Stable fixation of fractures of the distal radius can

Fractures of the distal radius treated by internal fixation and early function A PROSPECTIVE STUDY OF 73 CONSECUTIVE PATIENTS M. Jakob, D. A. Rikli, P. Regazzoni From the Kantonsspital, Aarau, Switzerland Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50 to 70 apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients. Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one. Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series. J Bone Joint Surg [Br] 2000;82-B:340-4. Received 7 April 1999; Accepted after revision 13 July 1999 The management of fractures of the distal end of the radius continues to evolve; many reports show a close correlation between anatomical and functional results. 1-24 Recently, it has been stressed that a fracture of the wrist should be treated on the same principles as any other fracture involving a joint, that is, by anatomical reconstruction, stable fixation and early function. 13,25 It is astonishing that these principles are rarely applied to fractures of the wrist, although they form one of the most common groups of injuries. In part, this may be due to an earlier lack of properly-designed implants and operative techniques, 13 but several new implants and techniques have now been described. 19,26-28 M. Jakob, MD P. Regazzoni, MD, Professor University Hospital, Spitalstrasse 21, CH-4021 Basel, Switzerland. D. A. Rikli, MD, Department of Traumatology, Kantonsspital, Buchserstrasse, CH-5001 Aarau, Switzerland. Correspondence should be sent to Dr D. A. Rikli. 2000 British Editorial Society of Bone and Joint Surgery 0301-620X/00/310099 $2.00 We have developed a double-plating technique using 2.0 mm titanium implants based on the three-column concept of the distal radius and ulna and have reported 20 preliminary cases. 19 We now describe a consecutive series of 74 fractures of the distal radius requiring surgery. They were studied prospectively, with special attention to technical aspects and the specific complications seen in some early cases. Patients and Methods Between November 1994 and June 1997, we treated 76 consecutive patients with 77 fractures of the distal end of the radius, by open reduction and internal fixation using two 2.0 mm titanium plates. 19 Three of these patients left the country and were lost to follow-up. We therefore report the results in 74 fractures in 73 patients, all reviewed at six weeks, six months and one year after operation. There were 21 men and 52 women with a mean age of 60 years (20 to 86). The dominant wrist was fractured in 38 (52%) and 14 had an associated fracture in the same arm (1 clavicle, 3 humeri, 7 distal and 1 proximal ulna, 1 scaphoid and 1 metacarpal). Four patients (5.5%) had a contralateral fracture of the distal radius which was treated conservatively. Three (4%) had multiple injuries including closed head injuries. Primary internal fixation was carried out in 52 patients (71%) and secondary fixation, after the failure of conservative treatment in 21. Of the latter, 12 had been managed in plaster, 4 by percutaneous pins and plaster and 5 by external fixation. According to the classification of Müller et al, 29 there were two simple extra-articular fractures (A2), 18 extra-articular fractures with metaphyseal comminution (A3), three partial articular fractures (1 B2, 2 B3), 11 simple articular fractures (C1) and 40 complex articular fractures (C2 and C3). The injuries were sustained in domestic falls (42%), in traffic accidents (38%), at work (12%) or at sport (8%). The operations were carried out according to the techniques (Fig. 1) described previously. 19 Metaphyseal defects were filled with cancellous autografts in eight wrists (11%) and with hydroxyapatite (Surgibone; Unilab Surgibone Inc, Mississauga, Canada) in 30 (41%). Four (5%) needed supplementary fixation with an external fixator for 340 THE JOURNAL OF BONE AND JOINT SURGERY

