OBSERVATIONAL STUDY ON MANAGEMENT OF DISPLACED INTRA-ARTICULAR, UNSTABLE FRACTURES OF DISTAL END OF RADIUS BY OPEN REDUCTION AND INTERNAL FIXATION.

Abstract

Background: Distal radius fractures represent one of the most common injuries treated by upper extremity surgeons accounting for 16% (1/6) of all fractures treated in the emergency room in the United States and 75% of fractures of the forearm.As a description of the fracture has evolved, as has the variety of treatment modalities like Closed reduction and cast immobilization, percutaneous pinning, External fixation ( Ligamentotaxis) and open reduction and internal fixation using plates and screws.

Objectives: The aim of this study was to assess the functional and radiological results of displaced intra-articular, unstable fractures of distal end of radius (DER) by open reduction and internal fixation(ORIF).

Study Design: This was a prospective hospital-based observational study conducted in the Postgraduate Department of Orthopaedics SKIMS Medical College and Hospital , Bemina over a period of one and half years  from October 2018 to March 2020.

Participants: A total of 30 patients with displaced Intra-articular, unstable fractures of distal end of radius and admitted for Open Reduction and Internal Fixation , were considered for this study.

Methods: 30 patients meeting the inclusion Criteria were admitted from Accident and Emergency department or outpatient department of our hospital.On admission clinical history was taken followed by a detailed general physical examination and relevant local examination. Subsequently standard X-Ray projections (AP/Lateral and Oblique) of the wrist with forearm of both normal and fractured limbs were taken in every patient. The patients were then assessed medically and prepared for surgery. Open reduction and Internal Fixation was done through either Volar approach or Dorsal approach depending on the geometry of fracture .The patients were followed upto an average of 12 months.

Results: out of 30 patients, 16 were males and 12 were females. The mean age of the patients was 46.9 years. Fall on outstretched hand ( FOOSH) was the most important cause of fractures (57%) followed by RTA (43%). Dominant wrist was involved in 53% and non dominant wrist in 47%. The mean operative time was 64 minutes. The average hospital stay was 6 days. The average follow up period was 12 months. The mean time to union was 11 weeks. The average palmar flexion, dorsiflexion, supination and pronation of the injured wrist was 70.7, 69.7, 73.7 and  76.2 degrees respectively.  The average grip percentage of the injured wrist was 89% compared to the uninjured side. Functional outcomes, assessed by Modified Mayo Score were Excellent in 33% patients, Good in 50 % patients and Fair in 17% patients.

The average Volar tilt and Radial inclination achieved in our patients were 6 degrees and 17 degrees respectively. The average Radial Height was 8 mm at the final follow up period. Radiological outcomes, assessed by Sarmentios modification of Lindstorm Criteria were Excellent in 50% patients, Good in 40% patients and Fair in 10% patients.The overall complication rate in our study was 30%

Conclusions: It was observed that stabilizing the fracture fragments with open reduction and internal fixation with plates and screws in the management of the fractures of  distal radius, is an effective method to maintain the reduction till union and prevent collapse of the fracture fragments, even when the fracture is grossly comminuted/intra-articular/unstable and/or the bone is osteoporosed.

Implications: The takeaway message is that the technique of open reduction and internal fixation in the management of unstable, Intra-articular distal radius Fractures is associated with reasonably good functional and radiological outcomes. However, a prospective randomised controlled trial  is required to resolve whether this mode of  internal fixation is superior to other treatment modalities.