Original Article
European Journal of Trauma and Emergency Surgery
Function Versus Position: A Randomized Controlled Trial of Interfocal Kirschner Wiring of Unstable Distal Radial Fractures Martyn Snow, Margaret Kelly, Muthu Jeyam, Nabil Fahmy 1
Abstract Introduction: A randomized, prospective study has been carried out to determine if immobilisation in dorsiflexion following K-wire fixation of unstable distal radial fractures improves functional outcome. Methods: Sixty patients with unstable fractures of the distal radius were entered into the trial. There were 52 female and 11 male with an average age of 60yrs (17-84). Randomisation was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and interfocal percutaneous K-wires inserted. Patients randomised to group I had their wrists placed in 30 degrees of dorsiflexion and group II had their wrists placed in 30 degrees of palmer flexion. Patients were reviewed with an x-ray at 1, 3, 5, and 17 weeks by a single physician. Dorsal angulation, Radial inclination, Radial length and Radial height were measured. The K-wires were removed in the outpatient clinic at 3 weeks and the plaster at 5 weeks. Blinded functional review was carried out by an Occupational therapist at 5, 8 and 17 weeks post operation. The power and pinch grip was measured using a Jamar dynamometer. Flexion and extension were measured with a goniometer. Results: There was no statistical difference in radiological or functional outcomes in either group. At 17 weeks the mean dorsal angulation was -0.5 and -1.9 degrees. The mean radial shortening was 1.5mm in both groups. The power grip was 86% and 82% and pinch grip was 99% and 101%. Patients regained 76% and 79% of flexion and 94% and 88% of extension compared to the opposite side. Conclusions: Immobilisation in dorsi-flexion following K-wiring for unstable distal radial fractures does
1
not improve functional outcome. The overall functional results were excellent and we believe that Kwiring still as a place in the treatment of distal radial fractures in the previously defined population. Key Words Orthopedic trauma Æ Wrist Æ Fractures Æ Hand Æ Upper extremity Eur J Trauma Emerg Surg 2007;33:81–86 DOI 10.1007/s00068-007-6059-z
Introduction Distal radial fractures are one of the commonest surgically treated fractures, but debate still exists regarding the best treatment. Probably, the most common method of fixation is with use of Kirschner wires (Kwires) and then cast immobilization. One of the suggested disadvantages of K-wire fixation is the immobilization postoperatively. Lenoble et al. [18] tried to overcome this by allowing early mobilization following Kapandji fixation. Pain, reflex sympathetic dystrophy, and radiological loss of reduction were higher in this group. Immobilization by external fixation of unstable distal radial fractures for 3 weeks has no effect on outcome [1, 2]. The reason for this is thought to be the population. An elderly population with reduced functional needs tend not to move the wrist. If patients are to impose self-immobilization then improved function may be achieved if the wrist is immobilized in a functional position. Immobilization has traditionally been in palmar flexion in an attempt to use ligamentotaxis to maintain
Trauma and Orthopaedics, Steppinghill Hospital, Stockport, UK.
Received: March 12, 2006; revision accepted: July 25, 2006; Published Online: February 27, 2007
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reduction. This can result in stiffness of the fingers and the metacarpophalangel joints. Conversely Gupta [20] found that immobilization of stable fractures with the hand in dorsiflexion improved early functional results. A randomized prospective study has been carried out to determine if immobilization in dorsiflexion, following K-wire fixation of unstable distal radial fractures improves functional outcome. Method Prior to commencement of the trial, full ethical approval was obtained from the local ethics committee. Between September 2002 and February 2004, 63 patients with unstable fractures of the distal radius were entered into the trial. The inclusion criteria for the study were failure to hold fracture position in a typical colles-type cast and redisplacement (following reduction in accident and emergency) with dorsal angulation greater than 10°. Patients were excluded if there was volar comminution, a displaced intra-articular fracture, and if there was a delay in recognizing displacement of greater than 14 days. Patients who were unable physically or mentally to undertake regular follow-up and perform functional assessment were excluded. Patients with previous malunion to the affected wrist and injury to the opposite wrist during the study were also excluded. There were 52 females and 11 males with an average age of 60 years (17–84). Three females were excluded as they had bilateral fractures during the study. The fractures were classified using the AO classification; a summary of the distribution is shown in Table 1. The fractures were caused by a fall of < 2 m in 52 cases, a fall of > 2 m in four cases, sport in two cases and two by RTA. Informed consent was obtained prior to surgery. Randomization was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and percutaneous Kirschner wires were inserted as described by Clancey [2]. One 1.6 mm wire was inserted at the tip of the radial styloid process just dorsal to the first extensor compartment and another was inserted into the dorsal ulnar corner of the distal part of the radius between the
fourth and fifth extensor compartments. The surgeon was given the option to insert a third wire for intraarticular fractures and when deemed necessary (Figure 1, Figure 2, and Figure 3). The wires were cut, bent, and left protruding from the skin. Meticulous care was taken to avoid skin tethering. A full plaster was then applied to wrist. Patients randomized to group 1 had their wrists placed in 30° of dorsiflexion, and group 2 had their wrists placed in 30° of palmar flexion. The angulation of the plaster was checked with a goniometer. Group I consisted of 27 patients and group 2 consisted of 33 patients. The groups were similar in age, gender, types of injury, initial displacement, and fracture type.
