A Prospective Study Of Functional Outcome Following Intra-articular

Fracture Of Distal Radius In Adults

-- A Comparison Between External Fixation And Internal Plating

Xu WeixinLim Beng Hai

Alphonsus CheongChloe Seow

Introduction

External fixation and internal plating are two common techniques used in the local hospitals for treatment of unstable distal radius fracture in the adults

Most of the studies on results of surgical intervention reported encouraging results (Catalano et al. 1997 J Bone Joint Surg 79A:1290-302 ; Rikli et al 1996 J Bone Joint Surg 78B:588-92; Jakim et al. 1991 J Bone Joint Surg 73B:302-6)

However, they were not done in a prospective, randomized manner

Introduction

Most of the randomized studies were comparing the results of casting with surgical treatments in a mixed-age population (Ludvigsen et al. Acta Orthop Scand 1997; 68: 225-258; Howard et al J Bone Joint Surg 1989; 71B: 68-73; Huchinson et al J Hand Surg 1995; 20B: 365-372; Stein et al Acta Orthop Scand 1990; 61:453-456)

This study evaluated the external fixation and internal plating for the treatment of unstable distal radius fractures in a randomized prospective manner

Aim of Study

To compare the functional outcomes following external fixation and internal plating in the management of unstable intra-articular distal radius fractures, using both subjective and objective outcome measures.

Methodology

Inclusion criteria Age: 16-60 Patients with closed comminuted intra-articular fr

acture of the distal radius (AO classification of C2-C3) requiring surgical fixation

Operation performed within three days post-injury

Methodology

Exclusion criteria Pathological fracture Old fracture on the same extremity Patients who are not likely to follow up to one

year Complicated cases which requires to following

different rehabilitation protocols (i.e. flap resurfacing, tendon repair/reconstruction and replantation done on the same injured extremity)

Methodology Written consent was obtained from the patients The subjects were randomly allocated to the two

different surgical treatment groups by the randomization envelop system

The patients were referred to hand therapy 2 days after operation following standardized rehabilitation intervention

Pre-op (case 1)

Pre-op (case 2)

Post-op (case 1)

Post-op (Case 2)

MethodologyDemographic information

Ext Fix Int Plate

Number 17 (M:14 F:4) 22 (M:18 F:4)

Mean age 37.6 42.6

R hand dominance

17 (100%) 22 (100%)

R side injury 8 (47%) 9 (41%)

MethodologyOccupation

Ext Fix Int Plate

Sedentary 7 (41%) 11 (50%)

Manual 10 (59%) 11 (50%)

Methodology

Ethnic distribution (int. plating): Chinese: 16 (72%) Malay: 2 (5%) Indian: 3 (14%) Others: 1 (5%)

Methodology

Ethnic distribution (Ext. fixation): Chinese: 13 (76%) Malay: 0 (0%) Indian: 3 (18%) Others: 1 (6%)

Methodology

Functional evaluation:outcomes were collected at 2 month, 3 month, 6

month and 1 year post injury active range of motion of the wrist and

forearm grip and pinch strength patient rated wrist evaluation (PRWE) modified Green and O'Brien scoring system.

Methodology

Standardized rehabilitation protocols were followed after both surgical interventions

Ext Fix Int Plate

0-4 weeks Finger AROM; C-bar splint if necessary

Interval wrist splint 2 weeks; gentle wrist AROM

4-6 weeks Wrist splint for 2 weeks after R/O ext fixator; gentle wrist AROM

Continue wrist AROM & PROM; gentle strengthening

Methodology

Ext Fix Int Plate

6-8 weeks Continue wrist AROM & PROM

Continue strengthening

8-12 weeks Start stretching & Strengthening

Work conditioning

12 weeks onwards

Work conditioning

Results

00.10.20.30.40.50.60.7

2 months 3 months 6 months 12 months

int plating

ext f ixation

Mean PRWE Score Over Time

Results

60

65

70

75

80

85

6 months 12 months

int plating

ext f ixation

Mean Modified Green and O'Brien Score Over Time

Results

Pearson Chi-square test were used, and showed no significant differences between groups with regards to age, hand dominance, fracture side, cause of injury, occupation and associated injuries (P>.05)

One-way ANOVA test were used to compare the functional outcomes between the two groups (P<.05) Dorsi-flexion at 2-month post injury (P=.029) Radiual deviation at 2-month post injury (P=.002) Radiual deviation at 3-month post injury (P=.001)

No statically significant deference was detected from other variables

Discussion

Both internal plating and external fixation showed good functional results for treating unstable extra-articular distal radius fracture

Internal plating provides earlier active rehabilitation and earlier return of certain range of motion of the wrist as compared with external fixation

Further data analysis is need to look into radiographic characteristics and complications between these two groups