SCIENTIFIC ARTICLE

Percutaneous Distal RadiuseUlna Pinning of Distal Radius Fractures to Prevent Settling Jin Young Kim, MD, Suk Kee Tae, MD

Purpose To evaluate the clinical and radiological outcomes of distal radius fractures treated by percutaneous fixation using distal radiuseulna pinning and to assess its effectiveness especially for preventing fracture settling. Methods We retrospectively reviewed 18 distal radius fractures (15 AO type A2 and 3 AO type C1). Range of motion and Disabilities of the Arm, Shoulder, and Hand scores were evaluated. We measured radiographic parameters at the final follow-up and compared them with those on immediate postoperative x-rays. Results All fractures united and average time to initial healing was 6.9 weeks (range, 6e7 wk). Average follow-up was 29 months (range, 26e43 mo). Average wrist flexion and extension were 70 and 65 , respectively. Average forearm supination and pronation were 82 and 83 , respectively. Average pain score was 1.2 and average Disabilities of the Arm, Shoulder, and Hand score was 13. Mean difference of ulnar variance, volar tilt, and radial inclination between immediate and final follow-up x-rays was 0.7 mm, 1 , and less than 1 , respectively. Conclusions Percutaneous fixation of distal radius fractures using distal radiuseulna pinning had favorable radiologic and functional outcomes and was effective in preventing fracture settling during initial healing in unstable extra-articular fractures and some simple sagittal split intra-articular fractures. (J Hand Surg Am. 2014;39(10):1921e1925. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Distal radius fracture, percutaneous pinning, fracture settling.

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ERCUTANEOUS PINNING IS AN accepted procedure for distal radius fractures and has produced reliable outcomes for extra-articular and certain type of intra-articular fractures.1 However, it has been criticized for a lack of fixation, especially for fracture settling during healing despite the advantages of lower cost and minimal invasiveness over

From the Department of Orthopedic Surgery, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Donggu, Ilsan, Goyang, Republic of Korea. Received for publication February 10, 2014; accepted in revised form July 11, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jin Young Kim, MD, Department of Orthopedic Surgery, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, 814 Siksadong, Donggu, Ilsan, Goyang 410-773, Republic of Korea; e-mail: [email protected]. 0363-5023/14/3910-0005$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.07.008

other fixation methods. Several authors noted that percutaneous pinning does not sustain immediate postoperative reduction, and a degree of radial shortening between reduction and fracture union must be anticipated.2,3 Radial shortening may affect patients’ functional outcomes by causing limitation of wrist motion, ulnar-sided wrist pain, and radiocarpal arthrosis.3e5 Thus, we inserted 1 or 2 distal radiuse ulna pins through the subchondral bone proximal to the joint line to prevent fracture settling when performing percutaneous pinning. We kept in mind that distal radioulnar joint (DRUJ) arthrosis might occur and thought that this distal radiuseulna pin would support the radius joint surface by anchoring it to the ulnar head until initial healing and by adding 1 or 2 distal radiuseulna pins to standard cross-pinning (radial styloid pin and dorsoulnar pin), which is the most biomechanically favorable construct for distal

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FIGURE 1: Displaced distal radius fracture (AO type A2). A Posteroanterior view. B Lateral view. Closed reduction was performed, but correction of volar tilt was slightly insufficient. C, D Alignment immediately after surgery. E, F Radial inclination, dorsal tilt, and radial length were well maintained 2 months later.

radius.6 We undertook the current study to assess the clinical and radiological outcomes of distal radius fractures treated by our method and to evaluate its efficacy especially in preventing fracture settling.

C1 (3 patients; 17%) fractures were included (Fig. 2). Fractures with severe metaphyseal or intra-articular comminution and articular shear fractures were excluded, but no exclusions were made on the basis of age or bone quality. Three patients with follow-up less than 2 years were also excluded. Fourteen patients had a concomitant ulnar styloid fracture and 1 had distal radioulnar instability identified intraoperatively. Average follow-up was 29 months (range, 26e43 mo). With the patient under general or regional anesthesia, finger trap or manual traction was applied to the thumb and index finger. The fracture was manually reduced and evaluated using an image intensifier. If reduction was complete, a 2- or 3-cm longitudinal incision was made, starting 0.5 to 1 cm distal to the radial styloid and proceeding proximally. After the branches of the superficial radial nerve and the first extensor compartment were identified and mobilized, 2 1.6-mm Kirschner wires were inserted from the

PATIENTS AND METHODS This study was approved by our institutional review board and we obtained informed consent from each patient involved in the study. We reviewed 18 patients with distal radius fractures treated by percutaneous pin fixation between February 2008 and February 2010. There were 5 men and 13 women with an average age of 51 years (range, 26e71 y). Inclusion criteria were an unstable extra-articular fracture that failed to maintain initial reduction or a simple intra-articular fracture that had minimal displacement and was easily reducible by closed means. Fractures were classified using the AO/ASIF system; type A2 (15 patients; 83%) (Fig. 1) and type J Hand Surg Am.

