Department of Orthopaedics,, Sir HN Reliance Hospital, Girgaon, Mumbai

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1 Orthopaedics Original Article International Journal of Clinical And Diagnostic Research ISSN Volume 5, Issue 6, Nov-Dec 2017 CONSERVATIVE VERSUS VOLAR PLATING FOR TREATMENT OF DISTAL END RADIUS FRACTURES- A PROSPECTIVE RANDOMIZED STUDY Vikas Jain 1*, Atul Patil 2, Siddharth Shah 3, Gaurav Sharma 4, Lokesh Naik 5 Abstract Introduction: Fractures of distal end radius continues to leave orthopaedic surgeons with dilemma with no proper consensus. The aim of the present study was to compare the radiological and functional outcome of these fractures using the conservative and operative modality (volar plating). Material and methods: A Prospective randomised study was conducted between May 2014 and May 2015 comprising of 60 patients. Group A (n=30) were treated with casting and Group B (n=30) were operated with volar plating. Results: As per Frykman s classification system, type 3 was the most common with 29 (48.3%) cases followed by type 1 with 18 (30%) cases. The average duration of surgery was 94±5.8 mins in patients with group B. The average radiological union was 9 ±2.3 weeks in group A and 8±3.6 weeks in group B patients. Parameters like range of movements, grip strength, radial inclination, volar tilt were better in operative group which were statistically significant (P<0.0001). Conclusion: Although it was a small study, yet it can be stated that plating gives a better functional and radiological outcome as compared to casting with fewer complication rates, early mobility and better anatomical reduction. Author Affiliations: 1, 4, 5 Department of Orthopaedics,, Sir HN Reliance Hospital, Girgaon, Mumbai 2 Department of Orthopaedics, Sushrusha Hospital, Mumbai, 3 Department of Orthopaedics, Nawale Hospital, Pune Keywords: Distal radius, Cast, Volar plating

2 *Corresponding Author: Dr Vikas Jain Department of Orthopaedics Sir HN Reliance Hospital, Girgaon, Mumbai. Mobile: INTRODUCTION Distal end of radius fractures are the commonest fractures occurring in upper extremity that account for 17% of all upper limb injuries [1]. The treatments of these fractures have been an issue of debate ever since its first encounter. Different modalities have been propped for the same namely closed reduction and cast application, Closed reduction with K wires, External fixation, Internal fixation with plating and also nailing. Conservative methods has always been the mainstay for treating these injuries since past many decades. However, complications like malreduction, collapse at the fracture site and stiffness has led to the development of new operative techniques [2.3].The decision for a specific modality is usually multifactorial depending upon patient s age, occupation, likelihood to return to work, fracture characteristics such as displacement, intraarticular extension, fracture communition and condition of the soft tissues [1,4-6]. These fractures are a result of high-velocity injuries in young adults whereas a trivial trauma can lead to these injuries in geriatric age group. With the lack of consensus for treating these injuries we decided to compare the functional and radiological outcome in fractures of distal end radius in geriatric age group. Material and Methods: A Prospective randomised study was conducted at a tertiary care hospital between May 2014 and May 2015 comprising of 60 patients presenting to the orthopaedic outpatient departments with distal end radius fractures. The inclusion criteria were patients with more than 60 years of age with closed intra and extra-articular distal end radius fractures, patients with low demanding profile. Patients with compound fractures, pathological fractures, polytrauma patients were excluded from the study. Once the patients met the inclusion criteria, a thorough clinical, radiological and haematological investigation was done for (Fig. 1). Frykman s

3 classification [7] was used to assess the fracture geometry and type. Primary treatment was given in the form of below elbow plaster slab. The selection of the treatment group was done on the basis of randomization using the closed envelope technique. The patient were asked to open the closed sealed opaque envelope just prior to the surgery following which, the final decision was taken. At the end of the study, there were 31 patients which were treated using the plaster technique (Group A), whereas 30 patients were operated using the variable angle volar plating of Zimmer (USA) (Group B). Well written informed consent was taken from all the patients. Ethical committee approval was obtained before the commencement of the study. Regular follow-up was done for ll the patients at 1,3,6,12 and 24 months respectively. Final outcome was calculated using the Lidstrom criteria [8] as excellent, good, fair and poor using the degree disability, deformity, grip strength, range of movements, activities of daily living and pain. Surgical Technique- Closed Reduction and Cast application- All the patients were operated under General anaesthesia. In supine position, first, the fragments were disimpacted using the traction-countertraction technique. Manual pressure was then applied to correct the dorsal tilt and displacement. The hand was then kept in ulnar deviation with the corrected volar tilt. Final reduction was then assessed in C-arm image intensifier in both the orthogonal planes. A below elbow plaster cast was then given with forearm in neutral position and hand in ulnar deviation (Fig. 2). The affected limb was kept in a sling for 1 week after which it was discarded. The cast was kept for a period of 6 weeks in total. A check x-ray was done just after the surgery top check for the displacement and then at 1 month and at the time of cast removal to assess the union. Open reduction and internal fixation with Volar plating- All the patients were operated using general anaesthesia and interscalene block. Three doses of intravenous third generation cephalosporin was administered (one just before the induction and two doses postoperatively at an interval of 12 hours). All the patients were operated under tourniquet coverage at a pressure of 250mm of Hg. A Trans-Flexor carpi radialis (FCR) volar approach [9] was used in all the cases. A vertical skin incision of 7-8cm was taken in all the cases starting from the distal palmar crease along the line of the FCR tendon. The tendon

