INTRODUCTION:

Fractures of the distal radius are the most common fractures of the upper extremity (Wulf et al., 2007)¹¹. They are also the most common fracture overall under the age of 75, when they are surpassed by hip fractures in the female population .One in five patients with a distal radius fracture will require a hospital admission (O'Neill et al., 2001)¹⁰, with the majority of those admitted undergoing some form of intervention.

The prevalence of distal radius fractures underscores the potential costs to the health system. Cost effective treatments are therefore important. These have proved difficult to identify as seen in the substantial variety of available therapeutic options and surgical techniques for the treatment of distal radius fractures. From cast immobilization, to percutaneous pinning and external fixation, to open reduction and internal fixation using one of several plates or approaches, all have been associated with some success, and yet none are universally accepted. In other words, we have not agreed on the optimal treatment, and have only addressed cost effectiveness to a very limited degree.

Current areas of controversy include debate regarding the superiority of external fixation versus open reduction and internal fixation. External fixation is associated with pin-track infection; the cumbersome nature of fixator wear; the potential for stiffness after prolonged immobilization; and a potentially higher risk of non-anatomic reduction. Open reduction risks include tendon irritation or injury. Many surgeons claim that internal fixation will allow earlier wrist motion, thereby improving ultimate function.

AIMS AND OBJECTIVES:

To compare functional outcome between external Fixator and plating in intraarticular fracture distal radius.

MATERIAL AND METHODS:

The study was conducted in J.L.N Hospital and Medical College, Ajmer, March 2015 to November 2016. This was a Prospective randomized study of 52 cases of distal radius intraarticular fracture who presented to hospital during the above mentioned study period.

52 consecutive cases of distal end of radius fracture, meeting the eligibility criteria were selected and alternately treated with either treatment modality. Total 52 patients satisfying the criteria were treated and followed up from admission to post-operative period and rehabilitation and beyond. AO Classification was used to classify the fracture pattern.

Out of 52 selected patients, 26 were be treated by open reduction and internal fixation and 26 by external fixator. The patients were randomly selected for a particular treatment option.

Inclusion Criteria:

All patients between 18-75 years of age group with intraarticular fracture distal radius.

Exclusion Criteria:

Ø Open fractures.

Ø Pathological fractures.

Ø Age of patient less than 18 years.

(1) External Fixator

The Joshi type of External fixator was used in our study. We have used two 3.5mm schanz pins for radius and two 2.5 mm schanz pins for the second metacarpal, and 4 mm connecting rods.

Under regional block Anaesthesia (Brachial block) or GA, patient was placed supine on the operating table. The forearm and hand were scrubbed with Beta dine and saline , painted with Beta dine and draped. The operating forearm was placed on a radiolucent arm-board. Two 3.5 mm Schanz pin inserted under direct vision through both cortices into the shaft of the radius proximal to the fracture site, keeping the forearm in midprone position. The interval between Extensor Carpi Radialis Longus (ECRL) and Brevis (ECRB) were identified and ECRL was retracted palmarly and ECRB dorsally to expose the radial shaft by making 2 small (1-2 cm) incisions along the radial border of the forearm and 3.5 mm pins applied. Then two 2.5mm Schanz pins are applied in 2^nd metacarpal through JESS distracter holes. Then with fixator pins securely in place, clamps and external fixator rod were mounted to pins. The clamps were loosened and longitudinal traction was given with manual moulding of the fracture fragments back into a more normal alignment and gentle flexion and ulnar deviation was maintained. The reduction was confirmed through image intensifier and then external fixation device was locked into place.

Active exercises of fingers, thumb, elbow, forearm and shoulder were commenced from the day 1 of operation. On the 3rd post operative day the dressing was removed. The pins were cleaned in external fixator and small dressing done applied in platting case. Patient was discharged after the 3rd day and was reviewed after 1 week. The patient was followed up after 2 weeks, 4 wks, 6wks, 8 wks and 12 wks. On demonstration of the radiological union, the external fixator was removed after 6 weeks and physiotherapy of the wrist was commenced. A removable splint for forearm was applied during night time and was removed during day time for physiotherapy for another 2 weeks and wrist and finger exercises were taught to continue at home.

The follow up period was 12 months. During the follow up, all the patients were observed for any possible complication. Each patient was evaluated for functional recovery at the end of 12 months.

(2) Volar distal radial locking plate

All patients were operated under general anaesthesia or axillary block. After proper painting and draping to in supine position. The fracture site was exposed through the distal part of the volar approach of Henry. The distal radius was exposed along the flexor carpi radialis tendon. After release of the pronator quadratus muscle from its radial insertion, the fracture site and volar surface of the distal radius were exposed. Fracture is reduced in anatomical position. Fracture reduction was verified with the image intensifier. Fixation of the fracture fragments was performed by a plate.

The wound was closed, sterile dressing done and after the surgery, the operated limb was supported with a below elbow splint. Sutures were removed on the 10th post-operative day. The patients were advised not to lift heavy weights for further 4 to 6 weeks. After discharge, all patients were reviewed every 2^nd week for the first 6 weeks. After the 6th week, physiotherapy was started, which include flexion - extension, adduction abduction and pronation supination exercises. The range of wrist movements was recorded and any deformity assessed. Follow – up were taken at 3 months, 6 months and final follow up at one year.

EVALUATION OF RESULTS:

Final evaluation of results done at 12 months. The assessment of functional outcome was made according to modified clinical system of Green and O’Brien 1978. This modified score includes independent scores for motion, strength, pain, and activity level, which can be objectively graded as per the table below. To achieve an excellent result full range motion of wrist and forearm, strength, function of hand and comfort must be present.

Table-1 : The Modified Green- O’Brien clinical scoring system.

Category	Score	Findings
Pain		None
		Mild
		Moderate (medication required)
		Severe (requires narcotics)
Function	25	Same job
	20	Different job
	15	Able, no job
	00	Unable
Motion	25	75-99%
	20	50-74% of normal side
	15	25-49%
	00	0-24%
Strength	25	100%
	20	75-99%
	15	50-74% of normal side
	05	25-49%
	00	0-24%
SCORING	Excellent	90-100%
	Good	80-89%
	Fair	65-79%
	Poor	<65%

RESULTS AND OBSERVATIONS:

Table-2 : Fracture pattern

Fracture pattern	No. Of cases
B1	5
B2	12
B3	8
C1	13
C2	9
C3	5

Table-3 : Age Distribution

Age Group (Years)	No. of cases	Percentage of case involved
>20	0	0%
21 – 30	14	27%
31 – 40	8	16%
41 – 50	17	33%
51 – 60	10	20%
61 onwards	3	4%
Total	52	100%

Table-4 : Sex Distribution

Total number of cases	No. of males	No. of females
52	46	6
Percentage	88%	12%

Out of 52 patients included in the study 46 i.e. 88% were males and 6 cases were female i.e 12%. TABLE-5 : Distribution of side involved (Dominant v/s Non dominant hand)

Table-5 :

Injured Hand	No. of cases	Percentage of cases involved
Dominant	37	70%
Non Dominant	15	30%
Total	52	100%

Overall dominant side was involved more than nondominant i.e. 37 out of 52 cases.

Table-6 : Distribution of Mode of Injury

Mode of Injury	No. of cases	Percentage
Fall on outstretched hand	34	65%
Road Traffic Accident	18	35%

More than half of the patients i.e. 34 (65%) got their injury due to fall on outstretched hand and remaining i.e. 18 (35%) patients were injured due to road traffic accidents.

Table-7 : Assessment at Final Follow-up

External fixator	Excellent	Good	Fair	poor
Type-b	6	3	-	-
Type -c	6	7	4	-
plating
Type-b	14	2	-	-
Type- c	4	1	5	-

In Group A, 53.84% cases had excellent results against 80.76% of Group B. In Group A Mean Modified Green-O’Brien Score were 85.19 and in Group B were 90.76.

In Group A type B fracture pattern Mean Score was 81.66 and in Group B type B fracture pattern was 98.12.In Group A type C fracture pattern Mean score was 87 and in Group B type C fracture pattern was 79. In patients of type B fractures results are significantly better in patient treated with plating (p value-0.0001). But in patients of type C fractures results are significantly better in patient treated with external fixator (p value-0.0288). Overall patients of intraarticular fracture distal radius results significantly better in patients treated with plating than external fixator (p value-0.0323).

Table-8 : Complications

Complications	External fixator	Plating
Pin tract infection	5 (21%)	-
Hand stiffness	2 (07%)	1 (03%)
Chronic pain syndrome	2 (07%)	3 (11%)
Hardware prominence	-	3 (11%)
Malunion	2 (07%)	2 (07%)
Total patients	7 (27%)	6 (23%)

11 complications were seen in 7 patients (27%) treated with external fixator and 9 complications were seen in 6 patients (23.07%) treated with plating.

DISCUSSION:

Distal end of radius fracture remains one of the most challenging fractures to treat. We assessed the functional outcome of operative management of distal radial fractures using JESS as compared to plating, evaluated our results and compared them with those obtained by various other studies utilising different modalities of treatment.

The ideal outcome these fracture should be a stable, pain free and non osteoarthritic wrist joint with a range of motion that is adequate for functional requirements. There is virtual universal agreement that proper reduction and stabilization of displaced fragments with early mobilization is necessary to achieve optimal results.

Patients were included in the study belonging to age group of 21 to 70 years with average age of 45 years which is comparable to the studies of Bradway et al¹, Jupiter JB² et al and Kapoor H³ et al,who had an average of 40 years,42 years and 39 years respectively. In the present study distal end radius fractures occurred maximum in the age group of 41-50 years i.e. 33%. This study shows an average age of 45 years, indicating that now a day’s young population get these fractures because of increasing incidence of motor vehicle accidents which is most common mode of injury in this group.

In our series males were predominant i.e. 46(88%), females were only 6 (12%). This male predominance can partly be explained by the fact that males are more commonly involved in road traffic accidents, outdoor activities, labour work . This is also due to the fact that most females were reluctant to surgery. These findings are consistent with Melone ^6,7(1984).

In this series 70% of patients were having dominant side involvement. The rates of dominant to nondominat was 2.33:1. Other studies such as Donald et al. also show more frequent involvement of dominant hand. The series of Jupiter JB⁴¹ et al and Kapoor H³ et al had increased involvement of the dominant wrist. But Bradway JK et al¹ had equal involvement of both wrists in their study.

We used AO classification in our series. Though AO classification is not always regarded as being the most precise classification system. However, in 2003, a study illustrated that it is the second most detailed classification after the Cooney classification. In our study fractures were easily classified using the AO classification.

The results of our study are comparative with these studies.

Table-9 :

Study	Treatment modalities	No. of cases	Outcome (excellent to good)	Complication
M. Fakoo⁸ et al 2015	ORIF With plate	39	75%	58%
M. Fakoo⁸ et al 2015	CR With ext. fix.	55	60%	69%
H.Kapoor ³Agarwal, Dhaon 2000, type c fracture	ORIF With plate	30	63%	Not available
H.Kapoor ³Agarwal, Dhaon 2000, type c fracture	CR With ext. fix.	30	80%	Not available
Ketan gupta et al⁴ 2015	ORIF With plate	15	86%	26%
	CR With ext. fix.	15	60%	33%

N. Schmelzer Schmied et al⁹ retrospectively evaluated 45 patients of distal end radius, AO type C1/C2. We studied in our series 52 patients of distal end radius falling in the category of AO type B and type C for distal end radius fractures.In our study 26 patients underwent JESS fixation and the other 26 were operated with open reduction internal fixation with plating. In the series of Bradway JK et al¹ more cases underwent open reduction internal fixation. In the series of Kapoor H³ et al there were equal number of cases treated with ORIF and EF. Their findings are comparable to our study.

Bradway JK et al¹ and Jupiter JB² et al reported a complication rate of 30% and 36% respectively. N.Schmelzer et al⁹ reported a complication rate of 46.67% in the external fixator group as compared to 10% in the plating group. But they had also compared non-locked and locking palmar plating, which was not done in our current series.

In present study, we got excellent functional results according to the modified G and O’Brein Functional scoring system in 18 (%) patients treated with Plating as compared to 12 (%) patients in the EF group, good results in 3 (%) patients in the plating group as compared to 10 (%) patients in the EF group. We got fair result in 4 (%) patients in the FE group as compared to 5 (%) patients in the Plating group. We got poor result none in the both groups. There was a significant difference in the mean value of the functional result in the plating group (90.76) as compared to EF group (85.19).

Considering the fracture pattern, in AO type B fracture pattern Plating showed better results as compared to JESS. In AO type C, the results were comparable between the two groups, with the JESS group having better results. Kapoor H³ et al concluded that articular anatomy was best restored with open reduction internal fixation, although external fixator achieved a better functional outcome.

