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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 138-142

Functional Outcome of Open Reduction and Internal Fixation of Intra-articular Distal Radial Fractures by Buttress Plate


1 Department of Orthopaedics, ESIC Medical College and Hospital, Joka, Kolkata, West Bengal, India
2 Resident, Orthopaedics, Fortis Hospital, Kolkata, West Bengal, India
3 Consultant, Radiology, Bhagirathi Neotia Woman and Child Care Centre, Kolkata, West Bengal, India
4 Faculty, West Bengal University of Health Sciences, Kolkata, West Bengal, India

Date of Submission26-May-2019
Date of Acceptance04-Feb-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Sanjay Keshkar
Department of Orthopaedics, ESIC Medical College and ESI PGIMSR, ESI Hospital Joka, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_30_19

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  Abstract 


Introduction: Treatment of displaced, comminuted, intra-articular fracture of the distal end of the radius by a closed method, such as pins and plaster or external fixation, gives unsatisfactory outcome in most of the cases. The purpose of this study is to evaluate the efficacy of open reduction and internal fixation (ORIF) of intra-articular distal radial fractures by buttress plate. Materials and Methods: We conducted a prospective study from January 1, 2015, to June 30, 2016, on patients having intra-articular distal radius fractures aged above 18 years (20–58 years), who were treated by ORIF with buttress plate. Males outnumbered females by a ratio of 2.67:1. The most common mode of injury was found to be road traffic accident (68.2%). The fractures were classified as per the Frykman classification system. Type III was the most common (54.5%), followed by Type IV (27.3%). Majority of the cases (54.5%) were operated in 2–5 days following injury. The mean time for union was 8.04 weeks. Results: Functional evaluation was done according to the modified demerit point system of Gartland and Werley. Functionally, 14 patients (63.6%) had excellent, 6 had good (27.3%), and 2 had fair (9.1%) restoration of functions. Radiological assessment and the results were graded according to the Sarmiento's modification of Lindstrom criteria. Anatomically, 16 patients (72.7%) had excellent restoration, 4 (18.2%) had good restoration, and 2 had fair (9.1%) restoration. One case of superficial infection and one case of injury to the superficial branch of the radial nerve were noted. In later follow-up, two cases presented with joint stiffness, and in one case, loss of reduction was seen at final follow-up. Conclusion: Around 91% of the patients had excellent-to-good result, both anatomically and functionally. Hence, we conclude that ORIF with buttress plate is an excellent mode of treatment for displaced intra-articular distal radius fractures.

Keywords: Buttress plate, distal radius fractures, intra-articular fracture, open reduction and internal fixation


How to cite this article:
Goel A, Daga S, Bhowal S, Sen B, Barman R, Keshkar S. Functional Outcome of Open Reduction and Internal Fixation of Intra-articular Distal Radial Fractures by Buttress Plate. J Orthop Traumatol Rehabil 2020;12:138-42

How to cite this URL:
Goel A, Daga S, Bhowal S, Sen B, Barman R, Keshkar S. Functional Outcome of Open Reduction and Internal Fixation of Intra-articular Distal Radial Fractures by Buttress Plate. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 May 12];12:138-42. Available from: https://www.jotr.in/text.asp?2020/12/2/138/305082




  Introduction Top


Fracture of the distal radius accounts for about one-sixth of all fractures seen and treated.[1] Depending on the pattern of involvement of the distal radioulnar and radiocarpal joints and the direction of displacement of the fracture fragments, they have been given different names such as Colles, Barton, or Smith fracture.[2],[3],[4]

It is very important to achieve near anatomical reduction for good anatomical and functional outcome. Restoration of radial tilt, radial length, and congruency of articular surfaces is necessary for satisfactory results.[5] Treatment of displaced, comminuted, intra-articular fracture of the distal end of the radius by a closed method, such as pins and plaster or external fixation, gives unsatisfactory outcome in most of the cases.[6],[7],[8]

Importance of obtaining anatomical reduction of fracture fragments by open reduction and internal fixation (ORIF) in these displaced, comminuted, intra-articular fractures has been stressed upon, however, documented evidence is lacking with respect to the final outcome of this method.[8],[9] Hence, here is an effort to evaluate the efficacy of ORIF of intra-articular distal radial fractures by buttress plate.


