groups at 6 months. Volvar tilt was found to be significantly (P = 0.001) higher in ORIF group (12.06 ± 0.89) than that in Ext. fix group (11.37 ± 0.56) at 6 months. Radial inclination was also found to be significantly (P = 0.008) higher in ORIF group (23.36 ± 1.63) than that in Ext. fix group (22.26 ± 1.45) at 6 months. Radial length was significantly (P = 0.005) higher in ORIF group (12.49 ± 0.32) than that in Ext. fix group (12.20 ± 0.46) at 6 months. Ulnar variance in Ext. fix group was −1.28 and ORIF group was −1.18 at 6 months, but the result was statistically nonsignificant.
Table 13: Comparison of radiological evaluation between the groups at 6 months

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[Table 14] show the comparison of complications between the groups. Wrist stiffness and pin-site infection were the most common complications in Ext. fix group (11.11%) and wrist stiffness and superficial nerve neuropraxia were the most common complications in ORIF group (9.09%). Hand shoulder syndrome was the least common complication in Ext. fix group (3.7%) and infection and hand shoulder syndrome were the least common complications in ORIF group (6.06%). There was no any complication in 62.96% of Ext. fix group and 69.69% of ORIF group patients.
Table 14: Comparison of complications between the groups

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Statistical analysis

The results are presented in frequencies, percentages, and mean ± standard deviation. The unpaired t-test was used for comparisons. P < 0.05 was considered statistically significant. All the analysis was carried out on IBM SPSS 24.0 version software.


  Discussion Top


More than 190 years have passed since Colles described the fracture of the distal end of the radius. It is remarkable that this common fracture remains one of the most challenging of the fractures to treat. Although Colles was evidently satisfied with the results of his treatment of distal radial fractures in 1814, more recent authors have drawn attention to the high prevalence of unsatisfactory results and toward the need for reviewing different modalities of treatment available.[34],[35],[36],[37],[38],[39]

Different types of fractures occur due to the anatomy of the distal radius and the effects of forces in different directions.[39],[40],[41],[42],[43],[44],[45] It is often not possible to have a successful outcome using the same modality or material for different types of fractures.[46],[47],[48],[49],[50],[51],[52] While mechanical characteristics are important in adopting a particular modality, the strategic placement of the selected material may in fact be more important than the characteristics of these materials, particularly in intra-articular fractures.[53] The best treatment option for different types of fractures may be determined by comparing different methods.

The use of ext fix and pinning has demonstrated successful outcomes in multiple studies.[54],[55],[56],[57],[58],[59],[60],[61],[62] Ext fix is versatile in managing both intra- and extra-articular fractures with acceptable functional results. Reasons for using ext fix include the improved reduction by ligamentotaxis and the ability to protect the reduction until healing occurs. The advantages of ext fix are the relative ease of application, minimal surgical exposure, and reduced surgical trauma.[63],[64],[65],[66],[67],[68],[69]

Several prospective studies have included ext fix and various methods of fixation.[70],[71],[72],[73],[74],[75],[76],[77],[78],[79] Hutchinson et al. prospectively evaluated ext fix and pins with plaster techniques.[60] Clinical outcomes were similar between groups. The ext fix group was better at maintaining radial length long term. In our study, we compare external fixation with distal radius locking plate, and we found that there is better maintenance of radial length in distal radius locking plate group than extrenal fixator group. However, it was more costly and sustained a greater number of minor complications including radial neuritis and pin tract infections. In our study, pin tract infection (11.1%) and complication-like stiffness (11.1%) were found more in Ext. fix group than that in ORIF group (9%) while superficial radial neuropraxia was more common in ORIF group (9%) than that in Ext. fix group (7.4%). This suggests that fracture-specific fixation with CR and ext fix is sufficient for certain distal radius fractures.

Complications were high with ext fix in some reports.[80],[81],[82],[83] Anderson et al. noted that 16 of 24 patients treated with ext fix had complications ranging from infection to superficial nerve neuropraxia.[80] Problems encountered included pin tract infections (9 patients), median and superficial radial neuropathies (5 patients), loss of reduction (4 patients), and pin loosening (2 patients). In our study, 10 out of 17 patients in the Ext. fix group develop complication. Problems included in the Ext. fix group were pin-site infection (3 patients), wrist stiffness (3 patients), hand shoulder syndrome (1 patient), and superficial nerve neuropraxia (2 patients). Hutchinson et al. also noted a 45% complication rate of which half were considered serious or major.[60] The most common problems again included pin tract infections, radial neuritis, and complex regional pain syndrome. In the present study, 37.1% of the patients from Ext. fix group and 31.1% of the patients from ORIF group develop complication during treatment.

