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Genij Ortopedii. 2022. Vol. 28, no. 3. P. 322-327 Гений ортопедии. 2022. Т. 28, № 3. С. 322-327
Original article
https://doi.org/10.18019/1028-4427-2022-28-3-32
Comparison between volar plating and external fixation augmented by Kirshner wires in comminuted distal radial fractures
Usama F. Attia, Mohamed A. El-Soufy, Tarek A.E. El-Hewala, Mohamed A. Abdelrazek
Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, Egypt
Corresponding author': Usama F. Attia, usamafawzy19@yahoo.com
Abstract
Background Volar locking plate (VLP) has gained the most popularity in the treatment of distal radius fractures due to its superior biomechanical property. In contrast, external fixation (EF) is not so extensively used. The aim of this study was to find what procedure is better in the management and achieves favorable outcomes in patients with comminuted distal radial fractures. Patient and methods This study included 30 patients with distal radial fractures AO types A3, C2, C3 in which 15 ubjects were managed with open reduction and internal fixation by volar plate, and another 15 were managed with external fixation augmented by K-wires. The minimum duration of follow-up in our study was six months. Results Patients treated with external fixation augmented by K-wires had grip strength range 15-27, patients treated with volar plating had grip strength range 8-27. There was no significant statistical difference between 2 groups regarding extension. In Group A MannWhitney test revealed that Gartland-Werely score had negative correlation with affected hand. In Group B the correlation was positive with AO/ OTA classification only and negative with affected hand and ulnar styloid fracture but also not statistically significant between Ouick-DASH score with affected hand, AO/OTA classification and ulnar styloid fracture. Conclusion Both volar plating and external fixation augmented by K-wires are treatment choices for distal radius fractures. Whereas external fixation maintains a significant role in the treatment of distal radius fractures, ORIF with locked volar plating has changed the way many surgeons treat certain types of distal radius fractures. Keywords: Volar Plating, External Fixation, Radial Fractures, DASH score
For citation: Attia U.F., El-Soufy, M.A.A., El-Hewala, T.A.E., Abdelrazek M.A. Comparison between volar plating and external fixation augmented by Kirschner wires in comminuted distal radial fractures. Genij Ortopedii, 2022, vol. 28, no 3, pp. 322-327. https://doi.org/10.18019/1028-4427-2022-28-3-322-327
Научная статья
УДК 616.717.56-001.5-089.227.84
Сравнение результатов применения волярной пластины и внешней фиксации, усиленной спицами Киршнера, при многооскольчатых переломах дистального отдела лучевой кости
Usama F. Attia, Mohamed A. El-Soufy, Tarek A.E. El-Hewala, Mohamed A. Abdelrazek
Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, Egypt Автор, ответственный за переписку: Usama F. Attia, usamafawzy19@yahoo.com Аннотация
Актуальность. Волярная блокирующая пластина (VLP) приобрела наибольшую популярность при лечении переломов дистального отдела лучевой кости благодаря своим превосходным биомеханическим свойствам. Напротив, внешняя фиксация (ВФ) используется не так широко. Цель исследования состояла в выявлении оптимального метода лечения, обеспечивающего благоприятный результат у пациентов с многооскольчатыми переломами дистального отдела лучевой кости. Материалы и методы. В исследование включено 30 пациентов с переломами дистального отдела лучевой кости типа A3, C2, C3 по классификации АО, 15 из которых лечили с использованием открытой репозиции и внутренней фиксации волярной пластиной, других 15 лечили при помощи внешней фиксации с усилением спицами Киршнера. Минимальная продолжительность наблюдения составила шесть месяцев. Результаты. У пациентов, лечившихся с применением внешней фиксации, усиленной спицами Киршнера, сила захвата отмечена в диапазоне 15-27; у пациентов, пролеченных с применением волярной пластины, сила захвата была в диапазоне 8-27. Не было существенной статистической разницы между двумя группами в отношении разгибания. В группе А тест Манна-Уитни выявил, что показатель Gartland-Werely имел отрицательную корреляцию с пораженной кистью. В группе B корреляция была положительной только в отношении классификации AO/OTA и отрицательной относительно пораженной кисти и перелома шиловидного отростка локтевой кости, но также не была статистически значимой между оценкой Ouick-DASH в отношении пораженной кисти, классификации AO/OTA и перелома шиловидного отростка локтевой кости. Заключение. Как волярная пластина, так и внешняя фиксация, усиленная K-спицами, представляют собой варианты лечения переломов дистального отдела лучевой кости. В то время как внешняя фиксация по-прежнему играет важную роль в лечении данных повреждений, ORIF с применением блокирующей волярной пластины изменила подход многих хирургов к лечению определенных типов переломов дистального отдела лучевой кости. Ключевые слова: волярная пластина, внешняя фиксация, переломы лучевой кости, DASH
Для цитирования: Comparison between volar plating and external fixation augmented by Kirschner wires in comminuted distal radial fractures / U.F. Attia, M.A. El-Soufy, T.A.E. El-Hewala, M.A. Abdelrazek // Гений ортопедии. 2022. Т. 28, № 3. С. 322-327. https://doi.org/10.18019/1028-4427-2022-28-3-322-327. EDN BIPAPB.