  Materials and Methods Top


A prospective, clinical trial was conducted for a total of 22 cases of intra-articular distal radius fractures aged above 18 years. Patients below the age of 18 years, unfit for surgery due to associated medical problems, and with pathological fractures were not considered in our study. The study was conducted for a period of 18 months from January 1, 2015, to June 30, 2016. The demographic data of all patients/subjects [Table 1] showing the age range of 20–58 years with an average of 37.6 years. Males outnumbered females by a ratio of 2.67:1. The most common mode of injury was found to be road traffic accident (68.2%). The fractures were classified as per the Frykman classification system. Type III was the most common (54.5%), followed by Type IV (27.3%). Out of 22 patients, 11 (50%) had some associated injuries such as head injury, chest injury, abdominal injury, and other fractures, which were managed appropriately. Majority of the cases (54.5%) were operated in 2–5 days following injury. All the cases were followed up for a minimum period of 24 weeks (ranging 24–36 weeks). The mean time for union was 8.04 weeks.
Table 1: General demographic data of patients/subjects

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On receiving the patient, initial symptomatic treatment, a detailed history, and a thorough clinical examination were carried out. Standard radiographs in posterior-anterior (PA), lateral, and oblique views were taken for confirmation of the diagnosis. The fracture fragments were analyzed, and involvement of radiocarpal and distal radioulnar joints was assessed and classified according to the Frykman classification.[10] The limb was initially immobilized with a below-elbow plaster of Paris slab.

After anesthetic checkup and proper consent, patients were prepared for surgery under general/regional anesthesia. The volar radial approach (Henry) which uses the interval between the flexor carpi radialis and the radial artery was used. Under an image intensifier, reduction was performed with the aid of intrafocal leverage, traction by an assistant, and provisional fixation by temporary Kirschner wires. Reduction of fracture fragments and joint congruity of radiocarpal and distal radioulnar joints were checked again by an image intensifier. After satisfactory reduction, definitive fixation was done by volar buttress plate. Most of the fractures had two-part volar Barton fracture or its variant which were reduced and fixed nicely. Frykman Type 4, 6, and 8 fracture, position/reduction of ulnar styloid fracture was also checked, and none of the cases required fixation of ulnar styloid fracture. After fixation of fracture, wound was cleaned, closed, and dressed and below-elbow plaster slab applied. Postoperative check X-rays were taken in both PA and lateral views. Wound was inspected on the 3rd postoperative day. Sutures were removed at the 10th–12th postoperative day. The plaster slab was removed after 2 weeks, elastocrepe bandage applied, and active exercises of wrist started.

The patients were followed up for minimum of 24 weeks. Clinical, radiological, and functional assessments were performed at periodic intervals. Radiological assessment was done in terms of residual dorsal angulation, radial shortening, and loss of radial inclination, and the results were graded according to the Sarmiento's modification of Lindstrom criteria.[11] These parameters were assessed during the follow-up of the patient to assess the quality of reduction and the ability of the technique to maintain the reduction. Functional evaluation of the patients was done at the last follow-up according to the demerit point system of Gartland and Werley.[12]


  Results Top


Clinicoradiological evaluation with final results and complications of patients/subjects [Table 2] were done. Radiological assessment was done in terms of residual dorsal angulation, radial shortening, and loss of radial inclination. Mean radial inclination/angle, palmar/volar tilt, and radial length were 19.72°, 6.72°, and 9.13 mm, respectively. Regarding the results of range of motion, mean palmar flexion, dorsiflexion, radial deviation, ulnar deviation, supination, and pronation was 69.77°, 65°, 17.95°, 23.40°, 75.9°, and 70°, respectively.
Table 2: Clinicoradiological evaluation with final results and complications of patients/subjects

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The above clinicoradiological results were graded according to the Sarmiento's modification of Lindstrom criteria.[11] Anatomically, 16 patients (72.7%) had excellent restoration of anatomy, 4 (18.2%) had good restoration, and 2 had fair (9.1%) restoration of anatomy. Thus, 90.9% of the patients had excellent-to-good alignment of fragments and good reduction could not be achieved in 9.1% of the patients.

