A Comparative Study Of The Functional Outcome Of k-wire Fixation With Cast Cersus Ligamentotaxis In Management Of Distal End Comminuted Fracture Radius

Ashok K Shyam, Chetan Pradhan, Rajiv Arora, Gaurav Pardesi, Parag Sancheti, Atul Patil, Chetan Puram

Sancheti Institute of Orthopaedics and Rehabilitation
India.

Address for Correspondence:
Ashok K Shyam
Consultant Orthopaedic Surgeon and Research Associate,
Sancheti Institute of Orthopaedics and Rehabilitation, India
E-mail : drashokshyam@yahoo.co.uk

Abstract:

Introduction: Distal radius fractures are among the most common fractures of the upper extremity. In this study we compared the functional outcome of treatment of distal radius fractures with two different modalities, K-wire fixation with cast versus Ligamentotaxis.
Materials and methods: Prospective study of Sixty five cases (40 males and 25 females) of intraarticular fractures of distal radius (Frykman types 3 to 8) treated by percutaneus K wire-cast or external fixator. Out of which 46 patients (25 male and 21 female) underwent K wire-cast and 19 patients (15 male and 4 female) underwent Ligamentotaxis with AO external fixator with supplementing pinning. Patients were evaluated clinically and functionally using Gartland and Werley Scoring system.
Results: Mean age was 46.89 ± 14.75 years (range, 19 – 78 years) in K wire-cast group and 42.84 ± 15.60 years (range, 23 – 79 years) in Ligamentotaxis group. For the K wire-cast group the average Gartland and Werley score was 85.45 ± 8.14 (range, 60-100 points) and average grip strength as measured by hand dynamometer was mean 86.41 ± 8.73 % (range 60-100 %) of the normal hand. Average Gartland and Werley score for the Ligamentotaxis group was 83.03 ± 9.73 (range 50 – 97.5 points) with average grip strength of 83.16± 9.01 % (range 65-95 %). With an exception of reflex sympathetic dystrophy, which is an important predictor of poor outcome, most complications were minor and did not affect the end-result significantly.
Discussion: There was no significant difference in results of K wire-cast and Ligamentotaxis, though the complication rates (pin tract infection) were slightly higher in external fixator group. Thus both methods work well for selected distal end radius fractures with acceptable clinical, functional results and low complication rates.

J.Orthopaedics 2010;7(3)e3

Keywords:

distal end radius fracture; K wire and cast; ligamentotaxis; Frykman classification; Gartland and Werley score

Introduction:
 

More than 195 years have passed since Colles described a fracture of the distal end radius (DER).¹ DER fractures are among the most common fractures of the upper extremity. Comminuted fractures of the DER are caused by high-energy trauma in young patients and by low-energy trauma in the elderly, and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments.^2-9

 Management of comminuted DER fractures continues to be a therapeutic problem and challenge for the orthopedic surgeon. Impacted intra-articular fractures have generated interest because of the failure to reduce these fractures to within 2 mm of articular congruity, has been shown to lead to symptomatic post-traumatic arthritis.¹⁰ In a retrospective study of intra-articular fractures of the distal radius in young adults, Knirk and Jupiter¹¹ found that if the fracture healed with greater than 2mm of residual articular incongruity, 100% of these patients had radiographic evidence of arthritis and two-thirds were symptomatic. The fact that these articulations are not weight-bearing does not exclude them becoming a major source of disability if the articular anatomy is not restored. Lafontaine et at¹² studied 112 consecutive DER fractures treated conservatively and suggested five factors that could relate to instability following fracture reduction: Initial dorsal angulation > 20 degrees, Dorsal metaphyseal comminution, Intra-articular disruption, Associated ulnar fracture, and Patients over 60 years of age with sever osteoporosis.

