*Manfred Infanger, *Erika Baum, +Daniela Grimm, *Wolfgang Ertel 

*Department of Trauma and Reconstructive Surgery, Charité-University Medicine Berlin, Germany
+Clinic Pharmacology and Toxicology, Charité-University Medicine Berlin, Germany

Address for Correspondence
Manfred Infanger, MD
Department of Trauma and Reconstructive Surgery
Charité-University Medicine Berlin,  Benjamin Franklin Campus
Hindenburgdamm 30, D – 12200 Berlin, Germany
Phone: 0049-30-84454848, Fax: 0049-3320386634
E-Mail:  Manfred.Infanger@charite.de

Background: The treatment of the distal intraarticular radius fracture is controverse discussed. Dorsal displaced, unstable and intraarticular compression fractures of the distal radius are commonly treated by external fixations, K wires or open reduction and internal fixation (ORIF) with dorsal plating. If instability criteria are encountered with bone grafting. All afore mentioned methods show significant morbidity and do not provide stability. Functional loss after immobilisation, secondary loss of reduction, pininfections, tendon ruptures and M.Sudeck are commonly encountered complications. These results after common distal radius fracture treatment and with special regard to interference with the surrounding soft tissue, have encouraged us to stabilize dorsal displaced unstable and intraarticular fractures through a palmar approach.
Methods: We describe the surgical treatment with approach, technique of new minimal invasive reduction an internal ankle stable fixation, our results obtained with this method over 1 year with 81 patients (AO classification A: 24.7%, B: 6.2%, C: 69.1%). Using this palmar approach and the minimal invasive open reduction technique, new internal fixation device utilizing the locking compression plate with fixed angle screws, we avoid the soft tissue problems associated with dorsal plating. We achieve also by intraarticular fractures stability for functional treatment and last but not least, we don’t need bone grafting.
Results: A follow up time of 12 months the fractures heated with highly satisfactory radiographic, and functional results, mean age 54,3 years. The overall outcome according to the Gartland and Werley score showed 49% excellent, 41% god, 9%fair and 1% poore results. DASH Score 15 points after 12 months (before trauma 6,8). Our experience indicates that all types of distal dorsal displaced and intraarticulare radius fractures can be anatomically reduced and fixed through a palmar approach without loss of reduction results.
Conclusions: This technique offers in our opinion several advantages: the stronger palmar cortex of the radius, no tuch from the vascularisation of the bone, possibility of minimal invasive reduction. The combination of minimal invasive reduction and stable internal fixation with preservation of the dorsal soft tissues rapid functional treatment resulted in rapid healing, no need for bone grafting no incidence of tendon problems in our study in young such as older patients

J.Orthopaedics 2006;3(3)e12

Introduction:

Distal radius fractures account for 17% of all fractures, the incidence is 2/1000/year making this fracture the most commonly seen traumatic fracture. The treatment is complicated by the broad range of encountered fracture types and the association with intraarticular ligamentary injuries. Especially dorsal  open reduction and internal fixation (ORIF) techniques show numerous anatomical and implant–related problems. The incidence of extensor tendon complications including irritations tendonitis, attrition and ruptures secondary to direct contact of these structures with dorsal plates is not negligible (3,13). A complication rate greater than 15% is reported for external fixators leading to unsatisfying results (9). Dorsal ¼ tube plates usually necessitate spongy bone grafts and prolonged cast immobilization as well as a longer hospital stay. K wires are not applicable to complex fractures and extend the range of complications with PIN infections or symphatic reflex dystrophy. Hahnloser et al (7) reports more than 15% complications in a study with Pi plates. Taking into account these commplications using common implants and a dorsal approach we opted for a palmar operation technique and the application of angle stable LCP-plates (10,12). This technique offers in our opinion several advantages: the stronger palmar cortex of the radial epiphysis with the additional anatomical advantage of non adherent neurovascular and tendinous structures. The major advantage seems to be the far superior soft tissue implant coverage through the pronator quadratus muscle as well as the overlying flexor tendons. The locking compression plate is very suitablefor the palmar approach due to its ability to securely stabilize dorsal displaced fractures with head locking screw, precluding any angutytory  instability (11).

