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External Fixators for Distal Radius Fractures


- See: orthofix fixator

- Discussion:
- convential "bridging" external fixation relies on ligamentotaxis to apply traction & restore displacement;

- indications:
- active pts when radial length is decr by > 3-4 mm;
- presence of dorsal comminution;
- when closed reduction fails to restore anatomic palmar tilt;
- for any unstable or intra-articular distal radial frx which can not be held in a reduced posisiton w/ a cast;
- as noted in the study by Trumble, et al (1998), external fixation provided clear advantages in specific situations;
- in older patients, pain relief, grip strength, and ROM were significantly better when external fixation was used;
- in younger patients, external fixation provided consistently better results when there was comminution in 2 or more cortices;

Distal radius fractures are a common injury and there is no agreed consensus on the best treatment method. The Cochrane review  “Surgical interventions for treating distal radius fractures in adults” was withdrawn in 2009 due to its size and complexity. There is however another Cochrane review covering some of this ground titled “External fixation versus conservative treatment for distal radial fractures in adults”. The authors of this suggest that, allowing for the limitations of the available studies, external fixation augmented with percutaneous pin fixation has better radiographic outcomes and may have better functional outcomes when compared with cast immobilisation.

The majority of orthopaedic surgeons and hand surgeons would tend to use internal fixation in preference to external fixation although there is a paucity of evidence to support this. There would probably be little disagreement about using a wrist-spanning external fixator for open fracture-dislocations of the radio-carpal joint. Non-bridging external fixators are typically used for extra-articular fractures or for stabilising extra-articular corrective osteotomies.

In my practice for a displaced closed distal radius fracture where a closed reduction is possible, I would treat this with manipulation under anaesthetic and K-wire stabilisation (MUA + K-wires). When a closed reduction cannot be achieved, then I would use open reduction internal fixation (ORIF). For open fractures, my decision for the method of treatment is determined by the degree of wound contamination. In contaminated wounds from high energy injuries (i.e. there is a broken bone within a significant soft tissue injury) I would initially apply a spanning external fixator. This will often require conversion to a formal open reduction and internal fixation. Initially this allows the soft tissues to either improve or declare themselves as non-viable prior to open surgery. In low energy fractures that are only mild-moderately contaminated, I feel with a thorough debridement and irrigation open reduction internal fixation is a safe and definitive strategy.

Open fractures should be managed according to the British Orthopaedic Association Standard for Trauma which sits on the BOA site and the guidelines section of this technique.

The principles for the management of open fractures include:

Combined Orthoplastic care Intravenous antibiotics within 1 hour Remove gross contamination (no mini-washout); photograph; saline soaked dressing Realign a deformed limb and splint (neurovascular assessment both pre- and post-reduction) Debridement immediately for highly contaminated wounds (agricultural, sewage, aquatic) Debridement within 12 hours for high energy open fractures Debridement within 24 hours for low energy open fractures.

The Hoffman II Compact External Fixator system is a modular system that is particularly suited for fracture management of the foot and hand & wrist. Its’ design allows many configurations and any deformity can be corrected in 3 planes. It can be used for both temporary and definitive fracture stabilisation.

Other techniques on OrthOracle that deal with the management of distal radial fractures are volar plating https://www.orthoracle.com/library/distal-radius-fracture-fixation-volar-approach-synthes-2-4-mm-variable-angle-locking-lcp/ ,K wiring  https://www.orthoracle.com/library/distal-radius-fracture-manipulation-under-anaesthetic-mua-and-k-wire-fixation/ , and dorsal plating https://www.orthoracle.com/library/distal-radial-fracture-fixation-dorsal-approach-synthes-2-4mm-variable-angle-plating-system/

Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006194

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- controversies:
- bridging vs non bridging external fixation:
- conventional external fixtion involves placing the distal pins into the first metacarpal (pins span the wrist joint), whereas non bridging fixators do not span the joint but rather are placed into the distal fracture fragment;
- in the study by McQueen MM, et al (1998), bridging and non-bridging fixators were compared in a randomized prospective study;
- non bridging fixation is not used when there is less than 1 cm of volar cortex or w/ articular displacement;
- more normal volar tilt, carpal alignment, grip strength, and flexion were maintained better in the nonbridging group;
- at one year from injury, the bridging fixator group showed a mean dorsal tilt of 12.2 deg vs 5.6 deg in the non bridging group;
- the authors point out that the non bridging fixator does not distract the wrist joint, and therefore allows better ROM both during fixator placement and following fixator removal;
- references
- Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus non-bridging external fixation.
- Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt.
- Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation.


