Intra-Articular Distal Radial Fractures – External Fixation Or Conventional Closed Reduction?

S.Thomas*, C.John**,T.P.Johnny**

*Clinical Fellow in Orthopaedics,North Tyneside Hospital, Tyne and Wear ,UK
**Consultant Orthopaedic Surgeon,Malankara Orthodox Church Medical College Hospital, Kolenchery,Kerala, India

Address for Correspondence:

Mr.S.Thomas
22, East Street, Tynemouth, UK.
NE30 4EB
Phone: 0044 7940309119
Fax: 0044 191 2932575
E-Mail: orthobug@gmail.com 

Abstract:

Aim:Fractures of the distal radius represent the most common upper extremity fracture. Today distal radial fractures are recognised as very complex injuries with a variable prognosis. The aim of the study was to assess the anatomical and functional outcomes of distal radial fractures managed with external fixation and conventional closed method. 
Materials and Methods:A series of twenty patients with intra-articular distal radial fractures were randomised allocating them to either treatment with conventional closed method (group 1) or external fixation (group2). They were treated either with an above elbow cast was or external fixation using the JESS fixator for six weeks.  Regular reviews were done and at six months they were assessed for anatomical and functional outcome using the method described by Older et al. 
Results:Anatomical and functional outcome was better in the group treated with external fixation especially in the younger patients. In this group, the excellent/good anatomical outcome did correlate with the functional outcome. There were no poor outcomes in both groups. Good outcome was seen in the elderly patients treated non- operatively and was a cost effective treatment for them. 
Conclusion:We recommend the use of external fixation in functionally demanding young patients with potentially unstable distal radial fractures. However conventional non operative management should still be an option especially in the elderly.

J.Orthopaedics 2007;4(2)e39

Introduction:

Fractures of the distal radius represent the most common upper extremity fracture. Beginning with the works of Pouteau, Dupuytren and Colles [1] physicians have thought of distal radial fracture as a homogenous group of injuries with a relatively good prognosis irrespective of the treatment given .However today distal radial fractures are recognised as very complex injuries with a variable prognosis that depends upon the fracture type and treatment given. The aim of the study was to assess the anatomical and functional outcomes of distal radial fractures managed with external fixation using the ligamentotaxis principle and conventional closed method.

Material and Methods :

A series of twenty patients were randomised allocating them to either treatment with conventional closed method (group 1) or external fixation (group2). There were eight females and two males in group 1 and seven females and three males in group 2.  Inclusion criteria were fractures presenting within three days of injury and fractures belonging to Frykman type three to eight [3]. Exclusion criteria were patients with multiple injuries and previous injury to the same limb.

Group one – Closed Reduction and Cast application

After clinical examination and radiographs (AP and Lateral) the fractures were reduced under image intensifier guidance and above elbow cast was applied with elbow in ninety degree flexion, forearm pronated, wrist in 10-15 degree palmar flexion and 20-25 of ulnar deviation. After check radiograph, the limb was elevated and active finger movement advised. Patients were reviewed in the fracture clinic after ten days with check radiographs. If reduction was lost, manipulation and cast application was repeated. Three weeks post reduction, the patient was reviewed and the above elbow cast was converted to below elbow cast and elbow mobilisation encouraged. The patients were then further reviewed at six weeks post reduction where the cast was removed. Clinical and radiological assessment was done and active wrist mobilisation started. They were then reviewed at monthly intervals to assess the hand function. At six months review included assessment of wrist movement with a goniometer and grip strength using a dynamometer. 

Group two – External Fixation

After clinical examination and radiographs the patients were operated on the next available trauma list. The same type of external fixator was used in all patients (Joshi’s External Stabilising System [4]). Two pins were passed through the second metacarpal and two pins passed through the radius proximal to the fracture. The fracture was then reduced and the external fixator applied with wrist in flexion and ulnar deviation. The fixator was removed at six weeks and then the same protocol as for the Group one was followed.

At six months patients in both groups had a clinical and radiological assessment. The system of Older et al [9] was used to evaluate the end result of functional and anatomical outcome.  

