Original Research Article TO COMPARE THE FUNCTIONAL ... · fixator was used to achieve ligamentotaxis effects. On the first post-operave day acve and assisted range of moon of

TO COMPARE THE FUNCTIONAL OUTCOME OF INTRA ARTICULAR DISTAL END OF RADIUS FRACTURE TREATED BY CONVENTIONAL

POP CAST AND EXTERNAL FIXATATOR FIXATATION

Affiliation

1. Assistant Professor, Department of Orthopedics, Birat Medical College Teaching Hospital, Biratnagar, Nepal.

2. Lecturer, Department of Orthopedics, Birat Medical College Teaching Hospital, Biratnagar, Nepal.

A R T I C L E I N F O

Article History

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publication with the work simultaneously licensed under

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others to share the work with an acknowledgment of the

work's authorship and initial publication in this journal.

Received : 28 July, 2018

Accepted : 19 April, 2019

Published : 30 April, 2019

Citation

Gupta PK, Chaudhary AK. To Compare The Functional Outcome of Intra

Articular Distal end of Radius Fracture Treated by Conventional Pop Cast

and External Fixatator Fixatation. BJHS 2019;4(1)8: 586 - 591.

* Corresponding AuthorDr. Pradip Kumar Gupta

Assistant Professor

Department of Orthopedics

Birat Medical College Teaching Hospital, Biratnagar, Nepal

Email: [email protected]

Orcid ID : https://orcid.org/0000-0003-1056-7070

ABSTRACT

Introduc�on

Distal end of radius fractures frequently have a high degree of comminu�on, instability, and associated with so� �ssue injuries. Treatment of this distal radius fracture is controversial and there is no single defini�ve treatment method that is considered the standard of care.

Objec�ve

1. To compare the func�onal results of the conven�onal POP cast and external fixator fixa�on of intra ar�cular distal end of radius fracture.

2. To compare the radiological changes with that of func�onal outcome.

Methodology

It was a prospec�ve study comparing the func�onal outcome of distal intra-ar�cular radius fracture when managed by conven�onal POP cast and external fixatator fixa�on. The final outcome was decided on the basis of modified Gartland and Werley scoring system. Total 50 pa�ents (19 – 54 years) were recruited. 30 were treated by closed reduc�on and POP cast and 20 by external fixa�on. Radiological parameters were graded according to Schecks criteria and fracture comminu�on was classified according to Frykman's classifica�on.

Results

The func�onal outcome of the treatment was a subjec�ve evalua�on in which 80% of the pa�ents had pain in external fixa�on as compared to 63% in closed reduc�on POP cast group. The restric�on of ac�vi�es was in 10% of the pa�ent in external fixa�on group as compared with 33% in closed reduc�on POP cast group. The final scoring system as modifica�on of Gartland and Werley point system had 5 ± 3 conven�onal pop cast group and 4 ± 4 in external fixa�on group. (p = 0.3764). On radiological evalua�on, there was no significant difference in radial length, radial angle and volar �lt in two groups.

ConclsionThe results show no sta�s�cally significant difference between the two modes of interven�ons. External fixa�on provides easy mobiliza�on of fingers and reduces edema and s�ffness of joints. The ac�ve ranges of movements at the wrist joints were significantly be�er in external fixa�on group.

KEY WORDS

Fractures, distal end radius, intra-ar�cular, conven�onal POP cast and external fixator.

ORA 95

DOI: h�p://dx.doi.org/10.3126/bjhs.v4i1.23927

Original Research Article

1* 2Gupta PK , Chaudhary AK

Gupta PK et al

586ISSN: 2542-2758 (Print) 2542-2804 (Online)

Birat Journal of Health Sciences Vol.4/No.1/Issue 8/ Jan - April, 2019

http://dx.doi.org/10.3126/bjhs.v4i1.23927

Original Research Article

INTRODUCTION

Distal end of radius fractures account for 14% of all extremity injuries and 17% of all fractures treated in the

1emergency department. Distal radius fractures occurring as a result of a high-energy injury represent a subset of fractures, o�en with significant injury and impairment to the upper extremity. These fractures frequently have a high degree of comminu�on, instability, and associated with so� �ssue injuries.