Altissimi et al¹³ further observed in a clinical review of 100 distal end radius fractures , that the severity of initial radial shortening was the most reliable indicator of instability. DePalma et al¹⁴ advocated that every attempt be made to restore normal anatomy. He suggested that a poor result was inevitable if "a residual dorsal tilt of the radius > 30 degrees and loss of the inward tilt of the articular surface of the radius exceeding 3mm" was found. Bio mechanical cadaveric studies support this clinical observation.¹⁵ It has been shown that shortening of the distal radius by small amounts (2.5mm) and/or the residual dorsal tilt results in a significant increase in the axial load transmitted to the ulnar shaft.^16,17 Also the dorsal tilt produces DRUJ incongruency and tightens the interosseous membrane, causing limitation of forearm rotation.¹⁸ Thus, this increased ulnar load leads to degenerative arthritis and pain on the ulnar side of the wrist.¹⁹

There are various methods of reducing and maintaining the reduction of the fracture published in the literature, which include the K-wire and cast, percutaneus pinning, Plaster of Paris cast, open reduction with internal fixation and external fixator or distractor using the principles of ligamentotaxis. Percutaneus pins to provide additional stability is minimally invasive and has shown to give good results for extra-articular or simple articular fractures.²⁰ This however may not be strong enough to prevent collapse. The need for application of cast may lead to so called fracture disease and there are chances of pins getting infected inside the cast.²¹

In Ligamentotaxis the traction applied by the external fixator produces tension in the intact ligaments and soft tissue surrounding the bone which not only acts as a counter traction but also aligns the displaced bone fragments. This tissue tension is maintained over a period of time by external fixator. This modality of treatment has been shown to be effective in the surgical management of unstable, intra-articular fractures of the distal radius but has also been linked with an unacceptably high rate of complications in some series with most important being collapse of the fracture.^22,23 This collapse may be secondary to stress relaxation of the soft tissues over a period of time.²⁴ To counter this complication adjunct fixation with K wires is advocated. In vitro cadaveric studies have concluded this method to give stability similar to volar plating²⁵ while clinical studies have reported favorable outcomes.^26,27

Both the above mentioned techniques have been studied separately and no comparative study is available. In this study we aim to compare the functional outcome and complications associated with treatment of DER with these two modalities.

Materials and Methods:

Prospective study of Sixty five cases of various fractures of the distal radius was treated by percutaneus K wire-cast and external fixator from July 2008 to April 2009. Frykman classification system for distal end radius fractures was used in this study.²⁸ Subjects with age >18 years, Frykman class type 3 to 8 and only isolated injuries were included while volarly displaced fractures, fractures with intra-articular comminution were excluded

The series includes 65 patients 40 males and 25 females. Out of which 46 patients (25 male and 21 female) underwent K wire-cast and 19 patients (15 male and 4 female) underwent Ligamentotaxis with AO external fixator, with or without supplementing pinning. There were 28 Left (20 for K wire-cast and 8 for Ligamentotaxis) and 37 right wrists (26 for K wire-cast and 11 for Ligamentotaxis). The youngest was 19 while the oldest patient in this series was 79 years of age.  The aims of treatment are to restore anatomy (radial length and angles, articular surface congruity, DRUJ) and to regain function. Key articular fragments are identified: dorsoulnar, palmar-ulnar, hyperextended palmar fragment, radial styloid, and impacted articular fragments. The three column concept helps in developing an operative strategy for reduction and stable fixation of the respective articular fragments. The intermediate column is the key to the radiocarpal joint surface.

Surgical procedure:
Ligamentotaxis: A tourniquet was used at the discretion of the surgeon. The external fixation group underwent closed reduction with the placement of two pins in the base of the second metacarpal and two in the distal third of the radius in a percutaneus or open surgical manner. After application of the fixator if acceptable alignment had been achieved, percutaneus K-wires were placed to hold the reduction. The hand and forearm are placed in a bulky soft dressing. No cast or splint is needed. The fingers are left free for a full range of motion.

Percutaneus pinning and cast: We used two or three Kirschner wires placed across the fracture site, generally from the radial styloid, directed proximally and from the dorsoulnar side of the distal radial fragment directed proximally. Above elbow cast in supination was applied in these patients

In Ligamentotaxis group Passive and active range of motion exercises were commenced the day of operation and on the 1^st post-operative day, the patient began training in activities of daily living.  Twice a day swabbing of the pin sites with hydrogen peroxide was done for the first week. 10th day after the surgery, sutures are removed and pin site care is continued. The fixation device is left in place for an average 6 weeks (range 4 to 8 weeks) until both clinical and radiographic evidence of healing is seen, depending upon the surgeon's evaluation of the post-operative radiographs. At this point, the external fixator is removed under sedation, and a volar removable thermoplastic splint is given for 2 weeks. This splint is removed regularly throughout the day for exercise. Eight to ten weeks postoperatively, strengthening is begun and ultimately, work and sports, hardening exercises are added.

