Open reduction and fixation with a supporting plate for treatment of unstable fractures of distal radius with volar displacement

Tratamento das fraturas instáveis da extremidade distal do rádio com desvio volar utilizando-se placa de apoio

Open reduction and fixation with a supporting plate for treatment of unstable fractures of distal radius with volar displacement

Tratamento das fraturas instáveis da extremidade distal do rádio com desvio volar utilizando-se placa de apoio

Luís Eduardo Lima de Andrade^I; Décio José de Oliveira^II; José Wagner de Barros^III

^IEx-Resident

^IIDoctor Orthopaedic surgeon In charge of hand surgery sector

^IIIChairman and responsible for Orthopedics and Traumatology

^{Address for correspondence}

SUMMARY

Eigtheen patients with unstable fracture of the distal radius were evaluated. They have undergone open reduction and buttress plate fixation. The average follow-up was 21 months. Radiographies and wrist function were analysed. It was concluded that this technique was good, allowing good functional results.

Key words: Osteosynthesis; fracture of the radius; buttrees plates fixation

RESUMO

Foram avaliados 18 pacientes, com fratura instável da extremidade distal do rádio, submetidos à redução aberta e fixação. Com seguimento médio de 21 meses, analisou-se a função do punho e radiografias, concluindo-se que a técnica foi adequada, permitindo bons resultados funcionais.

Descritores: Osteossíntese; fratura do rádio; placa de apoio volar

INTRODUCTION

Distal radius fractures in adults have a wide range of variations and are responsible for 10 to 20% of all skeletal fractures⁽⁸⁾.

Several eponyms are applied to such injuries leading to doubts in literature, particularly between Barton's and Smith's fractures, which are generated by flexion-compression mechanism. Smith's fracture is sub-divided into three types: Type I: with an extra-articular fracture line; Type II — the fracture line crosses into the dorsal articular surface and, Type III — the fracture line penetrates radiocarpal joint, being a marginal fracture-dislocation with a ventral displacement (it is equivalent to a ventral Barton's fracture)⁽⁹⁾.

Unstable fractures of distal radius are complex injuries. Its treatment is controversial with a wide range of therapeutic options, ranging since plaster molds, percutaneous fixation, bipolar cast fixation, external fixators with or without bony grafts, and support plates^(1,2,3,4,10).The two last mentioned are currently more used for allowing an anatomical reduction and suitable stability, leading to better results.

Through accurate technique, and suitable implant, it is looked for reaching the principles recommended by AO/ASIF. Anatomical reduction of the fragments, particularly in articular fractures; stable internal fixation, in order to match local biomechanical requests; keep bony fragments and soft tissues blood supply by means of an atraumatic technique; and finally, early active painless mobilization of adjacent muscles and joints, avoiding development of fracture disease ⁽⁷⁾.

The aim of this work was to evaluate a group of patients with unstable fractures of distal radius presenting a volar displacement (Smith's fractures) treated with open reduction and fixation with a supporting "T" plate.

CASES AND METHODS

From September 1998 to February 2001 were performed, at our service, 25 treatment procedures for unstable fractures of distal radius, using a supporting plate as fixation technique.

Eighteen cases were re-evaluated (Table 1). From these, seventeen (94.4%) were male and 1 (5.6%) was a female. The age ranged from 21 to 74 years, with an average of 34 years of age. Wrists right and left were equally affected (9 cases — 50% each). The mean follow-up period was 21 months (minimum of 6 months, maximum of 36 months).

The fractures were rated according to Smith⁽⁹⁾ (Figure 1) and Frykman⁽³⁾ (Figure 2).

Smith⁽⁹⁾ Type I, 4 (22.2%) cases; Type II, 2 (11.1%); and Type III, 12 (66.7%).

Frykman⁽³⁾ Type I, 1 (5.6%) case; Type II, 2 (11.1%); Type III, 2 (11.1%), Type IV 5 (27.7%); Type V, 1 (5.6%); Type VI, 1 (5.6%); Type VII, 2 (11.1%) and Type VIII, 4 (22.2%).

Were used the radiologic evaluation parameters: radial inclination angle, volar inclination angle, and radial length, graded according to Scheck's ⁽¹⁰⁾ criteria (Table 2).