Figure 1. AP and lateral X-ray of wrist showing typical distal radial fracture.
Table 1. A summary of AO fracture types in groups 1 and 2. Group
A3.2
A3.3
C2.1
C2.2
Group 1 Group 2 Total
9 12 21
11 9 20
2 2 4
5 10 15
82
Figure 2. Intraoperative AP X-ray of wrist showing the Clancy technique.
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normal side, allowing 30% less for the nondominant side as described by Bechtol [21]. Flexion and extension were measured with a goniometer expressing results as a percentage of the opposite normal side. The Rolyan nine hole peg test of dexterity was also carried out at each visit and is measured in seconds (s). Malunion was defined as more than 10° of dorsal angulation, more than 15° of volar tilt or more than 3 mm of radial shortening compared to the opposite side [15]. Statistical analysis was performed using the ttest, chi-squared test, and the Mann–Whitley U-test. Nonsignificance was defined as p > 0.05. Figure 3. Intraoperative lateral X-ray of wrist showing the Clancy technique.
The postoperative care of both groups was identical. Patients were reviewed at 1, 3, 5, and 17 weeks by a single physician. On each occasion, a standard AP and Lateral plain X-ray were obtained. Dorsal angulation, radial inclination, radial height, and radial length were measured. Dorsal angulation was measured using the same technique as van der Linden & Ericson [3] and expressed as the number of degrees from the neutral position. Radial height was measured as the vertical distance between the ulnar border of the distal radius and the tip of the radial styloid. Radial inclination was measured as the angle between a horizontal line drawn at the level of the ulnar border of the radius and a line from the tip of the radial styloid to the ulnar border of the radius. Radial length was measured as the vertical distance from the ulnar border of the distal radius to the most distal point of the ulnar head [4]. The K-wires were removed in the outpatient clinic at 3 weeks and patients were then placed back into their selected casts for a further 2 weeks. Functional review was carried out by an occupational therapist (who was blinded as to the patient group) at 5, 8 and 17 weeks postoperation. The power and pinch grip were measured using a Jamar dynamometer and expressed as a percentage of the opposite
Results Radiological At 1 week postoperatively the mean dorsal angulation in group 1 was –2.4 (thus 2.4° of volar tilt) and –2.7 in group 2. There was no statistical significance. Similarly, there was no statistical difference in radial inclination, height, or radial length. At 17 weeks there was an increase of dorsal angulation in both groups. Group 1 had a mean dorsal angle of –0.5° compared to –1.9° in group 2. This was not statistically significant. Similarly there was no significant difference in radial inclination, height or length (Table 2). Our malunion rate was 14%, four patients in group 1 and five in group 2. Functional Results At week 5, there was no statistical difference in power or pinch grip strength between the two groups. Similarly there was no statistical difference in the Rolyan dexterity test. Group 1 had a greater range of dorsiflexion compared to group 2 (p < 0.05). Conversely group 2 had a greater range of palmar flexion (p < 0.05). There was no statistical difference in any functional outcomes measured at weeks 8 and 17. At week 17, group 1 had regained 76% of dorsi-flexion and 94% of palmar flexion. Group 2 regained 88% of dorsiflexion and 79% of palmar flexion (Table 3). The
Table 2. A summary of radiographic results for groups 1 and 2 at weeks 1 and 17. Measurement Week 0 Week 1 Mean (reference range)
Week 17
Weeks 17–1 Week 0 Week 1 Mean (reference range)
Week 17
Weeks 17– 1 Analysis p value of covariance
Dorsal Radial Radial Radial
–0.5 (–13–28) 20.4 (4.8–29) 9.6 (2.3–12) –1.5 (–20.0–2)
1.9 (SD 5.2) –1.1 (SD 2.7) –0.4 (SD 1.0) 2.5 (SD 1.5)
–1.9 20.0 10.4 –1.5
0.8 (SD 4.6) –0.7 (SD 2.5) –0.8 (SD 1.5) 2.8 (SD 1.9)
angle angle height length
–2.4 (–13–12) 22 (9–30) 11 (4–17) 1.3 (–1–3.5)
–2.4 (–13–10) 21.5 (9–31) 10.1 (5–15) 1.0 (–1–3.0)
Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN & VOGEL
–2.6 (–12-8) 21 (12–33) 12 (6–18) 1.2 (–1-3)
–2.7 (–12–8) 20.7 (10–31) 11.2 (5–17) 1.3 (–1-2.5)
(–11–18) (8–28) (4–15) (–4 -1)
0.243 0.573 0.495 0.602
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manual dexterity was improved in group 1; it was superior to that of group 2 but the difference was not significant (p = 0.09). Complications There was one pin-site infection in group 1. This settled following removal on the K-wires and treatment with oral antibiotics. Pin-site infection was defined as erythema or discharge requiring removal of wires or antibiotics. One patient in group 2 had a distal radial osteotomy 17 months after injury for reduced flexion. Ten patients in group 2 were referred by the physician for physiotherapy compared to 2 in group 1; this was statistically significant (p < 0.05). Discussion The position of function of the hand was originally described by James [26, 27]. The rationale recommends splinting the wrist in 10–30° of dorsiflexion, the metacarpophalangeal joints in 40–70° of flexion, and the proximal interphalangeal joints in extension. Splinting in this position prevents length-associated changes in muscles and connective tissue, which lead to stiffness. The two groups in our study were comparative with regard to demographics, fracture pattern, and radiological outcome postsurgery. Apart from the initial significant difference in flexion and extension, (depending on the direction of immobilization) there was no difference in functional outcome. Thus, in our study the position of immobilization post-K-wire fixation has no effect on functional outcome. A criticism of intrafocal wiring in the elderly has been its inability to maintain volar tilt with late colTable 3. A summary of functional results for groups 1 and 2 at weeks 8 and 17.
