|Year : 2022 | Volume
| Issue : 1 | Page : 32-37
Management of unstable fractures of the distal end radius using bicolumnar radius plating
Ashok Sharma, Nayyar Ali, Umesh Vyas, Arvind Kumar Bohra, Shiv Bhagwan Sharma
Department of Orthopedics, SRGH, Jhalawar, Rajasthan, India
|Date of Submission||14-Oct-2021|
|Date of Acceptance||25-Dec-2021|
|Date of Web Publication||15-Jun-2022|
Dr. Ashok Sharma
Room No. 507, New PG Hostel, Jhalawar Medical College, Jhalawar - 326 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Controversy still exists regarding the current treatment modalities for unstable distal radius fractures. A prospective study was performed to evaluate efficacy of bicolumnar plating (radial buttress and volar plating) technique, which is designed to providing sufficiently secure fixation treatment of distal radius fractures. Materials and Methods: The prospective randomized study was done under the department of orthopedics at SRG hospital Jhalawar. We operated 20 patients, with distal end radius fracture of type 23C2 and 23C3 with radial column fracture using bicolumnar plating between May 2019 to MAY 2021. All patients presented for follow-up till union. Patients belonged to age group 20-75 years with the mean age of 45 years. Twelve patients were male and eight were female. The duration of follow-up was 12-18 months. Results: Bicolumnar plating led to complete union of unstable distal radius fractures without additional procedures. The assessment of post-operative functional outcome was done using the MODIFIED MAYO WRIST SCORE. At the final follow-up, 15 patients had excellent score, 3 had good score and 2 had fair score. Conclusions: Bicolumnar plating is feasible option for the management of displaced distal radius fractures and can result in favorable surgical outcomes.
Keywords: Bicolumnar plating, the modified Mayo wrist score, unstable distal radius fracture
|How to cite this article:|
Sharma A, Ali N, Vyas U, Bohra AK, Sharma SB. Management of unstable fractures of the distal end radius using bicolumnar radius plating. J Orthop Traumatol Rehabil 2022;14:32-7
|How to cite this URL:|
Sharma A, Ali N, Vyas U, Bohra AK, Sharma SB. Management of unstable fractures of the distal end radius using bicolumnar radius plating. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Dec 9];14:32-7. Available from: https://www.jotr.in/text.asp?2022/14/1/32/347355
| Introduction|| |
Distal radius fractures (pilon radiale) are the most common upper extremity fractures. DRFs are usually associated with other bony or soft-tissue injuries in variable percentages according to the magnitude of trauma and the bone quality.
DRFs are associated with ulnar styloid fracture, capsular tears, triangular fibrocartilage complex tears, scapholunate ligament injuries, lunotriquetral ligament injuries, and cartilage lesions (2%–30%).
Many studies have indicated trimodal pattern of occurrence in, i.e., at young adults (high-velocity trauma), elderly age > 60 years, and in postmenopausal osteoporotic women (low velocity).
The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.,,
Bicolumnar plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.,,,
The main aim of this study is to evaluate clinical outcome of volar radial T plate in addition to, lateral column buttress plate for unstable distal radius fractures.
A radial plate was used only in cases of difficult repositioning with radial shift and proximal displacement of the styloid process if satisfactory reduction was not achieved otherwise. The decision to add a radial plate was therefore taken intraoperatively. This technique may be particularly useful when a surgical assistant is not available.
The brachioradialis attaches to the radial styloid, due to which it exerts lateral pull on the radial styloid fragment in distal radius fractures [Figure 1]. This has to be kept in mind while reducing the fracture, especially in comminuted fractures and osteoporotic fractures. The surgeon must also know that when the elbow is extended with forearm supination (normal intraoperative position), the pull exerted by brachioradialis is exerted.
The buttress plate [Figure 1] helps in countering the brachioradialis pull, thus bringing about good reduction.
| Materials and Methods|| |
In this study, we selected 20 patients with unstable distal end radius fractures. We operated these patients at SRG Hospital, Jhalawar, with radiovolar bicolumnar plate fixation (radial buttress plate and volar locked plate). This study was conducted over a period of 12 months between May 2019 and June 2020 at our institution.
