Kiran Kumar L1, Mukhergee G. S2, Manikumar C. J3, Ramachandrudu M4
BACKGROUND
Various treatment modalities have been described for the treatment of distal radius fractures each with its own merits and demerits. Most of the work done with percutaneous pinning has shown a significant residual stiffness of the hand and wrist. Our technique involves percutaneous pinning of the fracture and immobilisation in neutral position of the wrist for. This study's aim was to examine the functional outcome of percutaneous K-wiring of these distal radius fractures with immobilisation in neutral position of the wrist.
METHODS
A prospective study conducted on thirty adult patients with distal radial fractures treated at Department of Orthopaedics, Rangaraya Medical college, Kakinada between October 2013 to September 2015.
RADIOGRAPHIC EXAMINATION
Standard radiographs in PA and lateral views were taken for confirmation of the diagnosis and also to know the type of fracture. Oblique views were also taken in a few patients who had complex comminuted fractures. The fracture fragments were analysed and involvement of radiocarpal and distal radioulnar joints were assessed and classified according to the Frykman classification. Of the cases, 6(20%) of the fractures were type I, 2(6.6%) of type II, 3(10%) of type III, 6(20%) of type IV, 8(26.6%) of type V, 5(16.6%) of type VI, no cases of type VII and VIII.
SURGICAL PROCEDURE
The procedures were performed under regional anaesthesia in all cases. After sterile preparation and draping, fracture is reduced by traction and the reduction was evaluated fluoroscopically. A 1.5 cm incision given longitudinally (if needed) beginning at the radial styloid and proceeds proximally across to the medial metaphysis and diaphysis. At least two pins (1.6 mm Kirschner wire) were inserted and adequate reduction was confirmed on AP/LAT views under image intensifier. Another 1.6 mm K-wire percutaneously 90 degrees orthogonally to these wires starting at the dorsal rim of distal radius just distal to the Lister’s tubercle. The correct starting point confirmed with fluoroscopy and the wire is driven in a proximal and volar direction across the fracture site to engage the volar cortex of the radius proximal to the fracture. Additional wires were passed as necessary to secure additional fracture fragments. The wires were bent and cut leaving them superficial to the skin. The radial styloid incision was closed with interrupted absorbable sutures. A below elbow POP slab was applied. The pins were removed between 4 to 6 weeks. Postoperative pain and inflammation were managed using anti-inflammatory drugs, diclofenac sodium 50 mg twice daily, and serratiopeptidase. All patients were given oral ceftriaxone 200 mg twice a day for 5 days. Patients were asked to perform active finger movements from day one. Immediate postoperative check x-rays were taken in both PA and lateral views. The reduction of the fracture was confirmed and any displacements were noted. Patients were discharged after the 5th postoperative day and advised active exercises. On followup at 2nd, 4th, 6th weeks and, 6th, 12th, 18th months, the fracture union was assessed clinically by absence of tenderness and radiologically by bridging callus formation. Below elbow slab was removed by 4 wks. and patient is advised for active movement of wrist (Fig. 5 and 6). Then, K wires were removed without anaesthesia on an outpatient basis by 4-6 wks. The patients were advised to defer lifting heavy weights for further 4 to 6 weeks. After discharge, all patients were reviewed weekly for the first 6 weeks. Patients were assessed subjectively for pain at the fracture site clinically for tenderness, loosening of the pins, and any signs of infection. Pronation and supination of the forearm and active movement of the elbow and shoulder were advised throughout the period of healing. After the 6th week, physiotherapy was initiated. The range of wrist movements was recorded and any deformity was assessed.
RADIOGRAPHIC ASSESSMENT
Check x-rays were taken at 12 weeks to assess consolidation or collapse at the fracture site and to note any displacement. The fracture was considered united when clinically there was no tenderness, subjective complaints, and radiologically when the fracture line was not visible. Malunion was defined as more than 5 mm radial shortening, more than 15° of volar tilt or more than 10° dorsal tilt, and more than 4 mm of radial shift. 60 arthritic changes were graded according to the system described by Knirk and Jupiter. 61 regular followup was done at an interval of 6 weeks, 6 months, 12 months, and 18 months. The results were assessed at 3 months after the procedures using the DASH score.
RESULTS
The present study consists of 30 cases of distal radius fractures treated at Rangaraya Medical College, Kakinada between October 2013 to September 2015. All cases were closed fractures. All cases were followed up periodically during the period 2013 to 2015. In this series, 4(13.3%) patients were between 21-30 years, 10(33.33%) between 31-40 years, 13(36.6%) between 41-50 years, 5(16.66%) between 51-60 yrs. Out of 30 patients, 23 (76.6%) were male and 7 (23.3%) were females showing a male preponderance. Right side (dominant wrist) was involved in 18 (60%) patients and the left side involved in 12 (40%) patients. Most common mode of injury is road traffic accidents (63.33%) while fall on out stretched hand is only 36.66% In present study, the most commonly injured are manual labourers (76.66%). Surgery was done between 2-6 days from the day of injury in 29 (96.67%) patients as an elective procedure. Surgery was delayed up to 10th day in 1(3.33%) patient who had co-morbidities (hypertension and diabetes). In the present study, 18 (60%) patients had union within 2-3 months and 12 (40%) patients had union in 3-4 months There were no cases of delayed union or non-union. In present study, 27 (90%) patients had dorsiflexion within the normal functional range (minimum 45°), 29 (96.66%) had palmar flexion within the normal functional range (minimum 30°), 24 (96.66%) had pronation within the normal functional range (minimum 50°), 26 (86.66%) had supination within the normal functional range (minimum 50°), 20 (66.66%) had radial deviation within the normal functional range (minimum 15°), and all patients had ulnar deviation within the normal functional range (minimum 15°). 29 (96.66%) patients had grip strength more than 60% compared to the opposite side. 1(3.33%) had significant loss of grip strength (>60% compared to the opposite side). 7 patients had pain in the distal radioulnar joint. None patients had stiffness of the wrist. 1 patient (3.33%) had a superficial wound infection and two (6.66%) patients had pin tract infection. None of the patients had median nerve injury or arthritic changes as described by Knirk and Jupiter. There were no intraoperative complications. The study had 16.66% excellent, 80% good, 3.33% fair, and 0% poor result.
CONCLUSIONS
Kirschner wire fixation is a simple and reliable and effective method for maintenance of reduction in distal radius fractures especially in young adults. Unstable distal radius fractures, which may have a tendency to redisplace, plaster, pinning is a relatively effective method of fixation for reducible extra-articular fractures, simple intra-articular fractures that are nondisplaced, and in patients with good bone quality for restoration of preinjury anatomical alignment and there by the functional outcome in the management of distal radius fractures and allows early rehabilitation without jeopardising the fracture alignment. The functional end results have a direct relationship with the anatomical end results particularly in young adults though sometimes good functional results can be obtained even when anatomical results are poor due to innate mobility of wrist joint in elderly people. Pinning demonstrates good reproducible outcomes with minimal risk in appropriately selected fracture patterns. This technique can provide adequate fracture stability and soft tissue and vascular preservation in addition to minimal patient morbidity, which may facilitate a more rapid return to function compared with more invasive methods of treatment.