4 sheath was incised and the FCR was mobilized ulnarly. The tendons of Flexor pollicis longus, flexor digitorum superficialis and the profundus tendons were retracted and mobilized towards the ulna. The pronatus quadratus was subperiosteally exposed in deep dissection and released carefully along the radial side. A cuff of the tendon was left to facilitate the later closure. Brachioradialis tendon was released only in case of difficult reduction. The fracture site was then exposed and temporary reduction was then attempted. A 3 or 4 hole plate was then applied in the buttress mode just proximal to the watershed line. Adequate reduction was obtained and checked in C-arm image intensifier in both the orthogonal planes (Fig. 3). Wound was then closed over layers and compression dressing was done. Similar standard pain control protocols was followed in all the patients. Mobilization in the form of finger and wrist movements were started after the check dressing on post-operative day 2. Patient was asked to use a sling post-operatively for a period of 1 week following which it was discarded. Suture removal was done after 2 weeks. Patients were asked to resume duties within 1 week of surgery and strenuous work was permitted after the radiological union was seen between 3-5 months. Results: The mean age of the patients was 63±3.4 years. There were 32 (53.33%) males and 28 (46.67%) females in the present study. 36 (60%) patients had left sided involvement while 24 (40%) patients had fracture on their right side. The commonest mechanism of injury was domestic fall comprising of 47 (78.3%) cases followed by road traffic accident and fall from height with 12 (20%) and 1 (1.67%) case respectively. As per the Frykman s classification system, type 3 was the most common comprising of 29 (48.3%) cases which was then followed by type 1 with 18 (30%) cases. The average duration of surgery was 94±5.8mins in patients with group B. The average radiological union was 9 ±2.3 weeks in group A and 8±3.6 weeks in group B patients. The mean range of movements and grip strength were as shown in Table 1. The comparison of radiological parameters amongst both the groups were as shown in Table 2. There was 6 (20%) case with loss of reduction in group A which later went in malunion. Two (6.66%) cases in group A and 1 (3.33%) case in group B had post-operative Sudeck s osteodystrophy which were treated conservatively. Two (6.66%) cases in group B had superficial infection

5 which responded well to oral antibiotics. Three (10%) cases in group A and 1 (3.33%) case in group B had carpal tunnel syndrome. One (3.33%) case from group A had preoperative median nerve symptoms while the others were treated conservatively. One (3.33%) case from group B underwent carpal tunnel surgery following which he was completely asymptomatic. (Table 3). The final outcome was calculated using the Lidstrom s criteria (Table 4). Table 1: Comparison of wrist range of movements and grip strength at 24 months followup Parameter Group A n=30 Group B n=30 P Value Palmar Flexion 79.53± ±2.98 < * Dorsal Flexion 83.04± ±2.42 < * Radial Deviation 65.87± ±3.74 < * Ulnar deviation 69.32± ±3.01 < * Pronation 33.01± ± Supination 42.01± ± Grip strength 74.14± ±6.34 < * *- statistically significant Table 2: Comparison of Radiological Parameters at 24 months Parameter Group A n=30 Group B n=30 P value Radial inclination 15.21± ±0.58 < * Volar tilt 5.14± ±1.23 < * Variance 0.31± ±0.24 < Radial length 7.14± ±0.35 < * *- statistically significant

6 Table 3: Complications Parameter Group A n=30 (%) Group B n=30 (%) Superficial infection 0 2 (6.66) Sudeck s osteodystrophy 2 (6.66) 1 (3.33) Carpal tunnel syndrome 3 (10) 1 (3.33) Malunion 6 (20) 0 Table 4: Final Outcome as per Lidstrom s criteria Grade Conservative Management Operative Management Satisfactory Excellent I 2 13 Good II Unsatisfactory Fair III 12 3 Poor IV 2 0