Distal radius fractures crush the mechanical founda�on of man's most elegant tool, the hand. No other fracture has a greater poten�al to devastate hand func�on and no metaphysis of bone is embraced by more precious so� �ssues. It is remarkable that this common fracture remains one of the most challenging of all fractures that are treated non-opera�vely. Many physicians believe that no special treatment is needed as the resul�ng deformity rarely results in loss of func�on. However this concept is being increasingly challenged.

A consensus exists that although minimally displaced stable fractures usually can be managed successfully by closed methods of treatment; unstable ar�cular fractures frequently require more invasive techniques to maintain an accurate reduc�on during the healing process. Foremost among these techniques is external fixa�on employing the concept of con�nuous distrac�on, commonly termed ligamentotaxis. Ligamentotaxis neutralizes the deprimental compression forces, which are likely to cause displacement of unstable ar�cular fracture components leading to progressive radial shortening. It is a significant advancement in the management of distal radius fractures.

Treatment of distal radius fracture is controversial; there is no single defini�ve treatment method that is considered the standard of care. Most studies are retrospec�ve in nature and use various classifica�on and inconsistent outcome tools, especially in regard to comminuted fractures with joint incongruity.

In an epidemiology survey of all fractures of the forearm that were treated over a 5- year period in Malmo, Sweden,

2Alffram and Bavar recorded nearly 2000 fractures of the distal end of radius, which was 74.5% of all fractures of the forearm.

OBJECTIVES1. To compare the func�onal outcome of the following

aspect amongst pa�ents treated by closed reduc�on POP cast and External fixator fixa�on of intra ar�cular distal end of radius fractures.

a) Subjec�ve evalua�on-Pain, Loss of movement, Weakness and Restric�on of ac�vi�es.

b) Range of movement- Palmar flexion, Dorsi flexion, Ulnar devia�on, Radial devia�on, Supina�on and Prona�on.

c) Grip strength2.� To compare the following aspect amongst radiological

changes with that of the func�onal outcome.Radial length, Radial angle, Volar �lt, and Distal radio-ulnar joint distance.

METHODOLOGY

This was prospec�-ve study of either sex, having closed intra-ar�cular fractures of distal end of radius. A total of 50 pa�ents, (19-54 years), were selected among them 30 pa�ents were treated by closed reduc�on and POP cast and 20 underwent through external fixa�on. The study was conducted at Birat Medical College, Biratnagar, Nepal from June 2014 to May 2016. Approval of the study was obtained from the ins�tu�onal ethical commi�ee. Informed and wri�en consents were obtained from the pa�ent and pa�ent rela�ves. Pre opera�ve evalua�on was done in both groups which include history regarding the mode of injury, clinical and radiological assessment. Radiological assessment of fracture pa�ern was assessed with antero-posterior(AP)/ posterior -anterior(PA) and lateral radiographic views of the wrist. The fracture pa�ern was classified according to Frykman's classifica�on. Radiographic assessment also includes radial length, radial angle and volar �lt.

The radial length (radial height) is measured on the PA view radiograph as the distance between one line perpendicular to the long axis of the radius passing through the distal �p of the radial styloid. A second line intersects distal ar�cular surface of ulnar head.

The radial angle (radial inclina�on) represents the angle between two lines-one drawn perpendicular to the long axis of the radius at the ulnar corner of the lunate fossa and the other between that point in the lunate fossa and the �p of radial styloid. This was measured on the PA view of radiograph.

The volar �lt (radial �lt) represents the angle between a line along the distal radial ar�cular surface and the line perpendicular to the longitudinal axis of the radius joint margin. This was measured on the lateral view of radiograph.

The pa�ent with previous deformity of the same limb, mentally retarded pa�ents with osteoporosis of the bone and previous surgery at the same site and neurovascular injuries were excluded.

Closed reduc�on and POP cast immobiliza�on group: - fractures were reduced under seda�on or hematoma block and below elbow or above elbow plaster of Paris (POP) cast was applied. Most of the pa�ents were given cast in palmar flexion and ulnar devia�on of the wrist but some were given cast in dorsiflexion posi�on a�er evalua�ng the fracture pa�ern Frykman type VII fractures had volarly displaced. The volarly displaced Volar Barton fractures were given the cast above elbow in dorsiflexion posi�on. Pa�ents were called a�er 24 hours for inspec�on to assess distal circula�on, swelling and �ghtness of plaster cast. Plaster cast was applied for 5 to 6 weeks depending upon clinical and radiological union. Reduc�on was a�empted again in selected cases in which fracture re-displaced within 10 days of ini�al closed reduc�on.