This new concept “do it the other way” necessitates a reevaluation of traditional treatment concept of distal extension and intraarticular displaced fractures of the radius (12). As there are only few preliminary studies without long prospective follow up. We have designed a prospective study to evaluate the clinical outcome of palmar stabilized distal fractures with angle stable LC Plates. We describe the surgical treatment with approach, technique of new minimal invasive reduction and internal fixation, our results obtained with this method.

Method and materials  

From August 2001 – June 2004 (mean follow up 12 months) we included 81 patients in our prospective study. The distal radius fractures were classified according to AO (13). There were A (24,7%), B (6,2%), C (69,1%) fracture types. 34 men, 57 woman with an mean age 54,3 + 3,7 years (range 18 – 89 years). To evaluate the effectiveness of palmar fixed angle stable locking compression plate of distal radius fracturesinformed consent was obtained from all patients. Criteria for study inclusion were one or more instability signs. After an initial attempt of closed reduction radiographic evidence of a persisting deformity of >15° of angulation in any plane, >2mm of articular displacement, or >3mm radial shortening defined the fracture type as unstable. Open fractures were excluded.

The causes of injury were mostly falls on the outstretched hand  (73%), work related accidents (4%) , car accidents (1%) or sport injuries (12%). Before treatment 4 patients had developed median nerve  symptoms. Mostly all had developed severe soft tissue swelling and pain with limitation of finger mobility that persisted for 3 days despite anti inflammatory medication and elevation of the forearm.

Preoperative radiographic evaluation showed an average dorsal angulation of -21,4° average radial inclination of 11,8°, average incongruity (step off , gap) 3,5mm. The time interval between injury and operation averaged 1 – 10 days, 86% had regional plexus, 14% general anesthesy. Follow up exams comprised clinical and radiological evalutation and scoring after 2,4,6 weeks, 6 and 12 months, according Gartland/Werley (4) and DASH Score (5). Result and functional outcome was measured by wrist, finger and forearm motion with goniometer, Jamar dynamometer and compared with the contralateral side.

Surgical strategy

Palmar approach:

If patients could not be operated on day 1, closed reduction under local anesthesia and cast immoblisation was performed initially. Definitive surgical stabilization until day 10 was achieved in all cases. The operation was performed mostly under axillary plexus anesthesia with an arm tourniquet inflated to 250- 280mmHg. We chose a radiopalmar approach without routine incision of the flexor retinaculum for decompression of median nerve.  The skin incision was centered over the Flexor carpi radialis (FCR) tendon with a length of 5 to 6 cm including the option of entering the carpal tunnel. A longitudinal incision of the palmar and dorsal FCR tendon sheats which form the lower arm fascia, was performed. Radially oriented we carried out a blunt dissection between the fascia of the flexor digitorum muscles (FDS and FDP) and the flexor pollicis longus muscle (FPL). 

Here its very important to coagulate two nutrition vessels of the FPL tendon to avoid arterial bleeding after release of the tourniquet. Reaching the parona space under the flexor tendons, FCR, the median nerve and the remaining tendons are all hold ulnary. After exposing the pronator quadratus muscle we incised it radially to retract it to the ulnar side. Frequently seen destruction or interposition of the distal muscle region in between the fracture fragments neccessitate partial resection.

Direct visualization of the fracture is now easily achieved, without arthrotomy, preserving the palmar capsular structures. This allows additional ligamentotaxis for fracture reduction, a condition for minimally traumatic reduction.

Minimally traumatic reduction technique :

Our intention was to develop a minimally traumatic reduction technique without extended approach to the joint surface and without forced gross maneuver (Fig 1), to avoid soft tissue damage apart from the fracture elements with more consecutive destruction and danger of reflex dystrophy. The key point is the ligamentotaxis for this technique (12). Anatomical reduction is achieved by palmar introduction of 1.4mm K wires into the fracture gap, which are then used as levers to reduce the palmar dislocation. Performing gentle lever maneuvers the anatomical position of even severly displaced fragments can be reestablished easily and quickly. Ligamentotaxis assures correct reduction (6).

So you achieve restoration of the anatomic continuity of the palmar cortex, restore the radial length, ulnar inclination and mostly the articular congruency of the joint surface. If not, one can repeat the same technique using a 1.4 or 1.7 mm K wire to raise the joint with subtle lever movements from within the fracture gap.