7 Fig 1: Pre-operative radiograph Discussion: Fig 2: After Cast application and Reduction Fig 3: Post-operative after Volar Plating Distal end radius fractures are the commonest fractures of upper limb with debatable treatment modalities. Whereas, the dictum followed among the orthopods is to undergo operative intervention in younger age groups, conservative treatment is usually reserved for the geriatric population. Various studies have stressed upon the linear co-relation of anatomical restoration with better functional outcome [10-12]. Once anatomical restoration has been achieved, methods like casting, external fixation, internal fixation should be used to maintain the same. Closed reduction and casting can help to achieve a three-point fixation required for proper union. Albeit, cast application alleviates the necessity for a surgical intervention, this method has limited rotational control and maintenance of length that is required for anatomical union to

8 Orthopaedics Original Article International Journal of Clinical And Diagnostic Research ISSN Volume 5, Issue 6, Nov-Dec 2017 occur [13]. There were 31 patients in Group A in the present study, off which there were 30 cases available till the last follow-up. One patient died at 3 months follow-up and thus was excluded from the study. Young et al [13] studied the functional and radiological outcomes in patients above 60 years of age treated with cast application. 22% of the patients had excellent outcome with only 3 patients with fair or poor results. Only 2 patients in their study had radiological signs of arthrosis which led to an unsatisfactory outcome. In the present study, there were 6 (20%) case in which there was loss of reduction after cast application. There were 80% cases with excellent and good results in the present study as per the Lidstrom s criteria. Zyluk et al 14 in their study stated that conservative treatment should be reserved only for undisplaced or minimally displaced fractures. We had similar findings as the rate of complications were more with the patients treated conservatively. In contrast, other studies have stated conservative treatment to be the safest options in most of the cases [15,16]. Operative modality has the benefit of better anatomical reduction, early mobilization and stable internal fixation with good functional stability leading to a better radiological and functional outcome [1]. Treatment of unstable distal end radius fractures with volar locking plates without additional bone graft can give good results [1,16-18]. However, many are of the opinion that the surgical modality is associated with higher morbidity and mortality especially amongst the geriatric age group with approximately 2% of the population with sustained complications within first 30 days of surgery [19,20]. Contradictory to this notion, the present study had better outcomes in patients who underwent volar plating in terms of range of movements, grip strength, radiological parameters which were statistically significant. Our findings were in consistent with that of Lutz et al [19], who prospectively studied 256 patients with distal end radius fractures from several databases and concluded that patients who underwent surgery had better functional and radiological outcome and better DASH scores. A recent meta-analysis [1] extensively compared 7 randomised control trials with 523 patients of distal end radius treated by conservative and operative modalities. They concluded that although, the patients treated with surgery had better radiological outcome, there were no statistically significant noted in terms of functional results and complication rates. Low sample size and less duration of follow-up were the limitations of the present study.

9 CONCLUSION The treatment for distal end radius fractures remains a challenge for every orthopaedic surgeon due to lack of consensus. However, it was our experience that the operative modality with volar locking plate had better radiological as well as functional outcome in elderly patients which are still inadequately treated. Conflict of Interest Statement- There is no conflict of interest. Informed consent was taken from the patient. REFERENCES: 1. Song J, Yu AX, Li ZH. Comparison of conservative and operative treatment of distal end radius fracture: a metaanalysis of randomized control trials. It J Clin Exp Med 2015;8(10): Ilyas AM, Jupiter JB. Distal radius fractures--classification of treatment and indications for surgery. Orthop Clin North Am. 2007;38(2): Schneppendahl J, Windolf J, Kaufmann RA. Distal radius fractures: current concepts. J Hand Surg Am. 2012; 37(8): Büyükkurt CD, Bülbül M, Ayanoğlu S, et al. The effects of osteoporosis on functional outcome in patients with distal radius fracture treated with plate osteosynthesis. Acta Orthop Traumatol Turc 2012;46: Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in lowdemand patients older than 60 years. J Hand Surg Am 2000;25: Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg [Am] 2006;88-A: Frykman G. Fracture of the distal radius including sequelae shoulderhand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;Suppl 108:3. 8. Lidstorm A. Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop Scand Suppl. 1959;41: Jupiter JB, Fernandez DL, Toh CL, et al. Operative treatment of volar intraarticular fractures of the distal end of the radius. J Bone Joint Surg [Am] 1996;78:

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11 complications following open reduction internal fixation of distal radius fractures. J Hand Surg Am 2014;39: