Nonbridging external fixation in the treatment of unstable fractures of the distal forearm

Early hybrid nonbridging external fixation of unstable distal radius fractures in patients aged ≥50 years

Objective

We evaluated hybrid nonbridging external fixation (NBEF) supplemented by K-wires as an effective and safe treatment option for osteoporotic distal radius fractures (DRFs) in a retrospective case series.

Methods

Sixteen extra-articular and one intra-articular DRF were treated by NBEF from 2016 to 2018 (mean patient age, 61.8 years; 15 women, 1 man). Radiographic parameters (volar tilt, radial inclination, and ulnar variance), range of motion, grip power, the visual analog scale score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed at 4 weeks, 6 weeks, 6 months, and 12 months postoperatively.

Results

The volar tilt and radial inclination were restored after surgery and maintained well. The mean visual analog scale score was 4 ± 1 at 4 weeks. Range of motion was restored to 79% to 91% at 6 weeks. The DASH score was good before NBEF device removal. Two superficial pin-tract infections were easily treated with antibiotics.

Conclusions

Hybrid NBEF transfixes DRFs in a multiplanar fashion, and augmentation with percutaneous K-wires provides direct fixation in radial shift and withstands axial loads in fracture fragments. It allows early mobilization with rigid fixation. Hybrid NBEF is reliable for unstable extra-articular and simple intra-articular DRFs in older patients.

Clinical Study registration number

ChiCTR1900021712

The role of external fixation in trauma

External fixation is a method of immobilization that uses percutaneous pins placed in bone and linked with external connectors to maintain the fracture segments in a desired spatial relationship. It is a valuable clinical treatment option, providing surgeons with the ability to affect the spatial relationship of tissues, both statically and dynamically, via minimally invasive techniques. The ease and speed of application, adjustability of the frame, and minimization of blood loss with preservation of blood supply at the cutaneous and osseous levels are advantages of the external fixation technique. Care of the trauma patient remains one of the major applications for external fixation. Open fractures with severe soft tissue injuries and/or massive contamination are ideally suited to this technique. External fixation is also a versatile salvage technique for the complications arising from extremity trauma. The management of residual fracture deformity, bone loss, infections, and complex post-traumatic arthritis are often facilitated by external fixation.

Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius

BACKGROUND

The aim of this study was to compare non-bridging external fixation to palmar angular stable plating with respect to radiological outcome, wrist function, and quality of life.

METHODS

One hundred and two consecutive patients (mean age: 63 years) were enrolled in the study. Fifty-two patients were randomized for plate osteosynthesis (2.4 mm, Synthes), 50 patients received non-bridging external fixation (AO small fixator). Objective (range of motion, grip strength), patient rated outcomes (quality of life, pain), and radiological outcome were assessed 8 weeks, 6 months, and 1 year after surgery.

RESULTS

Loss of radial length of more than 3 mm was not detected in any group. Volar tilt was better restored by external fixation (7.2°) than by volar plating (0.1°). Wrist function was good in both groups. The external fixator was tolerated very well, and the quality of life assessment revealed comparable results in both groups. Osteoporosis was found in 54 % of patients and had no influence on radiological and functional outcome.

CONCLUSION

Non-bridging external fixation employing multiplanar K-wires is a suitable treatment option in intra- and extra-articular fractures of the distal radius even in osteoporotic bone.

[First degree open, proximal and distal fractures of the lower arm with scapholunate ligament rupture. Case report of severe extremity trauma]

The combination of proximal and distal radius and ulna fractures with scapholunate ligament injury is extremely rare and this type of injury may potentially only be possible in osteoporotic bone. In this case report this rare injury is discussed, a possible therapy regime is presented and a typical postoperative complication is shown.

Treatment of unstable distal radius fractures with Ilizarov circular, nonbridging external fixator

Unstable distal radius fractures remain a challenge for the treating orthopaedic surgeon. We present a retrospective follow-up study (mean follow-up 12.5 months) of 20 patients with 21 unstable distal radius fractures that were reduced in a closed manner and stabilized with a nonbridging Ilizarov external fixator. Subsequent insertion of olive wires for interfragmentary compression was performed in cases with intra-articular fractures. According to the overall evaluation proposed by Gartland and Werley scoring system 12 wrists were classified as excellent, 6 as good, 2 as fair and 1 as poor. Grade II pin-tract infection in distal fracture fragment was detected in 3 wires from a total of 78 (3.8%) and in 4 half pins out of a total of 9 (44.4%). Pronation was the most frequently impaired movement. This was restricted in 4 patients (19%) in whom a radioulnar transfixing wire was applied. Symptoms of irritation of superficial sensory branch of the radial nerve occurred in 3 patients with an olive wire applied in a closed manner in the distal fragment. Ilizarov method yields functional results comparable to that of other methods whilst it avoids wrist immobilization, open reduction and reoperation for implant removal. The method is associated with a low rate of major complication and satisfactory functional outcome.

Treatment of distal radius fractures with a nonbridging cross-pin fixator (the CPX system)

Many treatment methods exist for patients presenting with a fracture of the distal radius. With the evolution of innovative procedures and devices, treatment of these particular fractures is shifting to more contemporary approaches. The minimally invasive technique with the cross-pin fixator (CPX) system offers a new biomechanical concept for relatively rigid fixation of distal radius fractures (DRF). The CPX system uses percutaneous cross Kirschner wire fixation in combination with a nonbridging external fixator. The stability of the model is derived from the external unilateral frame and the positioning of multiple 1.6 mm Kirschner wires at various angles and planes to each other. This allows for maintenance of DRF reduction, early wrist mobilization, and a prompt return to the usual activities. Between September 2004 and September 2008, there were 54 patients with 56 DRF who were treated with the CPX system. Excluded from the report are 2 patients who had a bone graft and 1 patient who was not willing to adhere to the postoperative protocol. Of the 51 patients with 53 DRF, no major complications were reported. This article describes the CPX surgical technique, the indications, the complications, and the postoperative management.

Colles' fracture treated with non-bridging external fixation: a 1-year follow-up

The results in 75 of 105 patients with Older type II/III (AO type A2.2, A3.1, A3.2) Colles' fractures, treated with non-bridging external fixation are presented. The mean age was 67.8 years, and all patients were followed prospectively for 12 months with radiological and functional assessment. No statistically significant loss of radial length, angulation or inclination was seen between the postoperative reduction and the 1-year follow-up examination. The clinical results after 1 year were 66 (88%) excellent/good, nine (12%) fair and 0 (0%) poor according to the modified Gartland and Werley score. Mean visual analogue scale pain score after 1 year was 0.8. In three patients (4%), re-displacement of the fracture occurred and was treated with plating. Non-bridging external fixation offers a reliable method of maintaining radiological reduction of Older type II/III fractures of the distal radius and gives a good functional outcome after 1 year.

Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture?

INTRODUCTION

Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation.

METHOD

We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer.

RESULT

Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations.

CONCLUSIONS

Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated.

Bridging and non-bridging external fixation in the treatment of unstable fractures of the distal radius: a retrospective study of 588 patients

BACKGROUND AND PURPOSE

Bridging external fixation is used more frequently than non-bridging fixation in the management of unstable distal radius fractures, despite evidence from randomized controlled trials of better outcome with the latter technique. This study was designed to investigate the generalizability of the technique of non-bridging external fixation, and to define the indications for the use of each technique and their complications.

METHODS

641 patients with unstable displaced fractures of the distal radius were treated with bridging or non-bridging external fixation. Non-bridging external fixation was used where there was space for pins in the distal fragment. 52 patients were lost to follow-up, leaving 588 patients available for study. Complete data from radiographic measurements after fracture healing were available for 546 patients. 59 % of fractures were treated with the non-bridging technique.

RESULTS

Fractures treated with bridging external fixation had a 6 times increased risk of dorsal malunion (p < 0.001) and a 2.5 times increased risk of radial shortening (p < 0.001) after adjusting for confounding factors (95% CI for odds ratio: 3-13 and 1.5-4, respectively) compared to non-bridging techniques. Minor pin tract infections were more common in the non-bridging group.

INTERPRETATION

Non-bridging external fixation of the distal radius is a generalizable technique, and reduces the risk of dorsal malunion compared with bridging external fixation. Major complication rates are low and the technique is applicable to most unstable fractures of the distal radius. We recommend that non-bridging external fixation be used where there is space for the pins in the distal fragment.

Evaluation of a novel, nonspanning external fixator for treatment of unstable extra-articular fractures of the distal radius: biomechanical comparison with a volar locking plate

PURPOSE

To compare the stability of a novel, nonspanning external fixator with a standard volar locked plate for treatment of unstable distal radius fractures.

METHODS

A simulated, unstable, extra- articular distal radius fracture was created in six matched pairs of fresh frozen human distal radii. One of each pair was treated with a nonspanning external fixator [Mirza Cross Pin Fixator (CPX), A.M. Surgical Inc. Smithtown, NY] and the other was treated with a volar locked plate [Distal Volar Radial Plate (DVR), Hand Innovations, Miami, FL]. Each specimen was axially loaded in central, dorsal, and volar locations, loaded in cantilever bending in volar to dorsal, dorsal to volar, and radial to ulnar directions and loaded in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading schema, with comparisons made between the two treatment groups. Specimens were then cyclically loaded with 50 N axial loads applied for 1,000 and 10,000 cycles. Measurement of construct stiffness was repeated and comparisons made both between the two treatments and within treatments to their precycling stiffness.