There are existing studies that compared volar-locking plate fixation with ext fix in distal radius fractures.

Gereli et al.[84] studied 30 patients with intra-articular comminuted distal radius fractures. Sixteen patients underwent open reduction and palmar-locking plate fixation, and 14 patients underwent CR and K-wire augmented ext fix. According to the AO/ASIF classification, there were four C1, 10 C2, and two C3 fractures in the locking plate group and three C1, eight C2, and three C3 fractures in the Ext. fix group. In their study, wrist flexion (P = 0.012) and supination (P = 0.003) at final follow up were significantly greater in the locking plate group. Other ROM parameters were similar in the two groups. In our study, all ROM parameters were significantly greater in locking plate group. On final radiographic measurements, there were no significant differences between the two groups with respect to losses in palmar angulation, radial length, and radial inclination and change in ulnar variance. In our study, palmer tilt, radial length, and radial inclination were significantly greater in volar plate group. Ulnar variance was more (−1.18 mm) in volar plate group than Ext. fix group (−1.28 mm), but data were nonsignificant. The mean QD scores and time to return to work were similar in patients treated with a locking plate and ext fix (QD score 2.4 ± 3.0 and 2.9 ± 5.4; 1.9 ± 0.5 months and 2.1 ± 0.7 months, respectively; P > 0.05). In our study, QD score in Ext. fix group was 9.71 compared to volar plating group (6.79) at the final follow-up. There were no complications in the locking plate group. In our study, 11 out of 33 patients develop complication in volar-plating group and 10 out of 17 patients develop complications. In the Ext. fix group, two patients (14.3%) had regional pain syndrome, three patients (21.4%) had superficial pin and wire tract infections, and pin tract infection was 11.1%. Overall, nine patients (64.3%) expressed dissatisfaction with the ext fix. In our study, 37.1% of patients from Ext. fix group and 31.1% of patients from ORIF group develop complication during the course of treatment.

Shukla et al.[85] reported results of ORIF with locking volar plates at 12-month follow-up on 31 distal radius fractures and found excellent ROM with flexion/extension of 57°/59° and radial/ulnar deviation of 17°/27°, respectively. Overall grip strength measured 79% of the contralateral side. The overall outcome according comparative study of ext fix versus volar-locking plate for displaced intra-articular distal radius fracture reported that after 1 year of surgery, ext fix showed significantly better results than volar-locking plates using the Green and O'Brien scores for ROM (22.0 ± 4.77 vs. 19.89 ± 5.05), grip strength (19.91 ± 5.4 vs. 16.89 ± 4.4), and final outcome (87.36 ± 11.62 vs. 81.55 ± 11.32). In our study, at the end of 6 months, Ext. fix group and volar-plating group, respectively, show flexion of 70.07°/78.0°, extension of 64.89°/67.0°, ulnar deviation of 21.81°/23.03°, radial deviation of 20.04°/21.79°, supination of 71.22°/80.12°, and pronation of 70.3°/77.58° in average. Hence, this result is contrary to the present study.

Williksen et al.[86] in their randomized controlled study of 5-year follow-up on ext fix and adjuvant pins versus volar-locking plate fixation in unstable distal radius fractures reported that the QD score between the Ext. fix group and ORIF group was not statistically significantly different at 5 years. Patients with volar locking plate (VLP) had statistically significant better supination (85° vs. 81°), better radial deviation (18° vs. 16°), and less radial shortening (1 mm vs. 2 mm). For AO/OTA type C2 fractures, the VLP had statistically significant better supination (84° vs78°), flexion (64° vs. 56°), and less ulnar shortening (1 mm vs. 3 mm). The QD score in the C2 subset analysis showed a difference of 10 (VLP 8 vs. EF 18), but this was not statistically significant. In the VLP group, 11 patients (21%) had their plates removed owing to surgically related complications. In this study at the end of 6 months, Ext. fix group and volar-plating group, respectively, show flexion of 70.07°/78.0°, extension of 64.89°/67.0°, ulnar deviation of 21.81°/23.03°, radial deviation of 20.04°/21.79°, supination of 71.22°/80.12°, and pronation of 70.3°/77.58° in average; and radiological outcome in the ext fix/ORIF group was radial inclination of 22.26°/23.36°, radial length of 12.20/12.49 mm, volar tilt of 11.37°/12.06°, and ulnar variance of 1.28/1.18 mm (nonsignificant), and Quick DASH score was 9.71 in Ext. fix group and 6.79 in volar-plating group. Hence, the results are comparable to our study.