For K-wire cast group, Postoperative arm elevation is advised to alleviate swelling. Careful watch for distal neurovascular compromise and tightening of plaster is observed. Follow up is advised after 1 week for examination of cast. If cast is loosened then reapplication of cast was done. At post op 3 weeks above elbow cast is converted into below elbow cast. The cast is continued for an average 6 weeks (range 4 to 8 weeks) until both clinical and radiographic evidence of healing is seen, depending upon the surgeon's evaluation of the post-operative radiographs. At this time the K-wires were removed at an average 4 weeks (range 4 to 6 weeks). After cast removal gentle wrist Range of motion exercises started. 8 to 10 weeks postoperatively, strengthening is begun and ultimately, work and sports, hardening exercises are added.

Follow up protocol:
All patients were called for follow up visits at 3 weeks, 6 weeks, 3 months, 6 months, 9 months and one year. The data was quantified with the system of Gartland and Werley²⁹ in which clinical and radiographic data are used. The quality of recovery was determined by range of motion, grip strength, peri and post-operative complications, patient satisfaction and radiographic evaluation by the modified Gartland and Werley's Wrist Grading System in which equal emphasis is placed for a maximum possible findings — each with 50 points for a maximum possible score of 100 points. Antero-posterior and Lateral radiographs of the injured wrist were used for various measurements. The radiographs made at the time of the latest follow-up were evaluated for joint congruity. Osteoarthritis of the radiocarpal and the distal radio-ulnar joint was graded according to the criteria of Knirk and Jupiter³ at the latest follow- up evaluation with Grade 0- No osteoarthritis; Grade I- Slight narrowing of the joint space; Grade II- Marked narrowing of the joint space with osteophytes formation; Grade III- Full thickness loss of articular cartilage   with formation of cysts and osteophytes.

Observations and Results:
For the K wire-cast group the mean age was 46.89 ± 14.75 years (range, 19 – 78 years), with 21 females and 25 males (Table 1). The patients were followed up for an average of  11.85  ± 3.69 months (range,  6– 18 months).The average time required for union of  fracture in our series was 7.47 ± 0.99 weeks (range,6.2 - 11.4weeks), Post operative average flexion 67.07 ± 9.64 degrees (range 50-80 degrees), average extension 73.15 ± 12.13 degrees (range 40-90 degrees), average Radial deviation 20.43 ± 3.63 degrees (range 15-25 degrees), average Ulnar deviation 29.57 ± 4.45 degrees (range 20-35 degrees),  average pronation 73.48 ± 10.64 degrees (range 50-90 degrees), average Supination 76.63 ± 9.07 degrees (range 50-90 degrees), average grip strength as measured by hand dynamometer was 86.41 ± 8.73 % (range 60-100 %), average Gartland and Werley score was mean 85.45 ± 8.14 (range, 60-100 points).

Table 1: Demographical details of the entire sample population

For the Ligamentotaxis group the mean age was 42.84 ± 15.60 years (range, 23 – 79 years), with 4 females and 15 males. The patients were followed up for an average of  11.21  ± 3.98 months (range,  6– 17 months).The average time required for union of fracture in our series was 7.17 ± 0.69 weeks (range, 6.5 – 7.6 weeks),. Post operative average flexion 63.95 ± 8.91 degrees (range 40-75 degrees), average extension 69.47 ± 11.17 degrees (range 40-85 degrees), average radial deviation 18.16 ± 3.42 degrees (range 15-25 degrees), average ulnar deviation 27.11 ± 4.81 degrees (range 15-35 degrees), average pronation 70.00 ± 9.57 degrees (range 50-90 degrees), average supination 74.74 ± 10.07 degrees (range 50-90 degrees), average grip strength as measured by hand dynamometer 83.16± 9.01 % (range 65-95 %),average Gartland and Werley score was mean 83.03 ± 9.73 (range 50 – 97.5 points). There was no significant difference in postoperative flexion (p value 0.229), extension (p value 0.224), ulnar deviation (p value 0.052), Pronation (p value 0.159) and supination (p value 0.270) between two groups. The P value 0.022 for postoperative radial deviation between two groups was significant however there was no difference in the functional scoring (Table 2). Figure 1 and 2 show two patients of this series treated with either technique.

Table 2:  Statistical comparison of various clinical variables using unpaired t test.