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FIGURE 2: Displaced distal radius fracture (AO type C1). A Posteroanterior view. B Lateral view. C, D Alignment immediately after surgery. E, F No articular stepoff was observed, and radial length (ulnar variance) was well maintained at 2 months.

radial styloid tip across the fracture site to engage the opposite cortex. Then, a 1.6-mm Kirschner wire was introduced at the dorsal rim of the distal radius, distal and medial to the Lister tubercle, and was driven in a proximal and volar direction across the fracture site. Finally, one 1.6-mm or two 1.4-mm Kirschner wires were placed parallel with the joint line through the subchondral bone of the distal radius and into the medial cortex of the ulnar head (Figs. 1, 2). When a pin was inserted close to the joint line, fixation became more rigid. If we found distal radioulnar instability intraoperatively, the forearm was placed in neutral rotation before distal radiuseulna pin insertion. The wrist was immobilized with a long arm orthosis for 3 to 4 weeks to control rotation. A short arm cast was then applied to allow elbow motion. The cast and pins were removed after 5 to 6 weeks when bony healing was observed on plain radiographs. In case of concomitant distal radioulnar J Hand Surg Am.

instability, a long arm cast was maintained for 6 weeks. Active assisted exercise was started immediately and functional use was encouraged by 8 weeks. We conducted radiographic assessments to evaluate union status, alignment, and implant position 3, 6, and 12 weeks after surgery and then annually. Radiographic parameters of radial inclination, ulnar variance, volar tilt, and articular stepoff were measured at the final follow-up and compared with immediate postoperative radiographs. Bone healing was defined as blurring of fracture gap or connections between disrupted cortex or trabeculae on standard posteroanterior and lateral x-rays. Wrist flexion-extension and forearm supinationpronation were measured using a goniometer. Patients rated pain using a visual analog scale and used the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to evaluate global upper extremity functions. r

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TABLE 1. Radiographic Parameters and Mean Difference of Ulnar Variance, Volar Tilt, and Radial Inclination Between Immediate and Final Follow-Up Radiograph Final Follow-Up (average [range]) Ulnar variance, mm Tilt (degrees)

2.7 (e2.1 to 4.8)

Difference Between Immediate and Final Radiographs (average [range]) 0.7 (0e2)

8 (10 dorsal to 10 volar)

1 (0e5)

Radial inclination (degrees)

22 (15e25)

< 1 (0e5)

Articular stepoff, mm

0.2 (0e1)

< 1 (0e1)

RESULTS All fractures united; average time to initial healing was 7 weeks (range, 6e7 wk). Table 1 lists results of radiographic parameters. No radiographic arthrosis was observed for all patients at final follow-up. Average flexion of wrist was 70 and average extension was 65 . Average forearm supination was 82 and average pronation was 83 . Range of motion gradually recovered over 3 months after surgery in all cases as exercise progressed. Average pain score was 1.2 and average DASH score was 13. Mild pin site infection was observed in one case but it improved with regular dressing changes. The patient with concomitant DRUJ instability was maintained in a long arm cast for 6 weeks. Anteroposterior translation was considerably decreased and DRUJ subluxation or limitation of forearm rotation was not observed. One distal radiuseulna pin was broken and was removed 4 weeks after surgery. Two patients reported sharp pain or tingling around the radial styloid owing to pin irritation especially when they moved their thumbs. The pain or tingling resolved after pin removal.

construct for distal radius pinning. Glickel et al1 stated that orthogonal cross-pinning (dorsoulnar pin) prevented “marked settling” of the fracture in their patients. Despite these studies, we considered that cross-pinning alone did not prevent progressive subsidence of the distal fragment especially when volar cortex apposition was not adequate or dorsal comminution was severe. Thus, we added 1 or 2 distal radiuseulna pins to support subchondral bone and prevent fracture settling. The radiuseulna pin was passed through the subchondral bone, which is the strongest part of the distal fragment; this pin could hold the articular surface in place and anchor it to the ulnar head. Furthermore, the radiuseulna pin was suitable for traversing sagittal split intra-articular fragments or fixing concomitant DRUJ instability. As shown in our results, the difference in ulnar variances between immediate and final radiographs was less than 2 mm in all cases. Differences in radial inclination and volar tilt between immediate and final radiographs were less than 5 in all cases. Articular stepoff in intra-articular fractures averaged 0.2 mm at final follow-up. Our results are comparable to volar plating regarding ranges of motion, postoperative pain, and radiologic outcome.12e14 There are several concerns regarding our method. A distal radiuseulna pin might damage the DRUJ and cause arthritis. We should evaluate whether DRUJ arthritis develops by comparing follow-up x-rays with the healthy side. To avoid thermal injury, we recommend intermittently pausing the wire driver as the Kirschner wire penetrates the DRUJ. Distal radiuseulna pin breakage might occur with forearm rotation. We experienced DRUJ pin breakage in one patient and modified our technique by leaving both ends of each pin out of the skin for easy removal if breakage occur. Nerve injury might be prevented by placing the pins under direct vision through small incisions, but nerve irritation by pins could occur depending on their proximity to nerve. A longer period of therapy is needed compared with plating because early motion is not allowed. However, favorable range