Fakoor et al.,[87] in their study, reported that all results including functional score and clinical and radiologic criteria were in favor of the ORIF method while there were less complications with this method. Radiological findings for the ORIF group were radial inclination 19.35°, radial length 10.35 mm, radial tilt 8.92°, and ulnar variance 1.64 mm, while for the CR + EF group, these were 15.13°, 8 mm, 4.78°, and 0.27 mm, respectively. The ROM for ORIF were flexion-extension 137°, radial-ulnar deviation 52°, and supination pronation 14°, while for the CR + EF group, these were 117°, 40°, and 116°, respectively. In our study, radiological outcome in ext fix/ORIF group was radial inclination 22.26°/23.36°, radial length 12.20/12.49 mm, volar tilt 11.37°/12.06°, and ulnar variance 1.28/1.18 mm (nonsignificant), respectively. Moreover, the ROM flexion-extension was 135/145, radial-ulnar deviation 41.8/45.8, and supination/pronation 140.5/157.5 respectively. The rate of complication with the ORIF method was 58% and in the Ext. fix group was 69%, In our study, 37.1% of patients from Ext. fix group and 31.1% of patients from ORIF group develop complication during the course of treatment. The patients in CR + EF had more than the ORIF course of physiotherapy and rehabilitation. Hence, these results are comparable to our study.

Kenan et al.[88] in their study reported that of 72 patients, 36 patients treated with volar plate (Group 1) and 36 patients treated with Ext. fix (Group 2); they found that wrist flexion, extension, and degree of radial and ulnar deviation at final follow-up in Group 1 were significantly higher compared to Group 2 (P < 0.05). When both groups were compared statistically, a significant difference was found in favor of Group 1 in terms of postoperative volar tilt (P = 0.001). In our study, ROM parameter was flexion of 70.07/78.0, extension of 64.89/67.0, ulnar deviation of 21.81/23.03, radial deviation of 20.04/21.79, supination of 71.22/80.12, and pronation of 70.3/77.58 in average, which was significantly higher in volar-plating group. There were no complications in Group 1, whereas superficial pin-wire tract infection was observed in one patient in Group 2. In our study, 10 out of 17 patients in Ext. fix group and 10 out of 33 patients in ORIF group develop complication. Problem included in Ext. fix group/ORIF group were pin-site infection (3 patients), wrist stiffness (3 patients/3 patients), hand shoulder syndrome (1 patient/2 patients), and superficial nerve neuropraxia (2 patients/3 patients). Hence, these results are comparable to our study.

Dash et al.[89] in there research article published in International General of Research in Orthpaedics studied 35 patients aged more than 20 years; 14 were treated with Ext. fix group and 21 were treated with internal fixation. In Group 1, wound infection was seen in two cases; both patients were diabetic and elderly average age of 62 years. There were no implant malposition or failure and tendon rupture. At 6 postoperative month, the average QD score was 12.9 (range, 6.8–18.2). At final follow-up visits, the average ROM of wrist joint included flexion 50° (range, 30°–70°), extension 60° (range, 45°–80°), and pronation-supination 65° (range, 60°–90°) and in Group 2. There pins tract infection in one case. At 6th postoperative month, the average QD score was 18.9 (range, 9.1–29.5). At final follow-up visits, the average ROM of wrist joint included, flexion 45° (range, 30°–70°), extension 62° (range, 35°–75°), and pronation-supination 55° (range, 40°–75°). In our study, ROM parameter was flexion of 70.07°/78.0°, extension of 64.89°/67.0°, ulnar deviation of 21.81°/23.03°, radial deviation of 20.04°/21.79°, supination of 71.22°/80.12°, and pronation of 70.3°/77.58° in average which was significantly higher in volar-plating group and QD score was significantly higher in Ext. fix group (9.71) than volar-plating group (6.79) at final follow-up. Wrist stiffness was more in Ext. fix group. 2 case were reported with pin tract infection in Ext. fix group. In this study, 10 out of 17 patients in Ext. fix group and 10 out of 33 patients in ORIF group develop complication. Problem included in Ext. fix group/ORIF group were pin-site infection (3 patients), wrist stiffness (3 patients/3 patients), hand shoulder syndrome (1 patient/2 patients), and superficial nerve neuropraxia (2 patients/3 patients).