Functional evaluation of the patients was done at the last follow-up according to the modified demerit point system of Gartland and Werley.[12] Functionally, 14 patients (63.6%) had excellent, 6 had good (27.3%), and 2 had fair (9.1%) restoration of functions. Thus, 90.9% of the patients had satisfactory (excellent + good) result in terms of radiological [Figure 1] and clinical [Figure 2] evaluation at the final follow-up.
Figure 1: Preoperative radiographs (anteroposterior and lateral views) of intra-articular distal radial fracture in a 37-year-old female (a) which was fixed by buttress plate, showing excellent bony union in postoperative (3-month follow-up) radiograph of the same patient (b)

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Figure 2: Clinical photographs of a patient at last follow-up with excellent result of wrist movements showing palmar flexion (a), dorsiflexion (b), radial deviation (c), and ulnar deviation (d)

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No intraoperative complication was noted in our study. One case of superficial infection and one case of injury to the superficial branch of the radial nerve were noted. In later follow-up, two cases presented with joint stiffness, and in one case, loss of reduction was seen at final follow-up. In our study, we found no cases with deep infection, malunion, nonunion, tendon rupture, or Sudeck's atrophy.


  Discussion Top


Various treatment modalities have been discussed in the literature for distal radius fractures ranging from closed reduction and cast immobilization to ORIF with variable angle locking plates and even fragment specific fixation with plates, not to forget closed reduction and fixation with Joshi's External Stabilization System (JESS). However, there remain a lot of controversies when it comes to gold standard treatment, but one thing is clear from the literature that displaced intra-articular fractures require surgical intervention and one cannot achieve good outcome with conservative management in these fractures. In our study, 22 patients were treated with buttress plates for intra-articular fractures of the distal end of the radius and they were analyzed for radiological, clinical, and functional outcome.

We observed a maximum number of cases in the age group of 31–40 years, with a mean age of 37.6 years. The mean age was 43 years in a study conducted by Jupiter et al.[13] on a total of 49 patients. In our study, we found a preponderance of distal radius fractures in male patients (16 out of 22) which is similar to other studies by Jupiter et al.[13] (29 out of 49) and Tang et al.[14] (19 out of 33). Increased incidence in males is probably due to their involvement in outdoor activities, riding vehicles, and manual labor. There were more number of cases involving the right side (63.6%) which is comparable and consistent with other studies (Jupiter et al.[13] − 61.2% right side and Tang et al.[14] –78.8% involvement of dominant limb). In all the cases, the left side was the nondominant side. The mode of injury in our study was mostly due to road traffic accident (68.2%), whereas fall accounted for 31.8% of the cases, which is comparable with the other studies (Jupiter et al.[13] – 49% renal tubular acidosis [RTA] and 25% of the cases from fall and Tang et al.[14] –57.6% RTA and 15.1% from fall). Frykman classification[10] was used in classifying the distal radius fractures. Type III fracture was the most common (54.55%), followed by Type IV (27.27%). The mean interval between injury and surgery was 6.36 days. Increased time interval is mainly because the cases were referred from primary health-care centers/district hospitals and often presented late. The maximum time interval was 20 days and minimum was 2 days. Twelve (54.5%) cases were done under regional anesthesia (supraclavicular brachial plexus block) and 10 (45.5%) cases under general anesthesia (GA). Among the cases requiring GA, 5 cases were associated with other injuries (lower limb fracture/chest injury, etc.) and 5 cases due to failure of supraclavicular block, i.e., regional anesthesia. All fractures were united within 3 months. The time taken for union ranged from 6 to 11 weeks with a mean of 8.04 weeks. The mean time of union was 8.8 weeks and 7.5 weeks in studies conducted by Agarwal and Nagi[15] and Jalil et al.,[16] respectively.

Functional evaluation of the patients was done at the last follow-up according to the demerit point system of Gartland and Werley[12] (with Sarmiento et al.'s modification[11]). Functionally, 14 patients (63.6%) had excellent, 6 had good (27.3%), and 2 had fair (9.1%) restoration of functions. Thus, 90.9% of the patients had satisfactory (excellent + good) result in terms of function at the final follow-up comparable to Jupiter et al.[13] (83.7%) and Tang et al.[14] (94.1%).