FRACTURES OF THE DISTAL RADIUS TREATED BY INTERNAL FIXATION AND EARLY FUNCTION 341 after one to two weeks. Load-bearing was allowed after six weeks. Review at six weeks, six months and one year after operation included standard assessments of pain, functional disability, range of movement and grip strength (JAMAR Hand Dynamometer, Clifton, New Jersey). Standard posteroanterior and lateral radiographs of the fractured wrist were taken and compared with the postoperative views. We used a modification of the score of Stewart et al 23 to rate the final anatomical result, and any post-traumatic arthritis was recorded using the scoring system of Knirk and Jupiter 15 We used a paired Student t-test with two-tailed distribution for statistical evaluation. Results Fig. 1 Diagram of internal fixation by double buttressing. The implants are placed at an angle of 50 to 70 to each other. four weeks because of persistent instability of the reconstructed articular surface. The other 70 (95%) started functional treatment soon after operation. Volar splinting was discontinued when the wound was healing satisfactorily All 74 fractures united without infection (Fig. 2). At one year, 55 patients (75%) were free from pain, 11 (15%) had occasional pain during heavy work, five (7%) had constant pain with heavy work and two (3%) had occasional pain during the minor activities of daily living. Of the 73 patients, 71 (97%) had resumed their previous work and daily activities after a median 25.9 weeks (6 to 44), but two with multiple injuries had continued disability because of head injuries. We compared the range of movement with that of the uninjured side in the 68 patients with unilateral fractures (Table I). There were statistically significant improvements in dorsiflexion, palmar flexion, supination and pronation between six weeks and six months (p < 0.001) and in dorsiflexion and palmar flexion between six months and one year (p < 0.05). The grip strengths in the same 68 patients are shown in Table II, revealing statistically significant increases in grip strength between six months and one year (p < 0.01). Table I. Range of movement (percentage of uninjured side) after operation in 68 patients Percentage of uninjured side Time after operation 10 to 20 20 to 40 40 to 60 60 to 80 80 to 100 Six weeks Dorsiflexion 2 10 18 16 22 Palmar flexion 11 27 12 18 Ulnar deviation 4 10 16 38 Radial deviation 2 7 12 20 27 Supination 4 7 7 16 34 Pronation 3 3 12 50 Six months Dorsiflexiion 1 4 7 16 40 Palmar flexion 1 4 12 18 33 Ulnar deviation 1 1 10 12 44 Radial deviation 1 1 10 15 41 Supination 2 1 2 7 56 Pronation 1 1 4 62 One year Dorsiflexion 1 1 3 11 52 Palmar flexion 1 3 6 18 40 Ulnar deviation 3 13 52 Radial deviation 6 8 54 Supination 1 5 62 Pronation 1 4 63 VOL. 82-B, NO. 3, APRIL 2000

342 M. JAKOB, D. A. RIKLI, P. REGAZZONI Fig. 2a Fig. 2b Radiographs showing a and b) an intra-articular fracture of the distal radius with a displaced dorsiulnar fragment and c, and d) six months after surgery. There is no osteoarthritis, no pain and an excellent range of movement. The plates are in the correct position. Fig. 2c Fig. 2d The final anatomical results according to the classification of Stewart et al 23 were excellent in 90%, good in 8% and fair in 2%. A more detailed analysis showed a mean loss of radial length of 1 mm (0 to 4) and a mean increase in palmar tilt of 1.7 (0 to 14) at six weeks (both p < 0.001). There was no later loss of reduction, no loss of radial angle and no residual intra-articular incongruity. As regards degenerative changes 15 one wrist showed grade-iii osteoarthritis, one grade II and three grade I (7% in total). The patient with grade-iii changes needed a Bowers hemiarthroplasty for distal radioulnar arthritis and ulnar impingement; the other four had no symptoms. Complications occurred in 16 wrists (21.6%). Four patients (5.5%) developed extensor tendinitis which settled after removal of the implants in three and spontaneously in one. In five of our early cases (7% of the whole series), ruptures of the extensor tendon required removal of the Table II. Grip strength (percentage of uninjured side) after operation in 68 patients Percentage of uninjured side 40 to 59 60 to 79 80 to 99 > 100 Dominant side (34) Six months 5 9 12 8 One year 2 3 9 20 Non-dominant side (34) Six months 10 9 7 8 One year 2 6 9 17 THE JOURNAL OF BONE AND JOINT SURGERY

