Author(s): Isaac Sunder Sen1
The aim of the study is to categorically suggest the apt method of surgical technique for a particular type of distal radius fracture (Frykman’s type III-VI). Distal radius fracture are among the most common fractures of the upper extremity inspite of increased focus on regular prevention of osteoporosis, early identification and its prompt management. Most distal radius fractures are the result of low energy mechanisms that can be successfully treated either nonoperatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches and familiarity with multiple fixation options. Although, majority of the extra-articular fracture without signs of instability can be successfully managed with POP immobilisation for a period of 4-5 weeks followed by active physiotherapy, other types (Frykman’s III-VI) need surgical management that too with combination of surgical techniques namely augmented spanning external fixator with supplemented K-wire fixation or external fixation followed by fragment specific volar locking compression plate osteosynthesis.
MATERIALS AND METHODS
I have studied 50 cases of distal radius fractures classified using Frykman’s classification using combination of techniques namely augmented spanning external fixator application with K-wire supplementation and spanning external fixator application followed by volar LCP fixation in which external fixator had been used as a reduction tool in majority of the cases and external fixator had been removed after plate osteosynthesis. In some cases retained for a period of 4-6 weeks after plate osteosynthesis, which is followed by bone grafting. By early removal of external fixator, fixator-related issues like muscle tendon and nerve impalement, pin tract infection at the site of pin insertion can be minimised.
Outcome is determined by multiple factors and depends greatly on the soft tissue injury, patient factors and management and the adequacy of restoration of osseous and ligamentous relationships. In contrary to prolonged use of augmented spanning external fixator, which resulted in stiffness of wrist and finger, pin tract infection in both groups (whether external fixator application followed by K-wire fixation as well as external fixator application followed by volar plate osteosynthesis) external fixator can be removed at the end of 4 weeks while K-wires are still in place. Patient can be encouraged to move their fingers and wrist, allowed them to do minimal daily activities. With the use of external fixation in combination protocol radial length has been achieved by ligamentotaxis in majority of the cases (except in die punch intra-articular fracture) and in spite of ground-glass comminution - good reduction is always almost possible.
In highly impacted intra-articular die punch fracture-variant arthroscopy-assisted reduction followed by K-wire fixation and further maintained on external fixation. Need for bone grafting was almost negligible unless there was evidence of segmental bone loss from day 1. As in one case (open fracture) where external fixator was applied in order to maintain length of distal radius and soft tissues healing followed by bone grafting and VLCP fixation.
Finally, combination techniques instead of single technique offers various advantages in the management of complex comminuted fracture distal radius both in closed and open fractures.