 To achieve palmar tilt an additional dorsal reduction is frequently necessary. It’s obtained by dorsal percutaneous intrafocal insertion of K wires, moving them in distal direction until the right position is reached. A dorsal 3.5 mm oblique Titanium LC Plate is then applied palmarly, 3 cancellous screws are inserted into the proximal plate holes. Direct digital pressure and counter pressure as well as K wire manipulation of the distal fragments optimize the fracture reduction prior to devinite retention with 2-3 head locking screws in the distal oblique T part of the plate. Placement of the subchondral support pegs 2-3 mm below the subchondral bone is essential or optimal fixation, especially in cases with osteoporotic bone (Fig 2). By this procedure the angular stabilization of the fracture is secured. Optional dorsal bone grafting through a small dorsal incision is still possible, but was not performed in our study group. All K wires are then removed. In isolated cases involving C 3 fractures one or two K wires for joint surface reduction were applied percutaneously. The above described technique obviates any gross reduction maneuvers.

Operations were followed by cast immobilization for 0-4 weeks according to fracture type and bone stock quality.  

Statistical Analysis

Statistical  analysis  was  performed  using  SPSS  10.0. Results  are  expressed  as  mean  ±  SEM. Comparisons between multiple groups were assessed by one-way analysis of variance, including a  modified  least-significant  difference  (Bonferroni)  multiple  range  test  to  detect  significant differences between two distinct groups, which were further analyzed using the Mann-Whitney U test. The strength of the relationship between two variables was assessed by calculation of the product-moment correlation coefficient (r). Statistical significance was accepted at the level of  p < 0.05.

Results 

In all cases we saw a timely ( 6 weeks) fracture consolidation, no non- or malunions were encountered. The intraoperatively attained fracture reduction was good. The mean follow up time was 10,6 months. AO classification included: A (A2: 6,2%, A318,5%), B (B1: 1,2%, B2: 1,2%, B3: 3,7%),  C (C1: 14,8%, C2: 27,1%, C3: 27,2%). All fractures healed with highly satisfactory radiographic and functional results: Palmar tilt angle pre operatively –21,4°, 1- 3 days postoperatively 5,7°. Pre operatively radial shift 11,7°, 1-3 days postoperative dorsal shift 24,8°, pre-operative ulnar variance 3,5, 1-3 days post-operative ulnar variance 0 mm. There were no significant differences in palmar tilt angle, dorsal shift and ulnar variance between the immediate post-operative  In the follow-up course we saw one patient with loss of reduction in a severly comminuted C3 fracture and infection. No implant failure was seen. The overall outcome according to the Gartland and Werley score showed 41,2% excellent,47,1% good, 9,8%fair and 1,2% poore results. DASH Score was 15,5  points after 12 (before trauma 6,8). Mobility of the wrist is shown in the Tab 1. The following complications were observed (Fig 3) : infection 1, crps 1, rupture of FPL tendon 1 (wrong operation technique, see Fig 3).

Figure 3: A: Dislocated screw after insuffizient technique surgery (cicle). B: This follows in a Flexor pollicis longus ruptur (arrow)

Discussion :

The need for dorsal dissection from extensor sheats, periosteum, retinaculum, and vascular supply to dorsal metaphyseal fragments, need of bone graftingand different complications such as tendonitis, rupture of tendons, reflex dystrophy, immobilization damage or technique damage (long time fixateur externe)(1), secondary displacement due to loosening of the distal screws (seen in Pi Platesand osteoporotic bone)(2) encouraged us to develop an new concept treatment “do it the other way”. With the locked compressed angle stable Titan plate, we have an implant to perform a stabil internal fixation that would prevent fracture collaps. With the palmar approach we have an easy and fast access to the fracture. With our minimally traumatic reduction technique using manually guided K wires and ligamentotaxis we avoid gross interference with the surrounding soft tissue. Covering the plate completely the pronator quadratus muscle prevents the overlying tendons from any damage. So we had no complications with tendon irritations or reflex dystrophy. Compared with other functional treatments we had the same outcome of functional results (8).