INTRODUCTION
Distal radius fractures comprise 16 % of all fractures that are treated surgically. Despite the high prevalence of this kind of fracture, there is still no consensus concerning the preferred way to manage this type of fracture. Another issue of significant concern is that the approach to dealing with intra-articular fractures of the distal radius remains even more challenging to treat than unstable extra-articular fractures [1]. Distal radius fractures are of the most prevalent
fractures in the middle-aged and elderly people [2, 3], so such fractures are an important concern. There has been an especially sharp increase in their incidence among women older than 40, and this brings into sharper focus the possible consequence of estrogen withdrawal and loss of bone density [4].
Unfortunately, such fractures are difficult to reduce and stabilize, so they are prone to malunion [5]. Also, they are
© Attia U.F., El-Soufy M.A., El-Hewala T.A.E., Abdelrazek M.A., 2022
prone to result in malfunctioning of the wrist and hand (which depends on radius alignment and the positioning of the carpal and ulnar joints) [6]. Such fractures can cause deterioration of the long-term functional outcome if they are not reduced well and in an anatomically correct manner [7, 8].
During the past 10 years, volar locking plate (VLP) has gained the most popularity in the treatment of distal radius fractures due to its superior biomechanical property [9, 10]. In contrast, external fixation (EF) is not so extensively used, but was preferred by a number of surgeons due to its easy application, improved reduction by ligamentotaxis, no need of a secondary procedure, and the acceptable results. However, the higher complication rate should be a concern, including pin-tract infection, loss of reduction,
the sensory radial nerve injury, and complex regional pain syndrome [11,12].
Randomized controlled trials (RCTs) or cohort studies have demonstrated the advantages of volar locked plating over external fixation for treatment of all types of distal radius fractures, especially at early postoperative period [13, 14]. As for AO type C2/C3 fractures, the reported results varied and were even contradictory, treated either by volar locked plating or external fixation alone, or combined. However, as far as we know, data on the direct comparison of clinical or radiographic outcomes for treatment of such fractures were favorable [1517]. The aim of the present study is to find what procedure is better in their management and achieves favorable outcomes in patients with comminuted distal radial fractures.
PATIENTS AND METHODS
A prospective comparative study was conducted involving 30 patients with distal radial fractures AO type A3,C2,C3 in which 15 subjects were treated with open reduction and internal fixation by volar plate and another 15 with external fixation augmented by K-wires. All patients fulfilled the inclusion criteria and completed at least a 6-month follow-up period. Participants were numbered from 1 to 30 and categorized into group A (volar plating) and group B (external fixation augmented by K-wires). Standard informed consents were taken from every patient.
Inclusion criteria
Patients with unilateral acute closed (> 14 days of occurance) comminuted extra-articular distal radius fractures type A3 according to AO/OTA classification; unilateral acute closed comminuted intra-articular distal radius fractures type C2 or C3 according to AO/OTA classification; surgically fit patients.