Week 17 Power Pinch Flexion Wrist ext Dexteritya (s) Week 8 Power Pinch Flexion Wrist ext Dexteritya (s) a
Group 1, mean (st. dev.)
Group 2, mean (st. dev.)
p value
86 99 76 94 20
(37) (30) (26) (35) (12)
82 (27) 101 (36) 79 (26) 88 (31) 21 (22)
0.64 0.80 0.65 0.59 0.10
55 79 63 79 22
(30) (33) (24) (43) (18)
53 74 68 68 23
0.84 0.58 0.27 0.28 0.09
Median (range) values shown
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(28) (35) (19) (33) (73)
lapse and shortening [5, 8, 9]. The prime determinant of a good functional outcome is the restoration of palmar tilt, with significant disability resulting with dorsal angulation greater than 12° [6]. Kapandji originally described his technique in a young population [7]. Our study has shown that while there is a loss of tilt following removal of the plaster cast it is possible to retain a palmar tilt. Similarly, mean shortening in both groups was 1.5 mm, which is acceptable [2]. Kapandji (Intrafocal) wiring fails to maintain reduction in the elderly due to dorsal comminution. The Clancey technique is a more stable construct. Cross pinning with a pin from the ulnar corner of the radius plus two radial styloid pins provides the most rigid construct [14], thus reducing the incidence of malunion. Power grip strength has been frequently reported to be slow to recover following distal radial fracture, regardless of treatment [1, 21–24]. This appeared not to be the case in our study. By 17 weeks patients had regained 86% and 82% of power grip strength. Pinch grip strength was even better at 99% and 100% of the unaffected side. It is expected that there will be continual sequential improvement in the power grip strength during the year as predicted by Yen et al. [21]. Physiotherapy has been shown to be of little benefit in distal radial fractures [25], and only 12 of our patients received formal intervention. The complication rate within our study was low in comparison to similar studies in the literature [10, 11]. Our pin-site infection rate was 2%, with no deep infections. This low rate we feel is secondary to meticulous surgical technique of skin release and early wire removal at 3 weeks. While 3 weeks would be considered too early to remove wires by most surgeons, this has been the practice of senior authors for years without complication. The results from our study confirm this. We thus disagree with previous recommendations for burying wires [12]. This leads to a further operation and the potential for tendon ruptures [13]. Our malunion rate was 15%, but only one patient went on to need a distal radial osteotomy due to functional impairment. There was no patient who suffered from reflex sympathetic dystrophy, which is a significant complication of external fixation. The functional outcome in our study was excellent when compared with other modes of treatment. A summary of results from three comparable studies using alternative methods of treatment is shown in Table 4. It can be seen that our functional results are similar to the other three methods. We have the shortest follow-up, which is a criticism of our study, but it can be expected that our results will continue to
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Table 4. A summary of the functional results from previous comparable studies in the literature. Method of fixation
Author
Follow-up
Dorsal angulation
Power grip %
Range of movement
Bridging ex fix Nonbridging ex fix Volar fixed angle plating K-wire
McQueen [1] McQueen et al. [15] Wright et al. [17] Snow et al.