We had a study group, comprising 12 males and 8 females. Among them, 7 had left-sided and 13 had right-sided fractures were involved.
The mean age was 45 years. Out of twenty patients, six were aged below 35 years but above 18 years and four were above 55 years of age. The remaining patients were between 35 and 55 years of age [Table 1].
The majority of patients had AO type 23C2 fractures and two of had 23C3 type. All the patients presented for subsequent follow-up visits at our outpatient department.
The inclusion criteria were:
- Adult patients (>18 years) who had the mental ability to give informed consent for treatment,
- Closed fracture
- Fractures presenting within 2 weeks of sustaining injury.
The exclusion criteria were:
- Presence of neurovascular compromise
- Fracture extending > 3 cm proximal from the radiocarpal joint
- Patients not fit for surgery
- Patient not giving consent for surgery
- Patients with acceptable anatomical reduction and stabilization.
All patients were thoroughly assessed including history recording, physical examination, preanesthetic workup, and patient workup.
Anterior–posterior, lateral, and oblique radiographs were obtained.
Patients were positioned supine, and the arm was placed in 90° abduction with forearm supinated on the side table, after application of tourniquet.
Painting and draping were done using aseptic precautions. Preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus.
A rolled towel was placed dorsal to the metacarpals, holding the wrist in volar flexion position. Distal Henry approach (volar approach) was used.
The plane of dissection was created between the flexor carpi radialis tendon and brachioradialis tendon. The flexor carpi radialis tendon was retracted medially thus protecting the median nerve. The radial artery was located and retracted laterally. The underlying flexor pollicis longus tendon was retracted medially to expose the pronator quadratus over the distal end radius.
The pronator quadratus was incised in an L-shaped manner and released to expose the fracture site. The insertion of brachioradialis tendon on the radial styloid fragment was lifted off the bone with periosteal elevator. The tendons of first extensor compartment were retracted laterally. Under the guidance of image intensifier, the distal fracture was reduced and temporarily stabilized with K-wire [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e. At this time here we can release the distal osseous insertion of the brachioradialis tendon if require.
The main volar plate was fixed after further aligning the fracture. We place two screws in the distal fragment. Then, the radial styloid was reduced and a 3.5-mm reconstruction plate was used to buttress the fracture fragment, placing one screw in the styloid fragment and one screw in the proximal fragment. Care was taken to make sure that neither the tendons nor radial artery was impinged between bone and implant. After checking the reduction in coronal and sagittal plane, the pronator quadratus was repaired and the incision was closed in layers.
Physiotherapy was started on postoperative day 2. Active motion of fingers, without weight-bearing, was advised.
To prevent elbow stiffness and to protect the fracture, the forearm was splinted with a below-elbow slab for 4–6 weeks.
After 4 weeks, the slab was removed and the gentle flexion and extension exercise of wrist joint were initiated.
After 6 weeks, partial weight-bearing was allowed if radiographic signs of fracture healing were seen.
Follow-up was done and both AP and lateral radio-graphs were taken [Figure 3] and [Figure 4] at 3rd week, 4th week, 10th week, 12th week, 14th week, 6th month, and annually thereafter
|Figure 3: Case 1 radiological outcome. (a) Preoperative x-ray (b) postoperative day X-ray (c) 1 month postoperative X-ray (d) X-ray at union|
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|Figure 4: Case 2 radiological outcome. (a) Preoperative X-ray (b) postoperative day X-ray (c) 1 month postoperative X-ray (d) X-ray at union|
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| Results|| |
We operated twenty patients, with distal end radius fracture of type 23C2 and 23C3 with radial column fracture using bicolumnar plating between May 2019 and May 2021. All patients presented for follow-up.
The patients belonged to age group 20–75 years with the mean age of 45 years. Twelve patients were male, and eight were female. The duration of follow-up was 12–18 months. We compiled data which included patient age, gender, handedness, and medical comorbidities. We also made note of the initial mechanism of injury, coexisting medical condition at time of surgery, initial management, and time take from time of injury to operation. All cases operated at 2nd day posttrauma.