Lee et al.[90] in their retrospective study included 201 distal radius fracture cases. Eighty-five patients in Group 1 were treated with volar or dorsal plate and 116 patients in Group 2 were treated with ext fix with additional fixation devices. Clinical (ROM, Green and O'Brien's score) and radiological outcomes were evaluated. In their study, they found that at the 12-month follow-up, Group 1 and Group 2, respectively, showed flexion of 64.4°/60.5°, extension of 68.3°/66.9°, ulnar deviation of 30.6°/25.5°, radial deviation of 20.8°/18.6°, supination of 76.1°/73.5°, and pronation of 79.4°/75.0° in average. In this study, at the end of 6 months, Ext. fix group and volar--plating group, respectively, show flexion of 70.07°/78.0°, extension of 64.89°/67.0°, ulnar deviation of 21.81°/23.03°, radial deviation of 20.04°/21.79°, supination of 71.22°/80.12°, and pronation of 70.3°/77.58° in average. The mean Green and O'Brien score was 92.2 in Group 1 and 88.6 in Group 2. In this study, we evaluated functional outcome with QD score and score was 9.71/6.79, respectively, in Ext. fix/volar-plating group at the end of 6 months. The radial height of group 1 and Group 2 was 11.6/11.4 mm; radial inclination was 23.2°/22.5°; volar tilt was 11.6°/8.7°; and the ulnar displacement was 1.27/0.93 mm. In this study, radial length of Ext. fix/ORIF group was 12.02/12.49 mm, radial inclination 22.26°/23.36°, volar tilt 11.37°/12.06°, and ulnar variance was 1.28/1.18 mm (nonsignificant), respectively. Hence, these results are comparable in both studies.

While ext fix maintains a significant role in the treatment of distal radius fractures, ORlF with locked volar plating has changed the way many surgeons treat certain types of distal radius fractures. The aim of this study was to compare the results of ext fix and ORIF in treating similar distal radius fracture patterns. As functional outcome, radiological outcome, and ROM were better in patients treated with ORIF with volar plate and complications were less, compared to patients treated with ext fix, which suggests that ORIF with volar plate is better method of treating intra-articular distal radius fracture than ext fix.


  Conclusion Top


The present study was undertaken to compare the outcome of intra-articular fractures of the distal end of radius treated by CR with ext fix and ORIF with locking distal radius volar plate and the following conclusions were drawn.

The ext fix is simple and inexpensive. It effectively stabilizes fractures and only a short hospital stay is required. Although a relatively longer period of immobilization is required, immobilization of 6–8 weeks is well tolerated and it does affect the final outcome in long-term follow-up. Both its ease of use and successful track record make it an extremely versatile tool for the treatment of these injuries.

The use of locked volar plates in distal radius fractures provides good-to-excellent results and is effective in the correction and maintenance of distal radius anatomy.[91],[92] It avoids bridging the radiocarpal joint and allows for early joint movement, owing to its fixation strength. Close placement to joint interface and screwing capability in different orders are its biomechanical superiorities.

Functional outcome as evaluated by QD score was better in ORIF group. Volar tilt, radial length, and radial inclination were better in patients treated with ORIF; there was no significant difference found in ulnar variance. Range of movement was better in patients treated with ORIF. Complication was less in ORIF group except superficial radial nerve neuropraxia.

The comparison between the results of the functional outcome as evaluated by the QD and the anatomical outcome evaluated as mentioned above confirms, what other studies have previously shown, that the functional result need not mirror the anatomical evaluation. It was found that range of movement radiographic parameters being superior in patients treated with ORIF, complications were less in volar-plating group, overall functional outcome are better in ORIF group which suggests that ORIF with volar plate is better method than ext fix for treating intra-articular fracture distal radius.

Summary

In present study it was found that volar tilt, radial length and radial inclination were better in patient treated with open reduction and internal fixation with volar plate group. However, there was no significant difference found in ulnar varience in two groups. Functional outcome as evaluated by Quick DASH score was better in volar plate group. Complications rate were less in volar plate group as compared to external fixator group. The present study suggests reduction and internal fixation with volar plate was better method than close reduction and external fixation in management of Intra-articular fracture distal radius.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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