6 1 1 4
7 ± 13 –5 ± 6 –5 –1.2
53 ± 30 74 78 84
82 ± 15%
months year year months
improve for up to 12 months, as predicted by Yen et al. [21] and Madcdermid et al. [16]. The function in our study is excellent despite inferior radiological results compared to those reported for nonbridging external fixation and ORIF. Open reduction has the best radiological results; the anatomy in these patients is almost fully restored [19]. Despite this, function compared to our study has not been improved. Patients have been shown to impose self-immobilization for at least 3 weeks following injury [1, 2]. Thus, the effect of cast immobilization for 5 weeks appears not to significantly reduce function. Improved motivation from immediate and regular review by an occupational therapist with simple education regarding exercises may play a role. Patient awareness of an objective improvement and increased motivation may also explain our results. Conclusion Immobilization in dorsi-flexion following K-wiring for unstable distal radial fractures did not improve functional outcome in our study. The overall functional results were excellent and we believe that K-wiring still has a place in the treatment of distal radial fractures in the previously defined population. Conflict of interest statement There are no financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) work submitted.
References 1.
2.
3.
4.
McQueen MM, Hajducka C, Court-Brown . Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. JBJS [Br] 1996;78B:404–9. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fixation of unstable fractures of the distal radius: a prospective, randomised comparison with static external fixation. JBJS [Am] 1994;76A:1149–61. der Vab Linden W, Ericson R. Colles’ fracture: how should its displacement be measured and how should it be immobilized?. J Bone Joint Surg [Am] 1981;63A:1285–8. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36.
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Flexion
Extension
66 79 78
82 68 91
5.
Geatting M, Bishop A. Intrafocal (kapandji) pinning of unstable fractures of the distal radius. Orthop Clin N Am 1993;24:301–7. 6. McQueen MM, Caspers J. Colles’ fracture: does the anatomical result affect the final function. JBJS 1988;70B:649–51. 7. Kapandji A. [Internal fixation by double intrafocal plate. Functional treatment on non-articular fractures of the lower end of the radius]. Ann Chir 1976;30:902–8. 8. Haas JL, Caffiniere de la JY. Fixation of distal radial fractures: intramedullary pinning versus external fixation. In: Saffar P, Cooney WP, eds. Fractures of the distal radius. London: Martin Dunitz, 1995;27:229–39. 9. Oskam J, et al. K-wire fixation for redislocated Colles’ fractures. Acta Orthop Scand 1997;68(3), 259–61. 10. Mah ET, Atkins RN. Percutaneous Kirschner wire stabilisation following closed reduction of Colles’ fractures. J Hand Surg [Br] 1992;17B:55–62. 11. Ludvigsen TC, Johansen S, Svenningsen S, et al. External fixation versus percutaneous pinning for unstable Colles’ fracture. Acta Orthop Scand 1997;68:255–8. 12. Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg [Br] 2004;29B:374–6. 13. Dowdy PA, Patterson SD, King GJW, et al. Intrafocal pinning of unstable distal radial fractures: a preliminary report. J Trauma 1996;40:194–7. 14. Naidu SH, Capo JT, Moulton M. Percutaneous pinning of distal radius fractures: a biomechanical study. J Hand Surg 1997;22A:252–7. 15. McQueen MM, Simpson D, Court-Brown CM. Use of the Hoffman 2 compact external fixator in the treatment of redisplaced unstable distal radial fractures. J Orth Trauma 1999;13:501–5. 16. MacDermaid JC, Richards RS, Roth JH. Distal radius fracture: a prospective outcome study of 275 patients. J Hand Ther 2001;14:154–69. 17. Kamano M, Koshimune M, Toyama M, et al. Palmar plating system for Colles’ fractures: a preliminary report. J Hand Surg 2005;30:750–755. 18. Lenoble E, Dumontier C, Goutallier D, et al. Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg Br 1995;77:562–7. 19. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am] 2005;30:629. 20. Gupta A. The treatment of Colles’ fracture: immobilisation with the wrist dorsiflexed. JBJS 1991;73B:312–5. 21. Yen ST, Hwang CY, Hwang MH. A semi-invasive method of treating articular Colles’ fractures. Clin Orthop 1991;263:154–64. 22. Dias JJ, Wray CC, Jones JM, et al. The value of early mobilisation in the treatment of Colles’ fractures. JBJS [Br] 1987;69B:463–7. 23. Cooney WP III, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles’ fractures. JBJS [Am] 1979;61A:840–5.
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24. McQueen MM, Michie M, Court-Brown . Hand and wrist function after external fixation of unstable distal radial fractures. Clin Orthop 1992;285:200–4. 25. Wakefield AE, McQueen MM. The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. JBJS 2000;82B:972–6. 26. James JIP. Fractures of the proximal and middle phalanges of the fingers. Acta Orthop Scand 1962;32:401–12. 27. James JIP. Common, simple errors in the management of hand injuries. Proc R Soc Med 1970;63:69–71.