RESULTS

There was no significant difference in the mechanical stiffness of the nonspanning external fixator and the volar locking plate after axial loading in any of the loading modalities. Cyclic loads of 1,000 and 10,000 cycles resulted in no significant difference in construct stiffness between the nonspanning external fixator and volar locked plate. However, the nonspanning external fixator demonstrated decreasing stiffness after cyclic loading with 10,000 cycles (p < 0.02).

CONCLUSION

This study demonstrated no significant difference in the mechanical stiffness of the CPX nonspanning external fixator and volar locked plate in a cadaveric fracture model. Both constructs appear to be biomechanically equivalent in this experimental model; however, this is only one factor in the choice of fixation device for the management of unstable distal radius fractures.

Ostéosynthèse des fractures du radius distal par plaque à vis bloquée

PURPOSE OF THE STUDY

Fractures of the distal radius are common. No one implant has demonstrated superior efficacy in terms of maintaining the reduction over time. We report our experience with plate fixation using a locking screw.

MATERIAL AND METHODS

Between September 2003 and June 2004, 67 displaced fractures of the distal radius were treated by plate fixation using the LCP-DRP 2.4 (Synthès). Three different plates (anterior, posterior, and external) were used. The patients wore a removable anatomic brace for three weeks. Self-controlled rehabilitation exercises began directly after surgery with mobilization of the digital chains. The Fernandez, Castaing and AO classifications were noted. Ulnar variance, anteversion of the radial glenoid, radial slope and the alpha angle were measured intraoperatively and at last follow-up to assess maintenance of reduction over time. The DASH test and Green and O'Brien and PRWE scores were used to assess clinical outcome.

RESULTS

Mean follow-up was eight months. Mean age was 55.8 years. Eight patients were lost to follow-up. The analysis included 59 patients who could respond to the questionnaires. Bone healing was achieved at six weeks. There were no cases of secondary displacement nor loss of reduction. The Green and O'Brien score was good or very good for 85%. The mean DASH was 20.6 and the mean PRWE 32.8.

DISCUSSION

The appropriate fixation method for distal fractures of the radius remains a controversial issue, leading to a variety of materials and fixation methods. Primary stability achieved with the locking screw in a plate enables early mobilization associated with more rapid recovery of function. The absence of secondary displacement, irrespective of the quality of the underlying bone enabled us to achieve equivalent results in young patients and older patients with osteoporotic bone. This study also confirmed the preference for the anterior approach, irrespective of the direction of the displacement. To date, no other material has enabled equivalent results. This is a major achievement in terms of fixation stability.

Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year

BACKGROUND

Non-bridging external fixation has been introduced to achieve better fracture fixation and functional outcomes in distal radius fractures, but has not been specifically evaluated in a randomized study in the elderly. The purpose of this trial was to compare wrist-bridging and non-bridging external fixation for displaced distal radius fractures.

METHOD

The inclusion criteria were women >/= 50 or men >/= 60 years, acute extraarticular or intraarticular fracture, and dorsal angulation of >/=20 degrees or ulnar variance >/= 5 mm. The patients completed the disabilities of the arm, shoulder and hand (DASH) questionnaire before and at 10, 26 and 52 weeks after surgery. Pain (visual analog scale), range of motion and grip strength were measured by a blinded assessor.

RESULTS

38 patients (mean age 71 years, 31 women) were randomized at surgery (19 to each group). Mean operating time was shorter for wrist-bridging fixation by 10 (95% CI 3-17) min. There was no significant difference in DASH scores between the groups. No statistically significant differences in pain score, range of motion, grip strength, or patient satisfaction were found. The non-bridging group had a significantly better radial length at 52 weeks; mean difference in change in ulnar variance from baseline was 1.4 (95% CI 0.1-2.7) mm (p = 0.04). Volar tilt and radial inclination were similar in both groups.

INTERPRETATION

For moderately or severely displaced distal radius fractures in the elderly, non-bridging external fixation had no clinically relevant advantage over wrist-bridging fixation but was more effective in maintaining radial length.

Non-spanning external fixation of the distal radius

Non-spanning external fixation of the distal radius is a simple, reliable, and noninvasive technique to restore the anatomy in unstable extra-articular or minimal articular fractures of the distal radius. Rehabilitation is faster and more complete than with other comparable techniques. It is also a successful technique for stabilization of corrective osteotomy of the distal radius formal union.