Exclusion criteria
Patients with old fractures, concomitant fracture at the same injured limb, systematic skeletal diseases (e.g. hyperparathyroidism) or local disorder (e.g. tumors, Paget disease, or rheumatoid arthritis); surgically unfit patients;
Patients with associated vascular injury, open fractures, contaminated fractures, pathological fractures and patients with compartmental syndrome.
I. Preoperative evaluation
Patients were evaluated by history taking, physical examination, investigations, consent taking and images. AO classification was used in this study. Standard examination of the hand was performed to assess skin condition, functions of muscles, tendons and nerves; and hand grip and fingers movement. Routine preoperativecomplete blood picture, liver and kidney functions were studied. Anteropsterior and lateral views of the affected wrist showed the site of fracture, articular extension, comminution, associated fractures (ulnar styloid, carpals, metacarpals), and disrupted distal radioulnar joint. Elbow X-ray was taken to detect higher level fractures or dislocation. To detect the site and degree of articular comminution (scaphoid and lunate fossae), CT was routinely ordered in all cases; however, twelve out of all cases could not do CT due to unavailabity of this service at the time of investigation.
II. Surgical Management
General or regional anaesthesia. The patient was positioned supine and the forearm placed on a hand table.
Group A: Volar plating, modified Henry approach
The modified Henry approach uses the plane between flexor carpi radialis tendon and the radial artery. Longitudinal incision is made over the flexor carpi radialis (FCR) tendon. The flexor pollicis longus muscle belly is bluntly swept to the ulnar side The pronator quadratus is mobilized by releasing its distal and lateral borders with an L-shaped incision then exposing the fracture site. After exposure and refreshing of the fracture site, the fracture was reduced and provisionally fixed under C-arm control using K-wires. In intra-articular fractures, large fragments were manipulated, reduced and preliminary fixed by wires. The plate should be positioned on the distal radius proximal to the Watershed line. A screw is inserted in the oval non-locking hole of the plate which permits fine adjustment of the plate position either proximally or distally (Fig. 1). The plate is applied to bone and a 3.5-mm cortical screw is inserted into the oblong hole in the shaft. Prior to fully seating the screw, the plate may be translated distally or proximally as needed. In polyaxial fixation, after achievement of the optimal plate position and insertion of a screw into the oblong hole of the plate in the shaft of the bone, the plate was fixed to bone distally beginning with the most ulnar screw using the funnel-shaped end of the VA-LCP drill sleeve at the desired angle.
Group B: External fixation
We used an external fixator with pinning by K-wires to retain the reduced position of the distal radius by adequate reduction of the distal radius fracture using traction to restore the radial height. Percutaneous K-wires were inserted (while an assistant maintaining the reduction). One or two wires inserted from the radial styloid directed proximally toward the opposite intact cortex. Another wire was added to maintain the distal radioulnar joint (DRUJ) and reduction of DRUJ was done by supination or pronation of the forearm depending on the direction of dislocation in case of associated distal radioulnar joint dislocation. The proximal fixator pin sites were exposed with a small incision made via a mini-open technique on the dorsal radial aspect of the radial shaft. The pins were placed in the radial shaft after predrilling and using a soft-tissue protector. The skin was then closed around the proximal pin sites. Application of the distal Schanz screw was done dorsoradially near the base of the metacarpal 4060 degrees in reference to the horizontal plane (Fig. 2).
Fig. 1. Modified Henry approach showing: (a) identification of flexor carpi radialis tendon; (b) pronator quadratus exposed and an L-shaped incision is made to elevate it; (c) preliminary fixation of large articular fragments and (d) plate adjustment on the volar surface of lunate facet
Fig. 2. External fixator with pinning by K-wires showing: (a) K-wire inserted from the radial styloid; (b) skin incision to introduce the proximal Schanz screw and (c) insertion of the distal Schanz screw
III. Follow-up
Radiological parameters of the distal radius on the operated side of both groups were followed up. The patients were advised to clean pin tracts with saline daily and encouraged to perform shoulder and elbow mobilization exercises.