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Address for Correspondence Martyn Snow 4 Newton Avenue Withington Manchester M20 1JJ United Kingdom Phone (+44/7971)-260576 e-mail: [email protected]
Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN & VOGEL
European Journal of Trauma and Emergency Surgery
Function Versus Position: A Randomized Controlled Trial of Interfocal Kirschner Wiring of Unstable Distal Radial Fractures Martyn Snow, Margaret Kelly, Muthu Jeyam, Nabil Fahmy 1
Abstract Introduction: A randomized, prospective study has been carried out to determine if immobilisation in dorsiflexion following K-wire fixation of unstable distal radial fractures improves functional outcome. Methods: Sixty patients with unstable fractures of the distal radius were entered into the trial. There were 52 female and 11 male with an average age of 60yrs (17-84). Randomisation was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and interfocal percutaneous K-wires inserted. Patients randomised to group I had their wrists placed in 30 degrees of dorsiflexion and group II had their wrists placed in 30 degrees of palmer flexion. Patients were reviewed with an x-ray at 1, 3, 5, and 17 weeks by a single physician. Dorsal angulation, Radial inclination, Radial length and Radial height were measured. The K-wires were removed in the outpatient clinic at 3 weeks and the plaster at 5 weeks. Blinded functional review was carried out by an Occupational therapist at 5, 8 and 17 weeks post operation. The power and pinch grip was measured using a Jamar dynamometer. Flexion and extension were measured with a goniometer. Results: There was no statistical difference in radiological or functional outcomes in either group. At 17 weeks the mean dorsal angulation was -0.5 and -1.9 degrees. The mean radial shortening was 1.5mm in both groups. The power grip was 86% and 82% and pinch grip was 99% and 101%. Patients regained 76% and 79% of flexion and 94% and 88% of extension compared to the opposite side. Conclusions: Immobilisation in dorsi-flexion following K-wiring for unstable distal radial fractures does
1
not improve functional outcome. The overall functional results were excellent and we believe that Kwiring still as a place in the treatment of distal radial fractures in the previously defined population. Key Words Orthopedic trauma Æ Wrist Æ Fractures Æ Hand Æ Upper extremity Eur J Trauma Emerg Surg 2007;33:81–86 DOI 10.1007/s00068-007-6059-z
Introduction Distal radial fractures are one of the commonest surgically treated fractures, but debate still exists regarding the best treatment. Probably, the most common method of fixation is with use of Kirschner wires (Kwires) and then cast immobilization. One of the suggested disadvantages of K-wire fixation is the immobilization postoperatively. Lenoble et al. [18] tried to overcome this by allowing early mobilization following Kapandji fixation. Pain, reflex sympathetic dystrophy, and radiological loss of reduction were higher in this group. Immobilization by external fixation of unstable distal radial fractures for 3 weeks has no effect on outcome [1, 2]. The reason for this is thought to be the population. An elderly population with reduced functional needs tend not to move the wrist. If patients are to impose self-immobilization then improved function may be achieved if the wrist is immobilized in a functional position. Immobilization has traditionally been in palmar flexion in an attempt to use ligamentotaxis to maintain
Trauma and Orthopaedics, Steppinghill Hospital, Stockport, UK.
Received: March 12, 2006; revision accepted: July 25, 2006; Published Online: February 27, 2007
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reduction. This can result in stiffness of the fingers and the metacarpophalangel joints. Conversely Gupta [20] found that immobilization of stable fractures with the hand in dorsiflexion improved early functional results. A randomized prospective study has been carried out to determine if immobilization in dorsiflexion, following K-wire fixation of unstable distal radial fractures improves functional outcome. Method Prior to commencement of the trial, full ethical approval was obtained from the local ethics committee. Between September 2002 and February 2004, 63 patients with unstable fractures of the distal radius were entered into the trial. The inclusion criteria for the study were failure to hold fracture position in a typical colles-type cast and redisplacement (following reduction in accident and emergency) with dorsal angulation greater than 10°. Patients were excluded if there was volar comminution, a displaced intra-articular fracture, and if there was a delay in recognizing displacement of greater than 14 days. Patients who were unable physically or mentally to undertake regular follow-up and perform functional assessment were excluded. Patients with previous malunion to the affected wrist and injury to the opposite wrist during the study were also excluded. There were 52 females and 11 males with an average age of 60 years (17–84). Three females were excluded as they had bilateral fractures during the study. The fractures were classified using the AO classification; a summary of the distribution is shown in Table 1. The fractures were caused by a fall of < 2 m in 52 cases, a fall of > 2 m in four cases, sport in two cases and two by RTA. Informed consent was obtained prior to surgery. Randomization was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and percutaneous Kirschner wires were inserted as described by Clancey [2]. One 1.6 mm wire was inserted at the tip of the radial styloid process just dorsal to the first extensor compartment and another was inserted into the dorsal ulnar corner of the distal part of the radius between the
fourth and fifth extensor compartments. The surgeon was given the option to insert a third wire for intraarticular fractures and when deemed necessary (Figure 1, Figure 2, and Figure 3). The wires were cut, bent, and left protruding from the skin. Meticulous care was taken to avoid skin tethering. A full plaster was then applied to wrist. Patients randomized to group 1 had their wrists placed in 30° of dorsiflexion, and group 2 had their wrists placed in 30° of palmar flexion. The angulation of the plaster was checked with a goniometer. Group I consisted of 27 patients and group 2 consisted of 33 patients. The groups were similar in age, gender, types of injury, initial displacement, and fracture type.
