Orthopaedic Journal of MP Chapter

Care was taken to avoid tendon injury or penetration. After that fracture was reduced and confirmed fluoroscopically and the fixator frame application was completed (Figure 1).

Postoperatively, patient’s limb was kept elevated and active finger movements encouraged. Further shoulder, elbow and wrist, active and passive movements were started from day one as per the American Academy of Orthopaedic Surgeons Guidelines [12]. Patients were followed up regularly (2, 4, 6 and 16 weeks).

Patients were assessed both clinically and on radiographs. The external fixator was removed at 6 weeks, when bridging callus was seen in at least three cortices in two views and clinically there was no pain / tenderness at fracture site. Objective clinical assessment included range of motion of the wrist as measured in all the six planes with the help of a goniometer and grip strengths measurement on both sides.

Standard anterio-posterior and lateral X-rays were taken at each follow up to assess the position of the fracture fragments, union status and for measurements of parameters by like radial length, radial angle and volar angle. DASH questionnaire was used for functional assessment. Complications, if any were noted and suitably dealt. The data thus obtained were statistically analysed using Chi square and student t-test on SPSS (Statistical Presentation System Software) for Windows version 17.

Results

Out of 22 patients enrolled, 13 were males and 9 females with a dominant hand injury in 16, 4 had injury in non-dominant limb and bilateral involvement in 2 cases. The average age of patients was 47.27 years.

Out of 22, 3 (13%) had a Frykman’s type I fracture, 9 (41%) had a type II, 4 (18%) had type III, 4 (18%) had type IV injury and 2 (10%) had type VI injury. Four had associated ulnar styloid fracture. The Flexion-Extension arc at the different follow up was analysed, there was an average change from 73° (36.2° flexion and 32.7° extension) at the 1st follow up at 2 weeks to 147° (73° flexion and 74° extension) at 16 weeks. Similarly the improvement in Pronation-Supination arc was 107° (48° supination and 59° pronation) at 2 weeks, which improved to 164° (79° supination and 85° pronation) over the period of 16 weeks.

Adduction and Abduction improved from 22° and 8° respectively at 2 weeks to 32° and 11° respectively at 16 weeks post-operative (Figure 1).

Improvement in range of movement improvement in the patients on 4th week and 16th weeks on applying the paired t-test reveals a statistically significant change in the outcome with less than 0.0001 for Flexion – Extension, 0.004 for Abduction – Adduction and 0.001 for Pronation – Supination (Figure 2). The average radial angle restored post operatively to 18.93° (range 12.7° to 25°). The average radial length restored to 11.68 mm (range 8 mm to 14.4 mm).

The overall functional outcome as assed with DASH scoring system has showed statistically significant improvement, with score improving from 4 weeks to 4 months. The most common complications encountered were wrist pain and radial subsidence. In addition, two cases have pin tract infection and subsequent loosening, which was treated by dressing and antibiotics. The incidence of wrist pain was 18.18% and located on the ulnar side noted during performance of heavy activity. The incidence of pain, as reported in literature varies from 10% to 57% in different studies [12,19,20]. Three of our four patients who had associated ulnar styloid fracture continued to have wrist pain even after 16 weeks on ulnar side.

There was loss of the radial height in 4 patients (range 2 to 6 mm) with maximum of 6 mm shortening in a 75 years old male, graded as grade 3 with articular incongruities according to the Kirk and Jupiter [21]. This patient also had pin tract infection leading to swelling and progressing into Sudeck’s osteodystrophy with poor functions requiring additional management. This is probably attributable to the fact that fixator configuration was supported by indigenously single bent rod connecting pins in two planes, and with early rehabilitation, excessive stress on the pins in osteoporotic bone lead to loosening, fixation failure and radial collapse.

Extensor tendon injuries are common complications of the non-bridging fixators due to the fact the distal pins go through the extensor compartment of the wrist as reported to be 10% by McQueen and 6.7 % by Krishnan [1, 22]. In our study we noted going through the tendons of extensor indicis on one occasion, but the complication was diagnosed on the table by doing passive finger and thumb movement (table 1). These patients developed pain on movement which subsided in 2 weeks. None of the patient had tendon rupture in our study. The reported incidence of tendon rupture in distal radius fracture is 0.9% due to the bony spikes at the distal fracture fragment [23].

In our series, finger stiffness and sudeck’s osteodystrophy was seen in less than 5% (one case), who was non-compliant for the physiotherapy, the subsequent stiffness persisted even at 6 weeks. By the 16 weeks follow up the stiffness was reduced but the grip strength was nearly 75% of the dominant hand. The incidence of finger stiffness and Sudeck’s Osteodystrophy reported in literature was is 0 to 31% and 0 to 6 % respectively [24,25] which increases with increasing traction.