Plating group to have better radiological and functional results in comparison to external fixation and the non-locking palmar plating methods according to N. Schmelzer et al⁹. The subjective assessment of plate fixation proved to be better than that of external fixation. In both plate and fixation group’s complications and reoperations were few.

In study of M.Fakoor⁸ et al 2015 ⁸comparison of ORIF and CR + EF, all results including functional score, clinical and radiologic criteria were in favour of the ORIF method while there were less complications with this method. We believe that ORIF is a better method for treatment of these types of fractures.

According to Ketan Gupta et al 2015⁴ range of movement at wrist at treatment completion with O.R.I.F was better than C.R.E.F. Clinical and radiological union was seen in all cases. Complications of C.R.E.F are more in incidence than O.R.I.F which results in larger morbidity, less functional recovery. O.R.I.F is generally preferred modality gives better results in terms of functional recovery and decrease morbidity to patient.

In the present study we observed complication rate of 27% in the ext. fixtor group of patients as compared to 23.07 % in the Plating group. The EF group had the complications in the form of pin tract infection in 05 (21%) patients, deformity(malunion) in 02 (07%) patient, chronic pain syndrome in 2 (07%) patients, persistent wrist and finger stiffness in 02 (07%) patients. In the plating group, we observed shoulder residual wrist and finger stiffness in 01 (03%) patient because of lack of compliance with physiotherapy. 5 patient from group EF developed pin tract infection, which cleared completely with oral antibiotics for 3 weeks and alternate day dressing.

CONCLUSION:

In our study, we concluded that in the treatment of intraarticular (AO type B and C) distal end of radius fractures, plating gives better functional results as compared to ext. fixator, and allows for early mobilisation of patients. But closed reduction and ext. fixation gives good results in the treatment of intra-articular comminuted distal end radius fractures (AO type C), with compare to ORIF with plating.

This original research done according to ethical declaration of Helsinki 1964 and there is no conflict of interest.

REFERENCES:

1. Bradway JK, Amadio PC, Cooney WP. Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius.J Bone Joint Surg Am. 1989 Jul;71(6):839-47.

2. Jupiter JB, Fernandez DL, Toh CL, et al. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78:1817–1828.

3. Kapoor H, Agrawal A, Dhaon B.K.: Displaced Intraarticular Fractures of distal radius: A comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation: Injury 2000 Mar 31(2): 75-9

4. Ketan Gupta, Nishant Gaonkar, Kapale Jineshwar Sudhir, Nirav Patel, Vaibhav Koli, Sudeep Date, Aminuddin Qureshi, Gaurang Chanchpura. To compare functional outcome, complications and results of open reduction and internal fixation with closed reduction and external fixation in volar displaced distal radial fractures ;JEBMH,vol 2, iss 9 March 2015; 1155-1167.

5. Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. Int J Epidemiol. 1993 Oct;22(5):911-6.

6. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation.Orthop Clin North Am. 1993 Apr;24(2):239-53.

7. Melone CP JrOpen treatment for displaced articular fractures of the distal radius.Clin Orthop Relat Res. 1986 Jan;(202):103-11

8. Mohammad Fakoor, Mohammad Hoseini P. Displaced Intra-Articular Fractures of the Distal Radius: Open Reduction With Internal Fixation Versus Bridging External Fixation.. Trauma Mon. 2015 Aug;20(3):e17631.

9. N. Schmelzer-Schmied, P. Wieloch, A. K. Martini, and W. Daecke. Comparison of external fixation, locking and nonlocking palmar plating for unstable distal radius fractures in the elderly: Int Orthop. 2009; 33 : 773–778

10 O'Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, Rowe R, Woolf AD, Wallace WA; UK Colles' Fracture Study Group. Incidence of distal forearm fracture in British men and women. Osteoporos Int. 2001; 12 (7) : 555-8.

11. Wulf CA, Ackerman DB, Rizzo M. Contemporary evaluation and treatment of distal radius fractures. Hand Clin. 2007 May; 23(2) : 209-26, vi. Review.

Received on 09.05.2017 Modified on 21.05.2017

Research J. Pharm. and Tech. 2017; 10(7):2355-2360.

DOI: 10.5958/0974-360X.2017.00417.6