Figure 1. AP and lateral X-ray of wrist showing typical distal radial fracture.
Table 1. A summary of AO fracture types in groups 1 and 2. Group
A3.2
A3.3
C2.1
C2.2
Group 1 Group 2 Total
9 12 21
11 9 20
2 2 4
5 10 15
82
Figure 2. Intraoperative AP X-ray of wrist showing the Clancy technique.
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normal side, allowing 30% less for the nondominant side as described by Bechtol [21]. Flexion and extension were measured with a goniometer expressing results as a percentage of the opposite normal side. The Rolyan nine hole peg test of dexterity was also carried out at each visit and is measured in seconds (s). Malunion was defined as more than 10° of dorsal angulation, more than 15° of volar tilt or more than 3 mm of radial shortening compared to the opposite side [15]. Statistical analysis was performed using the ttest, chi-squared test, and the Mann–Whitley U-test. Nonsignificance was defined as p > 0.05. Figure 3. Intraoperative lateral X-ray of wrist showing the Clancy technique.
The postoperative care of both groups was identical. Patients were reviewed at 1, 3, 5, and 17 weeks by a single physician. On each occasion, a standard AP and Lateral plain X-ray were obtained. Dorsal angulation, radial inclination, radial height, and radial length were measured. Dorsal angulation was measured using the same technique as van der Linden & Ericson [3] and expressed as the number of degrees from the neutral position. Radial height was measured as the vertical distance between the ulnar border of the distal radius and the tip of the radial styloid. Radial inclination was measured as the angle between a horizontal line drawn at the level of the ulnar border of the radius and a line from the tip of the radial styloid to the ulnar border of the radius. Radial length was measured as the vertical distance from the ulnar border of the distal radius to the most distal point of the ulnar head [4]. The K-wires were removed in the outpatient clinic at 3 weeks and patients were then placed back into their selected casts for a further 2 weeks. Functional review was carried out by an occupational therapist (who was blinded as to the patient group) at 5, 8 and 17 weeks postoperation. The power and pinch grip were measured using a Jamar dynamometer and expressed as a percentage of the opposite
Results Radiological At 1 week postoperatively the mean dorsal angulation in group 1 was –2.4 (thus 2.4° of volar tilt) and –2.7 in group 2. There was no statistical significance. Similarly, there was no statistical difference in radial inclination, height, or radial length. At 17 weeks there was an increase of dorsal angulation in both groups. Group 1 had a mean dorsal angle of –0.5° compared to –1.9° in group 2. This was not statistically significant. Similarly there was no significant difference in radial inclination, height or length (Table 2). Our malunion rate was 14%, four patients in group 1 and five in group 2. Functional Results At week 5, there was no statistical difference in power or pinch grip strength between the two groups. Similarly there was no statistical difference in the Rolyan dexterity test. Group 1 had a greater range of dorsiflexion compared to group 2 (p < 0.05). Conversely group 2 had a greater range of palmar flexion (p < 0.05). There was no statistical difference in any functional outcomes measured at weeks 8 and 17. At week 17, group 1 had regained 76% of dorsi-flexion and 94% of palmar flexion. Group 2 regained 88% of dorsiflexion and 79% of palmar flexion (Table 3). The
Table 2. A summary of radiographic results for groups 1 and 2 at weeks 1 and 17. Measurement Week 0 Week 1 Mean (reference range)
Week 17
Weeks 17–1 Week 0 Week 1 Mean (reference range)
Week 17
Weeks 17– 1 Analysis p value of covariance
Dorsal Radial Radial Radial
–0.5 (–13–28) 20.4 (4.8–29) 9.6 (2.3–12) –1.5 (–20.0–2)
1.9 (SD 5.2) –1.1 (SD 2.7) –0.4 (SD 1.0) 2.5 (SD 1.5)
–1.9 20.0 10.4 –1.5
0.8 (SD 4.6) –0.7 (SD 2.5) –0.8 (SD 1.5) 2.8 (SD 1.9)
angle angle height length
–2.4 (–13–12) 22 (9–30) 11 (4–17) 1.3 (–1–3.5)
–2.4 (–13–10) 21.5 (9–31) 10.1 (5–15) 1.0 (–1–3.0)
Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN & VOGEL
–2.6 (–12-8) 21 (12–33) 12 (6–18) 1.2 (–1-3)
–2.7 (–12–8) 20.7 (10–31) 11.2 (5–17) 1.3 (–1-2.5)
(–11–18) (8–28) (4–15) (–4 -1)
0.243 0.573 0.495 0.602
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Snow M, et al. Function Versus Position
manual dexterity was improved in group 1; it was superior to that of group 2 but the difference was not significant (p = 0.09). Complications There was one pin-site infection in group 1. This settled following removal on the K-wires and treatment with oral antibiotics. Pin-site infection was defined as erythema or discharge requiring removal of wires or antibiotics. One patient in group 2 had a distal radial osteotomy 17 months after injury for reduced flexion. Ten patients in group 2 were referred by the physician for physiotherapy compared to 2 in group 1; this was statistically significant (p < 0.05). Discussion The position of function of the hand was originally described by James [26, 27]. The rationale recommends splinting the wrist in 10–30° of dorsiflexion, the metacarpophalangeal joints in 40–70° of flexion, and the proximal interphalangeal joints in extension. Splinting in this position prevents length-associated changes in muscles and connective tissue, which lead to stiffness. The two groups in our study were comparative with regard to demographics, fracture pattern, and radiological outcome postsurgery. Apart from the initial significant difference in flexion and extension, (depending on the direction of immobilization) there was no difference in functional outcome. Thus, in our study the position of immobilization post-K-wire fixation has no effect on functional outcome. A criticism of intrafocal wiring in the elderly has been its inability to maintain volar tilt with late colTable 3. A summary of functional results for groups 1 and 2 at weeks 8 and 17.
Week 17 Power Pinch Flexion Wrist ext Dexteritya (s) Week 8 Power Pinch Flexion Wrist ext Dexteritya (s) a
Group 1, mean (st. dev.)
Group 2, mean (st. dev.)
p value
86 99 76 94 20
(37) (30) (26) (35) (12)
82 (27) 101 (36) 79 (26) 88 (31) 21 (22)
0.64 0.80 0.65 0.59 0.10
55 79 63 79 22
(30) (33) (24) (43) (18)
53 74 68 68 23
0.84 0.58 0.27 0.28 0.09
Median (range) values shown
84
(28) (35) (19) (33) (73)
lapse and shortening [5, 8, 9]. The prime determinant of a good functional outcome is the restoration of palmar tilt, with significant disability resulting with dorsal angulation greater than 12° [6]. Kapandji originally described his technique in a young population [7]. Our study has shown that while there is a loss of tilt following removal of the plaster cast it is possible to retain a palmar tilt. Similarly, mean shortening in both groups was 1.5 mm, which is acceptable [2]. Kapandji (Intrafocal) wiring fails to maintain reduction in the elderly due to dorsal comminution. The Clancey technique is a more stable construct. Cross pinning with a pin from the ulnar corner of the radius plus two radial styloid pins provides the most rigid construct [14], thus reducing the incidence of malunion. Power grip strength has been frequently reported to be slow to recover following distal radial fracture, regardless of treatment [1, 21–24]. This appeared not to be the case in our study. By 17 weeks patients had regained 86% and 82% of power grip strength. Pinch grip strength was even better at 99% and 100% of the unaffected side. It is expected that there will be continual sequential improvement in the power grip strength during the year as predicted by Yen et al. [21]. Physiotherapy has been shown to be of little benefit in distal radial fractures [25], and only 12 of our patients received formal intervention. The complication rate within our study was low in comparison to similar studies in the literature [10, 11]. Our pin-site infection rate was 2%, with no deep infections. This low rate we feel is secondary to meticulous surgical technique of skin release and early wire removal at 3 weeks. While 3 weeks would be considered too early to remove wires by most surgeons, this has been the practice of senior authors for years without complication. The results from our study confirm this. We thus disagree with previous recommendations for burying wires [12]. This leads to a further operation and the potential for tendon ruptures [13]. Our malunion rate was 15%, but only one patient went on to need a distal radial osteotomy due to functional impairment. There was no patient who suffered from reflex sympathetic dystrophy, which is a significant complication of external fixation. The functional outcome in our study was excellent when compared with other modes of treatment. A summary of results from three comparable studies using alternative methods of treatment is shown in Table 4. It can be seen that our functional results are similar to the other three methods. We have the shortest follow-up, which is a criticism of our study, but it can be expected that our results will continue to
Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN & VOGEL
Snow M, et al. Function Versus Position
Table 4. A summary of the functional results from previous comparable studies in the literature. Method of fixation
Author
Follow-up
Dorsal angulation
Power grip %
Range of movement
Bridging ex fix Nonbridging ex fix Volar fixed angle plating K-wire
McQueen [1] McQueen et al. [15] Wright et al. [17] Snow et al.