Statistical analysis
Data were entered to the Statistical Package for Social Science (IBM SPSS) version 23. The comparison between groups regarding qualitative data was done by using Chi-square test and/or Fisher exact test .The comparison
between two groups regarding quantitative data was done using Independent t-test while with non parametric distribution was done using Mann-Whitney test. One Way ANOVA test, Kruskall-Wallis test and Spearman correlation coefficients were used to assess the correlation between two quantitative parameters in the same group. The confidence interval was set to 95 % and the margin of error accepted was set to 5 %. So, the p-value was considered significant as the following: p-value > 0.05: Non significant (NS), p-value < 0.05: Significant (S); p-value < 0.01: Highly Significant (HS).
RESULTS
This study included 30 patients with a mean age of 40 years (range, 22-75 years) at the time of surgery. The group of patients included 22 males and 8 females. Twelve males and 3 females in Group A and ten males and five females for Group B. In Group A, 9 patients were smokers and
6 patients were non-smokers, while in Group A 8 patients were smokers and 7 patients were non-smokers. In Group A, there was 1 diabetic patient (6.7 %) and 2 hypertensive cardiac (13.3 %) patients; in Group B, there was 1 diabetic (6.7 %) and 4 hypertensive (26.7 %) patients. Fourteen patients had right-side fractures, 16 patients had left-side fractures, 29 patients with the right dominant hand and one with the left dominant hand (Table 1).
All patients were classified according AO classification as the following; group A: Type C2: 8 patients (53.3 %); Type C3: 7 patients (46.7 %); Type A3: 0 patients (0.0 %); and group B: Type C2: 7 patients (46.7 %); Type C3:
7 patients (46.7 %); Type A3: 1 patients (6.7 %) (Fig. 3).
Patients treated with external fixation augmented by K-wires had grip strength within the range of 15-27 kg.
Patients treated with volar plating had grip strength within the range of 8-27 kg (Fig. 4). There was no significant statistical difference between 2 groups regarding extension (p = 0.209).
In Group A, Mann-Whitney test revealed that Gartland-Werely score had negative correlation with the affected hand and AO/OTA classification with no statistical significance (Table 2). In Group B, the correlation was positive with AO/OTA classification only and negative with affected hand and ulnar styloid fracture but also not statistically significant between Quick-DASH score with affected hand, AO/OTA classification, and ulnar styloid fracture (Table 3).
Spearman's test revealed that Gartland-Werley score had positive correlation with age, operative time and injury to treatment interval in group A. This correlation was statistically significant with age only (p = 0.019) (Table 4). This correlation was not statistically significant but the correlation between Gartland-Werley score and injury to treatment interval was negative in group B (Table 5).
Table 1
Relation output of demographic results between two groups
Volar Plate group Ex- Fix group
N = 15 N = 15
Age Mean ± SD 37.33 ± 10.43 42.33 ± 16.60
Range 23-54 22-75
Young age 5 (33.3 %) 4 (2б.7 %)
Age groups Middle age 10 (бб.7 %) 9 (б0.0 %)
Old age 0 (0.0 %) 2 (13.3 %)
Sex Female 3 (20.0 %) 5 (33.3 %)
Male 12 (SO.O %) 10 (бб.7 %)
Occupation Active 13 (8б.7 %) 9 (б0.0 %)
Sedentary 2 (13.3 %) б (40.0 %)
Smoking No б (40.0 %) 7 (4б.7 %)
Yes 9 (б0.0 %) S (53.3 %)
Medical No 13 (8б.7 %) 11 (73.3 %)
history Yes 2 (13.3 %) 4 (2б.7 %)
DM No 14 (93.3 %) 14 (93.3 %)
Yes 1 (б.7 %) 1 (б.7 %)
HTN No 13 (8б.7 %) 11 (73.3 %)
Yes 2 (13.3 %) 4 (2б.7 %)
Previous No 15 (100.0 %) 15 (100.0 %)