Figure 1: Twenty two year male having frykman’s class VI distal fracture treated with K wire and casting with good functional outcome at one year follow up

Figure 2:  Twenty seven year old male having Frykman class VIII fracture treated with external fixator having excellent functional outcome at one year follow up

Fifteen of the 46 patients (32.6 %) treated with an K wire-cast and 2 out of 19 patients (10.5 %) treated with external fixator supplemented with percutaneus pinning were rated having excellent results according to the modified Gartland and Werley scoring system. Rest is as seen in table I

There was 1 poor result out of 46 (2.2 %) in K wire cast group in 78 year old lady with severe osteoporosis and pin tract infection at one year follow up. One poor result out of 19 (5.3 %) in Ligamentotaxis group -  Reflex Sympathetic Dystrophy was noted in one case in 67 year old male and was treated conservatively. The average grip strength exceeded 80% in comparison with that of the contralateral, unaffected hand, with a range of 60 to 100%.

Complications:
There were 4 pin tract infections in K wire cast group and 7 pin tract infection in Ligamentotaxis group; which resolved with local wound care and oral antibiotic therapy. No loss of reduction was observed. No pin breakage, iatrogenic fractures, persistent neuropathy was observed. Patient satisfaction was consistently high, although a variable degree of morning stiffness in the wrist was experienced in older patients. All of these patients returned to their former activities of daily living with no significant limitations, and no secondary operations have been required. With an exception of reflex sympathetic dystrophy, which is an important predictor of poor outcome, most complications were minor and did not affect the end-result significantly.

Discussion :

Distal end radius fractures are one of the most common and most challenging fractures. Closed reduction with K wire fixation and cast is one of the most frequently used minimally invasive methods while Ligamentotaxis offers advantage of neutralization of the axial load achieving indirect reduction . We studied both these methods with respect to their outcomes and complications. 

The two main operative procedures for an unstable distal end radius fractures are closed reduction and internal fixation and open reduction and internal fixation (ORIF). Strohm et al³⁰ showed that K wire cast is more superior than cast only, in treatment of distal end radius fractures. Among the closed methods external fixation allows controlled distraction and more accurate positioning than pins and cast, however there were more complication associated with external fixation than K wire cast. Kaempfie³¹ et al discovered that an increase in the duration and amount of distraction of distal radial fractures treated by external fixation adversely affected the final range of motion of the wrist, function, grip strength and the level of pain. In our series the Ligamentotaxis group had significantly less radial deviation (p <.05) than compared with the K wire group. Also the range of ulnar deviation approached statistical significance (p – 0.052). The other factors like the union time and range of flexion extension and pronation - supination were similar in both the groups.   We successfully restored radial length, angulation and articular congruity in most cases. The average residual dorsal angulation was 10 degree. Failure to correct this deformity fully confirms the conclusion by Bartosh and Saldana³² that ligamentotaxis alone is unreliable in reestablishing radiopalmar tilt and so recommend using percutaneus K wires along with ligamentotaxis. All of these patients returned to their former activities of daily living with no significant limitations, and no secondary operations have been required to date. Our results are comparable with review done by Handall et al³³ in which two trials comparing a bridging (of the wrist) external fixator versus pins and plaster found no significant differences in function or deformity. Thus, K wire-cast and external fixation supplemented by percutaneus pinning  both were found to be a safe and reliable method for treatment of comminuted distal radial fractures and the decision generally lies with the surgeon to choose the appropriate treatment modality for individual patients. Even though some motion is lost, 75% recovery of mobility and grip strength can be anticipated. The complication rates were quite low in our series with pin tract infection most common. Careful assessment of the fracture pattern, patient selection, meticulous surgical technique, appropriate choice of fixation device and pins, recognition the need for augmentation with limited internal fixation and aggressive post- operative rehabilitation provide foundation for successful management of these fractures while minimizing complications.

Our study has few shortcomings. The small sample size and unequal patient distribution in the two groups are the main issues; however we believe that the study offers useful insights for management of distal end radius fractures.

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This is a peer reviewed paper 

Please cite as: Ashok K Shyam: A Comparative Study Of The Functional Outcome Of k-wire Fixation With Cast Cersus Ligamentotaxis In Management Of Distal End Comminuted Fracture Radius.

J.Orthopaedics 2010;7(3)e3

URL: http://www.jortho.org/2010/7/3/e3

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