FRACTURES OF THE DISTAL RADIUS TREATED BY INTERNAL FIXATION AND EARLY FUNCTION 343 implant and repair of the tendon at one to six months. These five ruptures were caused by dorsiulnar T-plates which had been cut at operation to form L-plates. Although the cut edge had been smoothed with a file, it caused attrition rupture. Since we abandoned this technique we have had no further cases of rupture of the tendon. There were four secondary displacements (5.5%) during the first six weeks after operation. Three were due to technical error in that the radial plate had been placed too dorsal, parallel to the dorsiulnar plate. In this position, the plate does not buttress the radial column, allowing secondary dislocation of the radial styloid fragment. These three patients required reoperation to reposition the dorsiradial plate. The further course was uneventful and the final results were good. One patient needed an additional palmar buttress plate for a very comminuted fracture. We saw no cases of secondary carpal tunnel syndrome, but four patients (5.5%) developed acute algodystrophy (2 mild; 2 severe). This resolved completely in three after treatment with calcitonin and physiotherapy, but one patient still had moderate pain during daily activities at one year. The implants were removed from 17 wrists (23%), three for irritation of the extensor tendon and five for ruptures of the tendon caused by cut plates. In four wrists the plates had been placed on the dorsal rim for very short distal fragments and were restricting dorsiflexion; removal of the implant allowed significant improvement of movement. Five patients requested that the plates and screws be taken out despite lack of symptoms. The final result was considered to be excellent by 83%, good by 14% and fair by 3% of the patients. Discussion The indications for operation were articular involvement with a step or gap in the joint surface of more than 2 mm and/or instability due to metaphyseal comminution. Two young patients with A2 fractures lacked these indications, but requested surgery rather than plaster to allow early function. More than two-thirds of the fractures were intra-articular. We recognise that extra-articular injuries have a better prognosis, but felt that a consecutive series of fractures requiring surgery would give the best account of our practice. The technique using two 2.0 mm titanium plates, based on the three-column concept of the distal radius and ulna, has previously been described in detail. 19 Our overall results compare favourably with other reported series of such fractures treated by operation. 3,5-7,18,26-28,30,31 All our patients, except for two with associated head injuries, returned to their previous work and activities within 25.9 weeks. We believe that the good results in terms of range of movement, grip strength and pain were due to the restoration of the joints and the extra-articular anatomy. The anatomical results according to the score of Stewart et al 23 were excellent or good in 98%. The mean loss of radial length of 1 mm or less, and an increase in palmar tilt of 1.7 are tolerable, not leading to clinically significant ulnar impingement. Despite this, we are now developing a new 2.0 mm titanium T-plate with locked distal screws. This is being used in a pilot series in the hope that loss of radial length and increase in palmar tilt can be completely avoided in the future. Biomechanical testing of our double-plating technique on cadaver radii has shown superior initial stiffness in comparison with other methods. 32 It must be stressed, however, that buttressing of the intermediate as well as the radial styloid column is essential, with the plates placed at an angle of 50 to 70. Correct placement of the dorsiradial plate deep to the wrist extensors to support the radial styloid is crucial. All four secondary displacements were due to failure by the surgeon to appreciate this. In five early cases, ruptures of the extensor tendon were due to attrition by distally cut plates. We stopped cutting plates and then had no more such ruptures. Irritation of the tendon occurred in 5%, comparing favourably with the 23% reported for the Pi-plate. 27 We believe that this is due to the small size of the implants and our use of a strictly subperiosteal approach, which leaves the tendon sheathes of the second and third compartments intact. We also cover the extensor pollicis longus tendon with a flap of extensor retinaculum so that no tendon is in direct contact with the implants. Recent reports have described associated tears of the triangular radioulnar ligament in up to 53% and of the scapholunate ligament in up to 21% of extra- and intraarticular fractures of the distal radius. 33-35 It has been suggested that these injuries were responsible for poor results unless they were diagnosed and treated early, but their clinical significance is not entirely clear. We believe that minor tears of the intercarpal ligaments do not lead to significant instability and heal without further treatment, provided that the anatomy of the joint, including the distal radioulnar joint, is meticulously restored and undue traction with external fixation devices is avoided. We have not addressed this issue by MRI studies, arthrography, arthroscopy or stress radiographs. We concentrated on the clinical evaluation of a relatively new technique of internal fixation, and found no instability of the carpal or distal radioulnar joints in our clinical and radiological evaluation. Our follow-up of one year is probably too short to make a definitive statement, and we believe that this ligament problem deserves further clinical and biomechanical investigation. When open reduction of dorsal displaced fractures of the radius is indicated to restore congruency and extra-articular anatomy, we recommend our double-plating method. This is reliable in providing stable internal fixation and allowing early function, but it is a demanding technique, requiring careful attention to detail. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. VOL. 82-B, NO. 3, APRIL 2000

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Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg 1997;22-A:772-6. THE JOURNAL OF BONE AND JOINT SURGERY