- All patients had acceptable radial height, radial inclination, and volar tilt [Figure 3] and [Figure 4] at final follow-up
- Duration of surgery-an average of 45 min
- The average time taken by fracture to unite was 12 weeks
- Average range of motion was observed
- None of the cases reported positive ulnar variance.
Excellent functional outcome achieved in most of the patients at final follow-up [Figure 5] and [Figure 6]. After compiling the data, we obtained the following information [Table 2]. The mean range of motion at wrist joint: flexion 54° (range 20–74); extension 62° (range 30–84) pronation: 76° (range 64–88); and supination: 70° (range 62–80). Grip strength measured by handgrip dynamometer mean measurement 55 pound (range 32–88) was 92% (range 80–100) of the opposite hand.
|Figure 5: Case 1 functional outcome. (a) Movements at 1-month follow-up (b) movements at time of union|
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|Figure 6: Case 2 functional outcome. It showing movements at time of union|
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One of the patients reported with pain at base of thumb and was diagnosed with de Quervain's tenosynovitis-like symptoms which were caused by the radial plate. The radial plate removal was done after bony union was checked for. One patient presented with superficial skin infection, which was treated by debridement and antibiotics. All patients had bony unions.
The assessment of postoperative functional outcome was done using the Modified Mayo Wrist Score [Figure 7]. This score comprises four parameters (pain, satisfaction, range of motion, and grip strength in percentage of normal), parameters with a minimum score of 0 and maximum score of 25 for each parameter.
At the final follow-up, 15 patients had excellent scores, 3 had good scores, and 2 had fair scores.
We also recorded the radiographic data including direction and degree of radial and volar tilt [Figure 8], radial inclination, articular step off, and ulnar variance, which were obtained from standard anteroposterior and lateral radiographs.
The Mean measurement of initial volar tilt was − 10° (range-38–30), and at final radiograph Mean measurement was 9 (range-8–17) [Table 3]. Preoperative loss of radial height was 6.4 mm (range 3–12) and at final radiograph 0.1 mm (range 1 –−1). Preoperative radial inclination was 11° (−4–18) and at final radiograph 21° (range 16–28). Secondary dislocation was not observed in any patient.
| Discussion|| |
It has been observed that reduction of fraction of lateral column of the distal radius is better achieved with fixation of a radial buttressing plate. It complements the fracture fixation done using the standard volar plate. The fixation of the radial styloid fragment is very important for stability of the fracture reduction. In our study, we have fixed the distal radius fracture using bicolumnar plating.
A study done by Tang et al. included bicolumnar plating in 8 patients, in they reported a 100% union after 35 weeks without any major complications.
In distal radius fractures which involve the articular surface, apart from anatomic reduction and stability, the success of the surgery is also determined by the postoperative mobility of the wrist joint.
In a study of Jacobi et al., measurements of the movements of the wrist joint were assessed at 24-month postsurgery. The values showed a mean extension of 49°, 39°flexion, 75° supination, and 75° pronation.
Although DASH scores of 1 year for volar plating alone have been shown within 6 and 13 in the literature, 3- and 6-month scores have historically been > 18.,,,,,
According to the Gartland and Werley Score, 16 patients were rated as excellent, 2 as good, and 2 as fair, with all 20 cases achieved bony union. In this demonstrated no loss of volar tilt, radial length, or radial inclination. However, in both studies, the use of the radial column plate was advocated as a tool for fragment-specific fixation and not as a reduction tool.
In our study reported one case of postoperative wound infection. All the radiographic measures showed good maintenance of reduction in our study at final follow-up.
Due to the ease of surgery, many surgeons prefer the volar approach to the distal radius. A Modification of this approach was done by Orbay which involves the release of the distal osseous insertion of the brachioradialis tendon. This modification aids in reduction of the radial styloid fragment as the lateral pull exerted by the brachioradialis is no longer acting as the deforming force.
| Conclusions|| |
The presented bicolumnar plating technique using single-approach with a radial buttress plate for unstable intra-articular distal radius fractures is useful because it facilitates anatomic reduction and stable fixation. It is indicated only in a subgroup of patients with comminuted intra-articular distal radius fracture in which the lateral column needs to be buttressed to achieved reduction and fracture union. Many studies have shown excellent results and patient satisfaction.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]