Results :

In group one, seventy percent of the patients had good/excellent anatomical outcome whereas in group two, ninety percent of the patients had good/excellent results. Assessing the functional outcome, hundred percent in group one had fair/good results with no excellent results whereas in group two twenty percent of the patients had excellent functional outcome and eighty percent had fair/good results. There were no poor outcomes in both groups. The excellent anatomical outcome in thirty percent of the patients in group one did not give any excellent functional outcome. However in group two, the excellent/good anatomical outcome did correlate with the functional outcome.

The complications included redisplacement (group1-four cases, group 2-two cases), malunion (group 1- one case), stiffness (group1- two cases, group2-three cases), persistent pain (group1- two cases) and pin site infection (group2- one patient) .The cost analysis between the two groups showed that there was average cost of one thousand two hundred rupees in group one with one day stay in hospital. In group two there was an average expenditure of four thousand five hundred rupees with an average stay of four days.

Discussion :

Treatment of distal radial fractures still remains a controversy regarding which treatment method is superior. Although our series is not large, our study reflects a typical experience from the rural parts of India where different patient factors have to be considered when choosing the best available treatment. Treatment advised should be based on the best evidence, however patient preferences and cost effectiveness should be considered in choosing the final treatment. Our results show that the anatomical results were better in patients treated with external fixator. The functional outcomes were also better in the external fixator group especially for younger individuals. Fractures with loss of volar tilt in particular did not have optimal functional and anatomical outcome.

Howard [6] and Kongsholm [8] recommend external fixation compared to closed methods especially in young patients. However a randomised study by Horne et al[5] did not demonstrate any advantage by using the external fixation in younger patients. Karnezis et al [7] found that permanent radial shortening and loss of the palmar angle were associated with poor functional outcome. However Roumen et al [10] did not find any correlation between the final functional outcome and the anatomical position. Fernandez [2] suggested that anatomic restoration should remain the primary goal of conservative management. He added that though closed reduction and cast application render satisfactory results in stable fractures; intra-articular fractures have a high risk for redisplacement. Hence these types of fractures represent a contraindication for cast treatment.

Our results suggest that in elderly patient with low functional demand, non operative management still remains a good option. When expenditure to patients is important, a cost effective management that gives our patients good results should be the preferred approach and unnecessary surgical intervention should be avoided. As Abraham Colles quoted, the limb will at some remote period enjoy perfect freedom in all its motions and be completely exempt from pain. 

Conclusion:

We recommend the use of external fixation in functionally demanding young patients with potentially unstable distal radial fractures. However conventional non operative management should still be an option especially in the elderly.

Reference :

1. Colles A [1972], The classic: On the fracture of the carpal extremity of the radius. Clin Orthop 83:3-5.

2. Fernandez DL [2005]. Closed manipulation and casting of distal radius fractures. Hand Clin.Aug; 21(3):307-16.

3. Frykman G. [1967], Fracture of the distal radius including sequelae--shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;Suppl 108:3

4. Gulati S, Joshi BB, Milner SM [2004]. Use of Joshi External Stabilizing System in postburn contractures of the hand and wrist: a 20-year experience. J Burn Care Rehabil. Sep-Oct; 25(5):416-20.

5. Horne JG, Devane P, Purdie G [1990]. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures. J Orthop Trauma.4(1):30-4.

6. Howard PW, Stewart HD, Hind RE, Burke FD[1989]. External fixation or plaster for severely displaced comminuted Colles' fractures? A prospective study of anatomical and functional results. J Bone Joint Surg Br.  Jan; 71(1):68-73.

7. Karnezis IA, Panagiotopoulos E, Tyllianakis M, Megas P, Lambiris E[2005]. Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius. Injury. Dec; 36(12):1435-9.

8. Kongsholm J, Olerud C [1989]. Plaster cast versus external fixation for unstable intraarticular Colles' fractures. Clin Orthop Relat Res. Apr ;( 241):57-65.

9. Older TM, Stabler EV, Cassebaum WH [1965], Colles fracture- evaluation of selection of therapy. J Trauma, (5), 469-476.

10. Roumen RM, Hesp WL, Bruggink ED [1991]. Unstable Colles' fractures in elderly patients. A randomised trial of external fixation for redisplacement. J Bone Joint Surg Br. Mar; 73(2):307-11.

This is a peer reviewed paper 

Please cite as :S.Thomas : Intra-Articular Distal Radial Fractures – External Fixation Or Conventional Closed Reduction?

J.Orthopaedics 2007;4(2)e39

URL: http://www.jortho.org/2007/4/2/e39

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