It was used a functional evaluation technique according to Gartland & Werley⁽⁴⁾ (Table 3). In subjective patient's evaluation, it was considered the presence of residual deformity, when it was found articular range of movement associated to complications such as arthritic and nervous changes, and finger function impaired during the immobilization period.

At the starting visit, the wrist was radiographed in anterior and lateral views (Figure 3) and immobilization was performed by means of an antebrachial plaster splint.

Objective evaluation was performed at the following movement range, being considered as the minimum for a normal function: extension 45 degree; flexion 30 degree; radial deviation 15 degree; ulnar deviation 15 degree; pronation 50 degree; supination 50 degree⁽⁴⁾.

SURGICAL TECHNIQUE

Patients underwent regional or general anesthesia, antisepsis with iodinated alcohol, exsanguination with Esmarch bandage and pneumatic tourniquet.

It was used an anterior sagital approach, at the side of radial flexor of wrist tendon, from the second wrist fold up to 5 cm proximally. Retracting this tendon medially, and brachioradial tendon and radial artery laterally, it was reached the quadrate pronador fibers, divided at their origin in radius, exposing the fracture (Figure 4). Once the fracture was reduced a "T" plate was placed and screwed to proximal bone fragment of the radius, acting as a counter puff keeping fracture fragments in place (Figure 5). Quadrate pronador was replaced over the plate up to its origin, and a suture by planes was performed.

An antebrachial cast splint was maintained for the first four weeks as a complementary immobilization.

Physiotherapy was indicated for recovery of the range of movement.

RESULTS

All the patients presented bone healing, and returned to their usual activities.

Radiographic evaluations were excellent in 11 (61.1%) cases and good in 7 (38.9%).

According to the functional evaluation technique, 9 (50%) of the cases reached excellent scores; 6 (33.4%) good, and 3 (16.6%) regular.

Two cases had complications. One had a profound infection and was treated with débridements and antibiotics, having the plate removed. Another case had a superficial infection and was treated with débridements and antibiotics.

DISCUSSION

The wrist is one of the most complex joints of the human body. It is the ultimate positioner of the hand in this long multiarticulated effector mechanism that the upper limb is⁽¹⁾.

Fracture of distal radius occurs in the metaphyseal region, so, bone healing generally takes place.

An anatomical reduction allows recovery of wrist function^(4,5,6).

Studies testify that a healing with deviation is related to movement limitation, decrease of grip potency and pain^(4,5,6).

Any rating system will only be worthy if it is concise and practical, with elements for treatment and prognosis. An useful and well known rating is that by Frykman⁽³⁾, which does not take into consideration the comminution degree or the baseline deviation at the radiographic examination. It is concerned to separate the fractures into intra and extra articular, involving radiocarpal, distal radio-ulnar or both, together or not with distal ulna fracture⁽⁸⁾. For a better understanding of the fractures in this study, we jointed the use of Smith's rating criteria as modified by Thomas^(9).

The method of functional evaluation of final results should include all aspects of the fracture and the joining sequelae. For this we used the criteria from Gartland & Werley⁽⁴⁾, which are diffused and used in several papers.

By means of using an accurate technique and a suitable implant, we aimed the principles that base the AO/ASIF⁽⁷⁾ group.

Based on radiographic study, and checking the mentioned criteria, we believe that the results achieved in our study were considered as good and excellent in 100% of the cases. It was reached the same concept in 83.4% of the cases according to the functional evaluation. The result is comparable to the found in the literature, where Bradway et alli⁽²⁾ found 81% of their results as good and excellent in intra-articular fractures treated with open reduction and internal fixation as evaluated by Gartland & Werley's⁽⁴⁾ criteria.

CONCLUSION

Open reduction followed by internal fixation with a supporting plate is an efficacious method for treating unstable fractures of distal radius with volar displacement.

Trabalho recebido em 29/04/2002. Aprovado em 28/06/2002

Work performed at Departamento de Ortopedia e Traumatologia from Hospital Escola

da Faculdade de Medicina do Triângulo Mineiro - Uberaba - MG

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Publication Dates

• Publication in this collection
  25 Feb 2003
• Date of issue
  Dec 2002

History

• Received
  29 Apr 2002
• Accepted
  28 June 2002