External fixator fixa�on group: - The Bridging external fixator was used to achieve ligamentotaxis effects. On the first post-opera�ve day ac�ve and assisted range of mo�on of the fingers, forearm, elbow and shoulder was started. The

Gupta PK et al

587 ISSN: 2542-2758 (Print) 2542-2804 (Online)


Original Research Article Gupta PK et al

post-opera�ve dressing was removed a�er two days, and pa�ents were instructed regarding the care of pin sites.

X-rays were taken immediately a�er surgery, at 2 weeks and then a�er 6 weeks to assess the fracture alignment and union. Fixator was removed a�er clinical and radiological evidence of union. On outpa�ent basis below elbow cast was given for another 2 weeks to prevent fracture through the pin sites. Pa�ents were advised to undergo physiotherapy for 6 to 8 weeks following removal of fixators.

In the both groups the final assessment of the func�onal end results in the present series was based on a clinical examina�on carried out in accordance with a pre-determined plan i.e. (swelling, tenderness, ac�ve mobility of the wrist, grip strength and distance between the pulp of the fingers and the palm).

Radiological evalua�on – antero-posterior and lateral radiograph were taken at the �me of injury, immediately a�er reduc�on, at 2 weeks and at �me of last follow up which was at 6 months. Measurements of radial length, radial angle and volar �lt were measured. Also the distance between the distal end of the radius and ulna at the level of the distal radio-ulnar joint was measured.

Chi-square test was used to analyze the categorical data while student t test was used for con�nuous

data for comparing the final outcome of the func�onal end results on the basis of modified Gartland and Wereley

3scoring system. Sta�s�cal analysis was done using EPI Info 2000 so�ware. P<0.05 was considered as sta�s�cally significant.

RESULTS

The average age of the pa�ents was 34±11 years in closed reduc�on pop cast group and 33± 8 years in external fixator group. The frequency of sex in our study was male 38(76%) and female 12(24%).

Table 1: Show the Age and Sex Frequency.

Table 2: Mode of Injury

The most common cause of the distal end of radius fracture in our study was FOOSH (56%) followed by RTA. Table 2 shows the modes of injury encountered in our study.

(RTA- road traffic accident, FOOSH- fall on out stretch hand)

The most common type and sides of fractures were as men�oned in Table III and IV respec�vely.

Table 3: Fracture Classifica�on (Frykman's Grade) n = 50

Table 4: Side of involvement of fractures

Table 5: Subjec�ve, Range of Movement and Grip Strength Evalua�on

Table 6: Radiological Evalua�on

Final ScoreThe final scoring system was as modifica�on of Gartland and

Werley point system had 5 ± 3 in closed reduc�on pop cast group and 4 ± 4 in external fixa�on group. (p = 0.3764)




DISCUSSION

Thirty Years ago, the distal end of radius fractures were considered benign and conserva�ve treatment was the rule. The popula�on involved supposed consisted of osteoporo�c old women who were func�onally sa�sfied despite poor results and exact reduc�on was not mandatory, since good results were not said to be correlated with good reduc�on. Cosme�c deformity from malunion were no�ced, but deemed unimportant.

Since then, growing number of young male workers and sports enthusiasts have suffered high velocity injuries, o�en resul�ng in complex intra-ar�cular fractures. Pain and disability have resulted from subsequent malunions. Re-displacement or loss of reduc�on a�er conserva�ve treatment is another feature which was not well recognized in the past. This factor of re-displacement was also overlooked for a long �me.

As the Orthopedic community recognizes the complexity of this injury and focus a�en�on on the anatomical restora�on that is important for op�mal func�on, a variety of treatment op�ons are being inves�gated. Regardless of age of pa�ent, voca�on or recrea�onal interest, therapies are sought to maximize the poten�al for pain-free mo�on and acceptable cosme�c results.

Table 7: Compara�ve study of wrist movement

Fractures in the distal end of the radius has been es�mated to account for more than one-sixth of all fractures seeing

4.and treated in emergency department

A�er reviewing the ar�cles (Table 7) on the treatment of intra-ar�cular distal end of radius fractures we didn't find any prospec�ve study while comparing the two methods of treatment.