DISCUSSION Osteosynthesis using Kirschner wire fixation is a reliable procedure for distal radius fractures that cannot be stabilized by casting and are located close to the joint.7 It may be indicated for certain type of intra-articular fractures8e10 and has advantages over plating in terms of cost and invasiveness. However, a criticism of percutaneous pinning is fracture settling.2,3 Wilcke et al11 stated that fractures with greater than 2 mm radial shortening correlated with decreased DASH outcome and pain scale satisfaction scores. Beumer et al4 also reported that posttraumatic positive ulnar variance was the most important factor in predicting bad outcomes in nonosteoporotic patients. Naidu et al6 reported that cross-pinning with 1 or 2 radial styloid pins and dorsal pins orthogonal to radial styloid pins was the most biomechanically favorable J Hand Surg Am.

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of active motion including forearm rotation was regained by 3 months after surgery in all cases, and no patients reported functional impairment or disabling pain. This study had several limitations. The patient number was too small and follow-up period was too short to evaluate the presence of arthrosis in radiocarpal joints and DRUJs. This study was based on a retrospective review, and comparative studies with other fixation methods or other similar techniques are required to determine the clinical value of our technique.

5. Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T, Terai T. Fractures of the distal end of radius in elderly patients: a comparative study of anatomical and functional results. J Orthop Surg (Hong Kong). 2002;10(1):9e15. 6. Naidu SH, Capo JT, Moulton M, Ciccone W II, Radin A. Percutaneous pinning of distal radius fractures: a biomechanical study. J Hand Surg Am. 1997;22(2):252e257. 7. Strohm PC, Müller CA, Boll T, Pfister U. Two procedures for Kirschner wire osteosynthesis of distal radial fractures: a randomized trial. J Bone Joint Surg Am. 2004;86(12):2621e2628. 8. Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W. Combined Kirschner wire fixation in the treatment of Colles fracture: a prospective, controlled trial. Arch Orthop Trauma Surg. 1999;119(3-4):171e178. 9. Hermichen HG, Hansis M. Bore wire osteosynthesis in distal radius fractures. Aktuelle Traumatol. 1987;17:109e112 [in German]. 10. Stürmer KM, Letsch R, Koeser K, Schmit-Neuerburg KP. Treatment of distal radius fracture: surgical technique: bore wire osteosynthesis. Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir. 1990: 647e656 [in German]. 11. Wilcke MK, Abbaszadegan H, Adolphson PY. Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score. J Hand Ther. 2007;20(4):290e298. 12. Protopsaltis TS, Ruch DS. Volar approach to distal radius fractures. J Hand Surg Am. 2008;33(6):958e965. 13. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg Am. 2005;30(4):743e749. 14. Osada D, Kamei S, Masuzaki K, Takai M, Kameda M, Tamai K. Prospective study of distal radius fractures treated with a volar locking plate system. J Hand Surg Am. 2008;33(5):691e700.

REFERENCES 1. Glickel SZ, Catalano LW, Raia FJ, Barron OA, Grabow R, Chia B. Long-term outcomes of closed reduction and percutaneous pinning for the treatment of distal radius fractures. J Hand Surg Am. 2008;33(10):1700e1705. 2. Rosati M, Bertagnini S, Digrandi G, Sala C. Percutaneous pinning for fractures of the distal radius. Acta Orthop Belg. 2006;72(2):138e146. 3. Barton T, Chambers C, Lane E, Bannister G. Do Kirschner wires maintain reduction of displaced Colles’ fractures? Injury. 2005;36(12):1431e1434. 4. Beumer A, Lindau TR, Adlercreutz C. Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs. BMC Musculoskelet Disord. 2013;14:170.

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Percutaneous distal radius-ulna pinning of distal radius fractures to prevent settling.

To evaluate the clinical and radiological outcomes of distal radius fractures treated by percutaneous fixation using distal radius-ulna pinning and to...
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