Tab 1 : Functional wrist mobility 12 month after operation of distal radius fracture

In our experience we saw, that’s very easy to reduce A or B type fractures and perform the internal fixation. If the bone is osteoporotic or it’s an intraarticular C type fracture you have to consider the following hints to achieve a save and stable reduction result:

1.The distal pegs must be introduced as closely as possible to the subchondral plat of joint to prevent loss of reduction especially in osteoporotic bone or as a result of early functional treatment.

2.Before applying the plate, it’s important in intraarticular fractures to reach a good articular congruency of the joint surface (K wire through the fracture combined with ligamentotaxis = minimally traumatic technique), and a good reduction of the palmar cortex. This maneuvre restore good ulnar inclination and axial, radial length. Then you apply the T Plate with proximal screws. On the plate, with K wirs from dorsal or distal stable screws exactly behind the subchondral plate you can raise the palmar tilt in the right position. After that you fix the distal angle stable screws definitively.

3.For early functional treatment of intraarticular fractures it’s important that you fix the outer ulnar and radial fragments. Without this you must be aware of a secondary fracture displacement especially in the distal radio-ulnar joint.

Conclusion

Our results show that open reduction and palmar internal fixation with an angle stable dorsal T plate in combination with a minimally traumatic reduction maneuvre is an exellent possibility for the treatment of distal radius fracture, especially in dorsally displaced or intraarticular fractures.

In our learning curve we saw by intraarticular fractures you must consider the experience below: correct subchondral position of the screws, seize the radial an ulnar fragments. Our experience shows that because of the ligamentotaxis the use of minimally traumatic reduction maneuvers lead to best results in articular congruency and fracture reduction. "Don’t touch to much!"

Reference :

1. Basten K, Hansen M, Rommens PM. Die operative Behandlung der distalen Radiusfraktur durch T-Plattenosteosynthese. Akt Traumatol 29:137-143. 1999.
2. Carter PR, Frederick HA, Saseter GF. Open reduction and internal fixation of unstable distal radius fractures with a low profile plate: a multicenter study of 73 fractures. J Hand Surg Am 23:300-307. 1998.
3. Fernandez DL. Should anatomic reduction be pursued in distal radial fractures? J Hand Surg 2000.25B1-6.
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5. German G, Wind G, Harth A. Der DASH-Fragebogen. Ein neues Instrument zur Beurteilung von Behandlungsergebnissen an der oberen Extremität. Handchir Mikrochir Plast Chir 31:149-150. 1999.
6. Greatting MD, Bishop AT. Intrafocal (Kapandji) pinning of unstable fractures of the distal radius. Orthop Clin North Am 1993:24:301-307.
7. Hahnloser D, Platz A, Amgwerd  M, Trentz O. Internal fixation of distal radius fractures with dorsal dislocation: Pi Plate or two ¼ tube plates? A prospective randomized study. The Journal fo Trauma 47: 760-765. 1999.
8. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function: a prospective study of 73 consecutive patients. J Bone Surg. 82B:340-344. 2000.
9. Jupiter JB, Fernandez MD, Choon-Lai Toh et al. Operative treatment of volar intraarticular fractures of the distal end of the radius. J Bone Joint Surg Am 78:1817-1828. 1996.
10. Letsch R, Infanger M, Schmidt J, Kock H. Surgical treatment of fractures of the distal radius with plates: a comparison of palmar and dorsal plate position. Arch Orthop Trauma Surg 123: 333.339. 2003.
11. Orbay J, Fernandez D. Volar fixation for distally displaced fractures of the distal radius: A preliminary report. J of Hand Surg. 27:2. 2002.
12. Stahel P, Infanger M, Bleif M, Heyde C, Ertel W. Die palmare winkelstabile Plattenosteosynthese. Ein neues Konzept zur Versorgung instabiler distaler Radiusfrakturen. Trauma und Berufskrankheiten. 2004.
13. Zettl RP, Rucholtz S, Taeger G, Obertacke U, Nast-Kolb D. Postoperative Morbidität der operativ behandelten distalen Radiusextensionsfrakturen. Unfallchirurg 104 : 710-715.2001.

This is a peer reviewed paper 

Please cite as : Manfred Infanger: Palmar Reduction And Internal Fixation For Displaced Intraarticular Fractures Of The Radius With Locking Compression Plate: Operative Strategy Lead To Functional Treatment

J.Orthopaedics 2006;3(3)e12

URL: http://www.jortho.org/2006/3/3/e12

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