6 1 1 4
7 ± 13 –5 ± 6 –5 –1.2
53 ± 30 74 78 84
82 ± 15%
months year year months
improve for up to 12 months, as predicted by Yen et al. [21] and Madcdermid et al. [16]. The function in our study is excellent despite inferior radiological results compared to those reported for nonbridging external fixation and ORIF. Open reduction has the best radiological results; the anatomy in these patients is almost fully restored [19]. Despite this, function compared to our study has not been improved. Patients have been shown to impose self-immobilization for at least 3 weeks following injury [1, 2]. Thus, the effect of cast immobilization for 5 weeks appears not to significantly reduce function. Improved motivation from immediate and regular review by an occupational therapist with simple education regarding exercises may play a role. Patient awareness of an objective improvement and increased motivation may also explain our results. Conclusion Immobilization in dorsi-flexion following K-wiring for unstable distal radial fractures did not improve functional outcome in our study. The overall functional results were excellent and we believe that K-wiring still has a place in the treatment of distal radial fractures in the previously defined population. Conflict of interest statement There are no financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) work submitted.
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McQueen MM, Hajducka C, Court-Brown . Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. JBJS [Br] 1996;78B:404–9. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fixation of unstable fractures of the distal radius: a prospective, randomised comparison with static external fixation. JBJS [Am] 1994;76A:1149–61. der Vab Linden W, Ericson R. Colles’ fracture: how should its displacement be measured and how should it be immobilized?. J Bone Joint Surg [Am] 1981;63A:1285–8. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36.
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Flexion
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Geatting M, Bishop A. Intrafocal (kapandji) pinning of unstable fractures of the distal radius. Orthop Clin N Am 1993;24:301–7. 6. McQueen MM, Caspers J. Colles’ fracture: does the anatomical result affect the final function. JBJS 1988;70B:649–51. 7. Kapandji A. [Internal fixation by double intrafocal plate. Functional treatment on non-articular fractures of the lower end of the radius]. Ann Chir 1976;30:902–8. 8. Haas JL, Caffiniere de la JY. Fixation of distal radial fractures: intramedullary pinning versus external fixation. In: Saffar P, Cooney WP, eds. Fractures of the distal radius. London: Martin Dunitz, 1995;27:229–39. 9. Oskam J, et al. K-wire fixation for redislocated Colles’ fractures. Acta Orthop Scand 1997;68(3), 259–61. 10. Mah ET, Atkins RN. Percutaneous Kirschner wire stabilisation following closed reduction of Colles’ fractures. J Hand Surg [Br] 1992;17B:55–62. 11. Ludvigsen TC, Johansen S, Svenningsen S, et al. External fixation versus percutaneous pinning for unstable Colles’ fracture. Acta Orthop Scand 1997;68:255–8. 12. Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg [Br] 2004;29B:374–6. 13. Dowdy PA, Patterson SD, King GJW, et al. Intrafocal pinning of unstable distal radial fractures: a preliminary report. J Trauma 1996;40:194–7. 14. Naidu SH, Capo JT, Moulton M. Percutaneous pinning of distal radius fractures: a biomechanical study. J Hand Surg 1997;22A:252–7. 15. McQueen MM, Simpson D, Court-Brown CM. Use of the Hoffman 2 compact external fixator in the treatment of redisplaced unstable distal radial fractures. J Orth Trauma 1999;13:501–5. 16. MacDermaid JC, Richards RS, Roth JH. Distal radius fracture: a prospective outcome study of 275 patients. J Hand Ther 2001;14:154–69. 17. Kamano M, Koshimune M, Toyama M, et al. Palmar plating system for Colles’ fractures: a preliminary report. J Hand Surg 2005;30:750–755. 18. Lenoble E, Dumontier C, Goutallier D, et al. Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg Br 1995;77:562–7. 19. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am] 2005;30:629. 20. Gupta A. The treatment of Colles’ fracture: immobilisation with the wrist dorsiflexed. JBJS 1991;73B:312–5. 21. Yen ST, Hwang CY, Hwang MH. A semi-invasive method of treating articular Colles’ fractures. Clin Orthop 1991;263:154–64. 22. Dias JJ, Wray CC, Jones JM, et al. The value of early mobilisation in the treatment of Colles’ fractures. JBJS [Br] 1987;69B:463–7. 23. Cooney WP III, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles’ fractures. JBJS [Am] 1979;61A:840–5.
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24. McQueen MM, Michie M, Court-Brown . Hand and wrist function after external fixation of unstable distal radial fractures. Clin Orthop 1992;285:200–4. 25. Wakefield AE, McQueen MM. The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. JBJS 2000;82B:972–6. 26. James JIP. Fractures of the proximal and middle phalanges of the fingers. Acta Orthop Scand 1962;32:401–12. 27. James JIP. Common, simple errors in the management of hand injuries. Proc R Soc Med 1970;63:69–71.
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Address for Correspondence Martyn Snow 4 Newton Avenue Withington Manchester M20 1JJ United Kingdom Phone (+44/7971)-260576 e-mail: [email protected]
Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN & VOGEL
