Harish V Kurup, *V.
Mandalia, *K.A.
Shaju, *A.R. Beaumont. *Specialist Registrar in
Orthopaedics, Salisbury District Hospital, SP2 8BJ, UK.
Address for Correspondence
Harish V Kurup
Specialist Registrar in Orthopaedics
Gwynedd
District
Hospital
Bangor, North Wales LL57 2PW
Phone: +44 1248384384
Email:harishvk@yahoo.com
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Abstract The aim of this
study was to find out whether distal radius fractures treated by
K wire fixation loose reduction after wire removal and analyze
the variables may influence this. Patients who underwent K wire
fixation for unstable fractures of distal radius over a period
of 3 years were included in this retrospective study. Fractures
were classified according to AO classification. Radiographs
taken just prior to removal of K wires and radiographs taken at
least 1 month after wire removal were analyzed to study three
radiological parameters ; Palmar or dorsal tilt, radial
inclination and ulnar variance. Loss of these angles were
analyzed statistically against variables like age, sex, AO
classification, type of K wires used, delay in fixation and
duration of fixation. 59 fractures were analyzed with mean age
of 56 years and male to female ratio of 1:2. Average loss of
radial tilt was 2.6 deg, loss of palmar tilt was 2.6 deg and
loss of ulnar variance was 1.3 mm. We found that distal radius
fractures treated by percutaneous K wire fixation, do not suffer
significant loss of reduction of fracture position after removal
of wires. This remains true regardless of age, sex, fracture
type according to AO type, type of wires used, delay in fixation
or duration of wire fixation.
Keywords:
Distal Radius Fracture, K wire fixation, loss of reduction,
Radiological variables.
J.Orthopaedics
2006;3(4)e4
Introduction:
Fractures of the distal radius are the most
common of all orthopaedic injuries accounting for nearly 20 % of
all fractures presenting to emergency department [1]. Malunion
of distal radius fractures lead to posttraumatic arthritis, mid
carpal instability and pain [2]. Conservative treatment of
minimally displaced and stable fractures of distal end of radius
in elderly patients usually shows a good outcome but the
treatment of severely displaced and unstable fractures has been
controversial. The functional results in patients with
significant radial shortening are poor. Fujii et al [3]
recommended reduction of these fractures even in elderly
patients. Percutaneous pinning is a simple, minimally invasive
technique and is aimed at preventing redisplacement of the
fragments. Wires are usually retained for 4 to 6 weeks. Most
opponents of this technique claim that these fractures tend to
collapse even after removal of wires [4] . The aim of our study
was to find out whether these fractures loose reduction after
removal of wires and whether this has any statistically
significant association with any of the factors looked at.
Materials and methods
All patients who underwent K wire fixation
for distal radius fractures in our department (June 2000 to May
2003) were included in this retrospective study. Palmar Tilt,
Radial Tilt and Ulnar Variance were measured in these patients
on plane radiographs [5]. The exclusion criteria were paediatric
fractures, additional procedures like external fixation,
nonavailability of satisfactory and comparable radiographs for
measurement. The fractures were classified using AO
classification. K wires were removed in outpatient clinic
usually between 4-6 weeks depending on the preference of the
consultant surgeon in charge of the patient. The loss of palmar
tilt, radial tilt, and ulnar variance were measured from
radiographs done prior to wire removal and later in follow up (3
to 4 months after injury). Only patients who were reviewed at a
later date in clinic with a radiograph were included in this
study.
The variables studied were age, sex,
fracture type (AO), presence of ulnar fracture, type of K wires
used, delay in fixation and period of wire stabilization.
Continuous normally distributed data was analyzed using
Chi-Square test, T-test and Fischers exact test using SPSS 10.0
software (SPSS Inc. Chicago, Illinois, USA). P value < 0.05 was
considered to be significant for the purpose of this study.
Results
59 patients were included in this study of
which 39 (66%) were females and 20(34%) males. Mean age of
patients was 56 years (Range: 18 to 86 years). We divided
patients into two age groups (<65 years and > or = 65 years). 56
% were < 65 years old and 44 % were > 65. [Table 1] Age ( P
value 0.939) and sex ( P value 0.966) had no influence on the
loss of radiological parameters after wire removal.
Table 1 : Loss of angles and Age / Sex
Category
(Number of
patients ) |
Loss of angles
Mean ( Range ) |
Radial Tilt-
o |
Ulnar
Variance- mm |
Dorsal Tilt-
o |
< 65 years
(33) |
2.2 (0-12) |
1.1 (0-4) |
2.2 (0-12) |
> 65 years
(26) |
2.0 (0-30) |
1.5 (0-10) |
3.1 (0-12) |
P value 0.939 |
Male
(20) |
2.3 (0-12) |
1.4 (0-4) |
2.1 (0-12) |
Female
(39) |
2.8 (0-30) |
1.3 (0-10) |
2.9 (0-12) |
P value 0.966 |
All patients
(59) |
2.6 (0 30) |
1.3 (0-10) |
2.6(0-12) |
Fractures were classified using AO system.
No patients were in class B, due to different treatment protocol
followed in these. AO Class of the fracture had no influence on
loss of angles after wire removal (P value 0.923). [Table 2].
Most fractures were fixed on first week and some were delayed to
second week or still later. The delay in fixation did not appear
to influence loss of reduction after wire removal (P value
0.803). [ Table 3] Some patients had one or two Kapandji
intra-focal wires in addition to percutaneous wires. Use of
Kapandji wire did not provide a statistically significant (P
value 0.514) difference in the loss of angles.[Table 4] Wires
were mostly removed in outpatients after 5 or 6 weeks with some
at 4 and some after 6 weeks. The duration of fixation had no
association with the radiological outcome (P value 0.905) [Table
5]
Table 2 : Loss of angles
and AO Class
AO Class
(Number of
patients) |
Loss of angles
Mean ( Range ) |
Radial Tilt- o |
Ulnar Variance-
mm |
Dorsal Tilt- o |
A2
(10) |
5.4 (0 30) |
1.1 (0 2) |
2.7 (0 12) |
A3
(18) |
1.7 (0 4) |
1.2 (0 4) |
3.4 (0 12) |
C1
(14) |
1.8(0 6) |
0.9 (0 2) |
2.5 (0 8) |
C2
(12) |
1.5 (0 6) |
1.8 (0 10) |
1.6 (0 6) |
C3
(5) |
4 (0 12) |
1.2 (0 4) |
3.0 (0 4) |
P value 0.923 |
Table 3 : Loss of angles and delay in fixation
Delay in
fixation
( Number of
patients ) |
Loss of angles
Mean ( Range ) |
Radial Tilt- o |
Ulnar Variance-
mm |
Dorsal Tilt- o |
< 1 week
(40) |
2.8
(0-30) |
1.3
(0-8) |
2.8
(0-12) |
>1 & < 2 weeks
(17) |
2.2
(0-8) |
1.4
(0-10) |
2.9
(0-8) |
> 2 weeks
(2) |
1
(0-2) |
1
(0-2) |
0
(0) |
P value 0.803 |
Table 4 : Loss of angles and type of wire
Type of K-wire
( Number of
patients ) |
Loss of angles
Mean ( Range ) |
Radial Tilt- o |
Ulnar Variance-
mm |
Dorsal Tilt- o |
With Kapandji
wire
(8) |
1.3
(0-2) |
0.5
(0-2) |
4.0
(0-12) |
Without
Kapandji wire
(51) |
2.8
(0-30) |
1.4
(0-10) |
2.4
(0-12) |
P value 0.514 |
Table 5 : Loss of angles and timing of wire removal
Timing of K-wire
removal
( Number of
patients) |
Loss of angles
Mean ( Range ) |
Radial Tilt- o |
Ulnar Variance-
mm |
Dorsal Tilt- o |
4 weeks
(8) |
1.5
(0-4) |
0.9
(0-4) |
1.5
(0-4) |
5 weeks
(12) |
3.6
(0-12) |
1.0
(0-2) |
3.2
(0-12) |
6 weeks
(33) |
1.8
(0-6) |
1.2
(0-8) |
2.7
(0-12) |
> 6 weeks
(6) |
6.7
(0-30) |
2.7
(0-10) |
2.2
(0-4) |
P value 0.905 |
Conclusions
We make the following
recommendations based on our findings:
-
Junior doctors should
be encouraged to do re-audits along with new projects.
-
Audits should identify
the person responsible for the planned change and the progress
made should be discussed in the following meeting.
-
Every department
should audit its own audits periodically to review changing
practice and identify defects in the system.
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