11Palmer et al conducted a�er an extensive study of ac�vi�es of living (ADL). The normal func�onal wrist range of movement was 5º Flexion, 30º of extension, 10º of radial

12devia�on, and 15º of ulnar devia�on. Ryu et al in a similar study concluded that ADL could be accomplished with 70% of maximal wrist mo�on, or 40º of flexion, 40º of extension, and 40º of combined radial and ulnar devia�on. The ranges

achieved in our study fits within both these ranges.

Radiological criteria for success includes the radial length (radial height) in PA view measurement averages 10-13mm, Radial angle (radial inclina�on) in PA view measurement averages 21º-25º and volar �lt (radial �lt) in Lateral view measurement averages 11º. Studies have shown that the radial length is the single most important factor affec�ng the final outcome. Loss of radial length results in an a�enua�on in weight transmission across the wrist joint, manifested by limited rota�on of the forearm and impingement of the ulna

13and radius. Since the classic paper of Knirk and Jupiter which demonstrated that the largest tolerable ar�cular step was 2 mm, numerous ar�cles have appeared demonstra�ng that the long term outcome of treatment of intra-ar�cular fracture depends more on integrity of the ar�cular surface than on any other measures.

Radiological parameters were measured and graded according 14to Schecks criteria. Our study showed average radial length

was 8 ± 2 mm in closed reduc�on POP cast group and 10 ± 4 mm in external fixa�on group, radial angle was 20 ± 3º in closed reduc�on POP cast group and 19 ± 7º in external fixa�on group and volar �lt was 0.26 ± 9º in closed reduc�on POP cast group and 10 ± 8º in external fixa�on group. These comparison shows that the radiological parameters of our study vs. others studies which is shown in table 8.

Table 8: Comparison of Radiological Parameters




The radiological parameters were compared with that of func�onal outcome. In our study 85% of the pa�ents had good to excellent radiological parameters according to the func�onal outcome. Out of the 3 parameters volar �lt was the least important factor in the func�onal outcome.

The func�onal outcome of the treatment is subjec�ve evalua�on to which the pain had 80% in external fixa�on group as compared to 63% in closed reduc�on pop cast group. The restric�on of ac�vi�es had 10% in external fixa�on group as compared with 33% in closed reduc�on pop cast group.

Since pa�ent with external fixa�on could use their hand for rou�ne ac�vi�es, incidence of finger s�ffness was very low. However they required good physiotherapy under supervision during ini�al period of management. In the past majority of complica�on in the fixa�on group were due to

Table 9: Complica�on Comparison

the pins infec�on. Since we were using limited open surgical technique, threaded pins and be�er construct for fixa�on, the complica�ons were avoided. In the study by Henrik G

16 Ahlborg et al ,there were 27% pin related complica�ons out of 314 fractures treated with external fixa�on. The same percentage of complica�on was found in the study of

17, 18 19Howard PW et al Soren Solgaard and McQueen et al.

Fractures through pin site is an uncommon complica�on 8 15with reported rates of 0 – 20% Vaughan et al , Schuind et al.

In our study five were found pin tract infec�on out of 80 pins in external fixator group. These infec�ons were superficial and healed on an�bio�cs and didn't cause any changes in the progression of the healing of the fractures.

The complica�on comparison of external fixata�on of our study vs others studies are shown in table 9.

CONCLUSION

The results show no sta�s�cally significant difference between the two modes of interven�ons.External fixa�on provides a be�er mode of treatment for comminuted intra-ar�cular fracture of distal end radius as compared to conven�onal POP cast immobiliza�on. It provides easy mobiliza�on of fingers and reduces edema and s�ffness of joints. The ac�ve range of movements at the wrist joints was significantly be�er in external fixa�on group.

RECOMMENDATIONS

The treatment of intra ar�cular distal end radius fracture is controversial. There is no defini�ve treatment method which is considered the standard of care.

LIMITATION OF THE STUDY

This study would have been more informa�ve if we had included the percutaneous pinning and internal fixa�on with plate.

ACKNOWLEDGEMENTS

We extend our sincere gra�tude to the Department of Orthopaedics faculty members of Birat Medical College, Biratnagar for their support to conceptualize this ar�cle.

CONFLICT OF INTEREST

None declared.

FINANCIAL DISCLOSURE

None




REFERENCES1. Gellman, H: Fracture of the distal radius. American Academy of

orthopedics surgeons monographs series. Rosemont, IL, American

Academy of orthopedic surgeons, 1998.

2. Alffram PA, Bauer GCH: Epidemiology of Fractures of the forearm. A

biomechanical inves�ga�on of bone strength. JBJS (Am) 44A; 105 –

114, 1962. PMID-14036674

3. Gartland JJ Jr, Werley, CW: Evalua�on of healed colles’ fractures.

JBJS Am, 3(A); 895 – 907, 1951.PMID-14880544

4. Owen RA, Melton L J, Johnson KA, IIstrup DM, Riggs BL: Incidence of

Colles’ Fracture in a North Community, Am J.

Pub. HealAmerican Cth 72; 605 – 607 1982. PMID- 7072880.

5. Cooney WP, Linscheid RL and Dobyns JH: External Pin fixa�on for

unstable colles’ fractures. JBJS Am 61(6A), 840 – 845, 1979. PMID-

6155380.

6. Cooney WP, Dobyns, JH and Linscheid RL: Complica�ons of colles’

fractures. JBJS (Am), 62(4), 613 – 619, 1980. PMID-6155380.

7. Nakata RY, Chand Y, Ma�ko JP et al: External fixators for wrist

fractures. A biomechanical and clinical study, J. Hand Surg 10 A;

845-51, 1985. PMID-4078267.

8. Vaughan PA, Lui SM, Harrington, IJ et al: Treatment of unstable

fractures of the distal end of radius by external fixator. JBJS Br, 67(3),

385-9, 1985.PMID-3997946.

9. Fernandez, DL: Fracture of the distal radius – opera�ve treatment.

AO’s Instruc�onal Course Lecturers, 42, 73 – 88, 1993. PMID-

8463706.

10. Zano�i RM, Louis DS: Intra ar�cular fractures of distal end of radius

treated with an adjustable fixator system. J. Hand Surg Am. 22(3);

428 – 440, 1997. PMID-9195451.

11. Palmer AK, Werner FW et al: Func�onal wrist mo�on – a

biomechanical study. J. Hand Surg Am. 10(1): 39-46, 1985. PMID-

3968403.

12. Ryu JY, Cooney WP, Askew LJ, An KN, Chao EYS- Func�onal ranges of

mo�on of the wrist joint. J Hand Surg (Am) 1991, May, 16 (3), 409- 19.

PMID- 1861019.

13. Knirk, JL, Jupiter, JB: Intra-ar�cular fractures of the distal end of the

radius in young adults. JBJS (Am), 68, 647 – 659, 1986. PMID-3722221.

14. Scheck, M: Long term follow up of treatment comminuted fractures of

the distal end of the radius by Tran’s fixa�on with krischner wires and

cast. JBJS Am, 44-A, 337-51, 1962. PMID-14039000.

15. Schuind F, Donkerwolcke M, Rasquin C, Burny F. External fixa�on of

fractures of the distal radius. A study of 225 cases. J Hand Surg (Am)

1989; 14:404–407. PMID-2732436.

16. Henrik G Ahlborg & Per Olof Josefsson : Pin-tract complica�ons in

external fixa�on of fractures Of the distal radius, Acta Orthopaedica

Scandinavica 70:2, 116-118,1999. PMID-10366908.

17. Howard PW, Stewart HD, Hind RE et al: External fixa�on or plaster for

severely displaced comminuted colles’ fracture: A prospec�ve study

of anatomical and func�onal results. JBJS Br 71(1), 68-73, 1989.PMID-

2915010.

18. SøRen Solgaard, Bjarne Kris�ansen & JøRgen Steen Jensen: Evalua�on

of instruments for measuring grip strength, Acta Ortho Scand 55, 569

– 572, 1984. PMID-6507083

19. McQueen, M, Caspers, and J: Colles’ fracture: Does Anatomic results

affect the final func�on? , JBJS 70-B, 649, 1988. PMID- 3403617

20. Sanders RA, Keppel FL, and Waldrop JI: External fixa�on of Distal radial

fracture: Result and Complica�ons. J Hand Surg. 16-3, 385 – 391,

1991.PMID-1861015

21. Weber SC, Szabo RM: Severely comminuted distal radial fractures as

an unsolved problem. Complica�ons associated with external fixators

and pins and plaster techniques. J Hand Surg. 11-A, 157 – 165, 1986.

PMID-3958443



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Original Research Article TO COMPARE THE FUNCTIONAL ... · fixator was used to achieve ligamentotaxis effects. On the first post-operave day acve and assisted range of moon of