operation Yes 0 (0.0 %) 0 (0.0 %)
Dominance Right 15 (100.0 %) 14 (93.3 %)
Left 0 (0.0 %) 1 (б.7 %)
Fig. 3. Distribution of the patients regarding to AO classification
Fig. 4. Bar chart illustrating comparison of grip strength between two groups
Table 2
Correlation of Gartland-Werley score with affected hand, AO/OTA classification, and ulnar styloid fracture in group A
Gartland-Werley Test value P-value
Median (IQR) Range
Affected side Right 3 (2-5) 0-б -0.295 0.7б8
Left 2 (1.5-4.5) 1-9
AO C2 2 (1.5-2.5) 0-5 -1.714 0.0S7
C3 4 (2-б) 1-9
Ulnar styloid fracture No 3 (2-5) 1-9 -1.359 0.174
Yes 2 (1.5-3) 0-б
Table 3
Correlation of Gartland-Werley score with affected hand, AO/OTA classification, and ulnar styloid fracture in group B
Gartland-Werley Test value P-value
Median (IQR) Range
Affected side Right 5 (2-5) 2-9 -0.89б 0.370
Left 3.5 (2-4.5) 2-б
AO C2 4 (2-5) 2-9 1.430 0.4S9
C3 4 (2-5) 2-б
Ulnar styloid fracture No 2 (2-2) 2-2 -O.35S 0.720
Yes 4 (2-5) 2-5
Table 4
Correlation of Gartland-Werley score with age, mean operative time , injury to treatment interval and articular stepoff in group A
Gartland-Werley
Correlation coefficient (r) P-value
Age 0.594* 0.019
Mean operative time (min.) 0.332 0.22б
Injury to treatment interval (days) 0.230 0.410
Articular stepoff (mm) 0.1бб 0.555
Table 5 Correlation of Gartland-Werley score with mean operative time, injury to treatment interval and articular step-off in group B
Gartland-Werley
Correlation coefficient (r) P-value
Mean operative time (min) 0.137 0.б27
Injury to treatment interval (days) -0.321 0.243
Articular stepoff (mm) -0.303 0.273
P-value > 0.05 - Non significant; P-value < 0.05 - Significant; P-value < 0.01 - Highly significant. r = Spearman correlation coefficient
Mann Whitney U test revealed that mean union time had negative correlation with postoperative complications in groups A and B. This negative correlation was statistically significant with pin-tract infection (p = 0.01) (Table 6, 7).
Table 6
Correlation of mean union time with postoperative complications in group A
Union (weeks) Test value P-value
Mean ± SD Range
Complications Not complicated 6.75 ± 1.16 5-8 0.064^ 0.950
Complicated 6.71 ± 0.95 б-S
Stiffness No 6.71 ± 1.07 5-8 -0.258^ 0.800
Yes 7 ± 0 7-7
Carpal Tunnel Syndrome + screw perforation No 6.69 ± 1.03 5-8 -0.380^ 0.710
Yes 7 ± 1.41 б-S
Tendon rupture No 6.79 ± 1.05 5-8 0.722^ 0.483
Yes 6 ± 0 б-б
Scar hypertrophy No 6.79 ± 1.05 5-8 0.722^ 0.483
Yes 6 ± 0 б-б
Inflammation of surgical wound No 6.79 ± 1.05 5-8 0.722^ 0.483
Yes 6 ± 0 б-б
Delayed healing No 6.64 ± 1.01 5-8 -1.300^ 0.21б
Yes 8 ± 0 8-8
P-value > 0.05 P-value < 0.01
Non significant; P-value < 0.05 - Significant; Highly significant; • - Independent t-test
Table 7
Correlation of mean union time with postoperative complications in group B
Union (weeks) Test value P-value
Mean ± SD Range
Complications Not complicated 6.5 ± 1.07 5-8 -2.228^ 0.044
Complicated 8 ± 1.53 6-10
Stiffness No 6.92 ± 1.32 5-10 -2.059^ 0.060
Yes 9 ± 1.41 8-10
Pin tract infection No 6.67 ± 0.98 5-8 -4.079^ 0.001
Yes 9.33 ± 1.15 8-10
Tendon rupture No 7.21 ± 1.53 5-10 0.135^ 0.894
Yes 7 ± 0 7-7
Complex regional pain syndrome (CRPS) No 7.15 ± 1.57 5-10 -0.299^ 0.770
Yes 7.5 ± 0.71 7-8
Nerve injury No 7.29 ± 1.49 5-10 0.834^ 0.420
Yes 6 ± 0 6-6
P-value > 0.05 - Non significant; P-value < 0.05 - Significant; P-value < 0.01 - Highly significant; • - Independent t-testt
DISCUSSION
Current treatment goals for fractures of the distal radius are centered on restoration of bony anatomy of the distal radius (radial inclination, radial length and volar tilt) with specific attention to the restoration of articular surfaces of the radiocarpal and radioulnar joints [20].