In terms of radiological features, our results (volar inclination – 6.72° and radial inclination – 19.72°) are comparable with that of Jupiter et al.[13] (volar inclination – 7.5° and radial inclination –22°). Radiological results were graded according to the Sarmiento et al.'s modification of Lindstrom criteria.[11] Anatomically, 16 patients (72.7%) had excellent restoration of anatomy, 4 (18.2%) had good restoration, and 2 had fair (9.1%) restoration of anatomy. Thus, 90.9% of the patients had excellent-to-good alignment of fragments and good reduction could not be achieved in 9.1% of the patients.

Stiffness involving the wrist and joints of the fingers was the most common complication of our study, seen in two patients (9.09%). Superficial infection was noted in one patient (4.5%) in the present study at the incision site. Fortunately, the infection healed uneventfully on conservative treatment with regular dressing and antibiotics. In one patient (4.5%) superficial branch of the radial nerve was injured leading to paresthesia. The patient recovered within 6 weeks. Loss of reduction at the final follow-up (from the postoperative reduction) was seen in one patient (4.5%). We noted no case of median nerve dysfunction or any compression neuropathy. In this regard, our finding is consistent with that in the study of Agarwal and Nagi[15] and Jalil et al.[16] There was no malunion, nonunion, or tendon rupture in our cases. No case had developed Sudeck's atrophy.


  Conclusion Top


ORIF with buttress plate is an efficient and rewarding procedure for intra-articular fractures of distal radius as it allows anatomical reduction with union and quick functional recovery.

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.

Acknowledgment

We sincerely thank Prof. Biplab Acharyya (Prof and Head, Department of Orthopaedics) and Dr. Bhupes Sil (Asst. Professor, Department of Orthopaedics) of AGMC and GBP Hospital, Agartala, Tripura, for their motivation and constant support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jakim I, Pieterse HS, Sweet MB. External fixation for intra-articular fractures of the distal radius. J Bone Joint Surg Br 1991;73:302-6.  Back to cited text no. 1
    
2.
Colles A. Fracture of the carpal extremity of the radius. Edinb Med Surg J 1814;10:182-6.  Back to cited text no. 2
    
3.
De Oliveira JC. Barton's Fractures. J Bone Joint Surg 1973;55-A: 586-94.  Back to cited text no. 3
    
4.
James E. Smith's and Barton's fractures – A method of treatment. J Bone Joint Surg 1965;47-B: 724-7.  Back to cited text no. 4
    
5.
Jupiter JB. Current concepts and review of fracture of distal end radius. J Bone Joint Surg (Am) 1991;292:48-61.  Back to cited text no. 5
    
6.
Chapman DR, Bennett JB, Bryan WJ, Tullos HS. Complications of distal radial fractures: Pins and plaster treatment. J Hand Surg Am 1982;7:509-12.  Back to cited text no. 6
    
7.
Cole JM, Obletz BE. Comminuted fractures of the distal end of the radius treated by skeletal transfixion in plaster cast-an end-result study of thirty-three cases. J Bone Joint Surg 1966;48-A: 931-45.  Back to cited text no. 7
    
8.
Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68-A: 647-59.  Back to cited text no. 8
    
9.
Melon CP. Open treatment for displaced articular fracture of distal radius. Clin Orthop 1986;202:103-11.  Back to cited text no. 9
    
10.
Frykman GK. Fracture of the distal radius including sequelae shoulder hand finger syndrome, Disturbance in the distal radioulnar joint and impairment of nerve function-A clinical and experimental study. Acta Orthop Scand Suppl 1967;108:1-155.  Back to cited text no. 10
    
11.
Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles' fracture-functional bracing in supination. J Bone Joint Surg Am 1975;57:311-7.  Back to cited text no. 11
    
12.
Gartland JJ Jr., Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am 1951;33-A: 895-907.  Back to cited text no. 12
    
13.
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.  Back to cited text no. 13
    
14.
Tang Z, Yang H, Chen K, Wan G, Zhu X, Qian Z. Therapeutic effects of volar anatomical plates versus locking plates for volar Barton's fractures. Orthopedics 2012;35:1198-203.  Back to cited text no. 14
    
15.
Agarwal AK, Nagi ON. Open reduction and internal fixation of volar Barton's fracture-a prospective study. J Orthop Surg 2004;12:230-4.  Back to cited text no. 15
    
16.
Jalil SA, Mughal RA, Haque SN, Shah RA. Treatment outcome of volar Barton fracture fixed with locking compression plates. Pak J Surg 2010;26:265-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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