- Radiographic Findings: (Melone Classification)


- Surgical Technique:
- positioning:
- ensure that the flouroscopic monitor is placed at the patient's head;
- this will allow the surgeon to look straight ahead as pins are inserted from the radial styloid to the ulnar cortex of the radius;
- perform an initial closed reduction under flouroscopy;
- surgical technique for fixator application:
- metacarpal pin insertion;
- radial pin insertion;
- initial reduction w/ fixator:
- ligamentotaxis:
- distraction facilitates articular reduction and restoration of palmar tilt;
- w/ inadequate reduction following application of Ex Fix, consider insertion of percutaneous pins or limited ORIF;
- it may necessary to apply wrist flexion and ulnar deviation inorder to maintain a temporary reduction;
- percutaneous K wires
- reduction and final wrist position:
- avoid over distraction of wrist joint:
- ulnar styloid fracture:
- if frx involves ulnar styloid, place upper extremity in a long arm posterior splint in mid supination for 3-4 weeks;
- bone grafing: (bone graft menu)
- w/ depression more than 5 mm, make a small longitudinal extra-articular incision over the dorsal fracture site to provide bone graft;
- Leung, et al reported on 100 distal radius fractures radius in which iliac bone graft was used to support the reduction;
- they removed the external fixators frame at 3 wks and used a functional brace for an additional 3 wks.
- they noted few complications, & there was maintenance of reduction w/ good or excellent function in nearly all patients;
- references:
- An effective treatment of comminuted fractures of the distal radius.
- Cancellous grafting and external fixation for unstable Colles' fractures.


- Post Operative Care:
- references:
-
Severe fractures of the distal radius: effect of amount and duration of external fixator distraction on outcome.


- Case Examples:



Unstable Colles' fractures in elderly patients. A randomised trial of external fixation for redisplacement.

External fixation for intra-articular fractures of the distal radius.

External fixation or plaster cast for severely displaced Colles' fractures? Prospective 1-year study of 46 patients.

A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures.

Cast or external fixation for fracture of the distal radius. A prospective study of 126 cases.

Plaster cast versus external fixation for unstable intraarticular Colles' fractures.

Displaced distal radius fractures. A comparative study of early results following external fixation, functional bracing in supination, or dorsal plaster immobilization.

Limited open surgical approach for external fixation of distal radius fractures.

Dynamic external fixation for comminuted intra-articular fractures of the distal end of the radius.

Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques.

Treatment of forearm fractures by Hoffman external fixation. A study of 93 patients.

Hand and wrist function after external fixation of unstable distal radial fractures.

Severe fractures of the distal radius: effect of amount and duration of external fixator distraction on outcome.

Pattern of forearm fractures in children.

Comminuted intra-articular fractures of the distal end of the radius treated with the Hoffmann external fixator.

Year Book: Unstable Colles' Fractures in Elderly Patients: A Randomised Trial of External Fixation for Redisplacement.

Severe fractures of the distal radius: effect of amount and duration of external fixator distraction on outcome.

Biomechanical analysis of pin placement and pin size for external fixation of distal radius fractures.

Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques.

Dynamic external fixation of unstable fractures of the distal part of the radius. A prospective, randomized comparison with static external fixation.

A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures.

The surgical treatment of severe comminuted intraarticular fractures of the distal radius with the small AO external fixation device. A prospective three-and-one-half-year follow-up study.

Dynamic external fixation for comminuted intra-articular fractures of the distal end of the radius.

Cancellous grafting and external fixation for unstable Colles' fractures.

Biomechanical analysis of pin placement and pin size for external fixation of distal radius fractures.