Most of the patients in our study were males. The percentage of males were 66.7 % in the external fixator group and 80 % in the volar plate group. This is similar to Duramaz et al. [21] reporting the percentage of males in the external fixator and volar plate groups 65.5 % and 60.7 %, respectively, and also to the study of Yu et al. [22] in which the percentage of males in the external fixator and volar plate groups were 56.5 % and 59.0 %, respectively. But this is different than the study of Rizzo et al. [23] in which most of patients were females, the ratios of females to males for the external fixator and volar plate groups were 8/6 and 25/6, respectively.
In this study, the mean age of the external fixator group was 42.33 years while of the volar plate group was 37.33. The age distribution between the two groups was not different. This is similar to Kreder et al. [11] study, in which the mean age in the external fixator group was 39 years and in the volar plate group was 40, and Xu et al. [24] study, in which the mean ages in the external fixator and volar plate groups were 41.8 years and 45.3, respectively. Generally, neither age nor gender distribution made a significant difference between the two groups, an observation that was similar to the results of Phandis et al. [25].
In this study, volar plate group patients had better functional outcomes in Quick DASH score (6.8 vs 9.1) when compared to external fixation group patients. And also Gartland-Werley score has better results in volar plate group (53.3 % excellent and 40 % good) than external
fixation group (33.3 % excellent and 60 % good) but that did not differ significantly (p > 0.05) as mentioned by Richard et al. [26] in a retrospective cohort of 115 patients with AO type C2/C3 fractures demonstrated a better DASH score and more improved pronation/ supination arc in VLP group at 12 postoperative months. Williksen et al. [27] compared volar plating (52 patients) and external fixation (59 patients) and reported that patients with volar locked plates had a higher Mayo wrist score (90 vs 85) and better supination (89° vs 85°) at 52 weeks compared to external fixation group.
In our study, volar plating group had an overall decreased incidence of complications compared with external fixation. Thus, seven cases had complications out of 15 patients treated by volar plating in comparison to nine cases treated by external fixation. These results are in concordance with most of the prior studies, which have tended to show less complications in patients treated with ORIF as in Abramo et al. [28] study who reported 14 complications in 26 patients treated with ORIF and 20 complications in 24 patients treated with external fixation. Grewal et al. [29] reported 7 complications in 29 patients treated with ORIF and 8 complications in 33 patients treated with external fixation. Karantana et al. [30] reported 16 complications in 66 patients treated with ORIF and 27 complications in 64 patients treated with external fixation. On the other hand, some studies showed higher incidence of complications in ORIF patients than in external fixation patients, which is different than the results of the current study, as in Mellstrand et al. [31] study which reported 35 complications in 69 patients treated with ORIF and 29 complications in 65 patients treated with external fixation.
CONCLUSION
Both volar plating and external fixation augmented by K-wires are treatment choices for distal radius fractures. Whereas external fixation maintains a significant role in the treatment of distal radius fractures, ORIF with locked volar plating has changed
the way many surgeons treat certain types of distal radius fractures. Volar plating had better performance in initiating early wrist motion and some radiological outcomes like maintaining the radial head height and improving articular congurance.
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No conflict of interest.
