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A Prospective Study Of Functional Outcome Following Intra-articular
Fracture Of Distal Radius In Adults
-- A Comparison Between External Fixation And Internal Plating
Xu WeixinLim Beng Hai
Alphonsus CheongChloe Seow
Introduction
External fixation and internal plating are two common techniques used in the local hospitals for treatment of unstable distal radius fracture in the adults
Most of the studies on results of surgical intervention reported encouraging results (Catalano et al. 1997 J Bone Joint Surg 79A:1290-302 ; Rikli et al 1996 J Bone Joint Surg 78B:588-92; Jakim et al. 1991 J Bone Joint Surg 73B:302-6)
However, they were not done in a prospective, randomized manner
Introduction
Most of the randomized studies were comparing the results of casting with surgical treatments in a mixed-age population (Ludvigsen et al. Acta Orthop Scand 1997; 68: 225-258; Howard et al J Bone Joint Surg 1989; 71B: 68-73; Huchinson et al J Hand Surg 1995; 20B: 365-372; Stein et al Acta Orthop Scand 1990; 61:453-456)
This study evaluated the external fixation and internal plating for the treatment of unstable distal radius fractures in a randomized prospective manner
Aim of Study
To compare the functional outcomes following external fixation and internal plating in the management of unstable intra-articular distal radius fractures, using both subjective and objective outcome measures.
Methodology
Inclusion criteria Age: 16-60 Patients with closed comminuted intra-articular fr
acture of the distal radius (AO classification of C2-C3) requiring surgical fixation
Operation performed within three days post-injury
Methodology
Exclusion criteria Pathological fracture Old fracture on the same extremity Patients who are not likely to follow up to one
year Complicated cases which requires to following
different rehabilitation protocols (i.e. flap resurfacing, tendon repair/reconstruction and replantation done on the same injured extremity)
Methodology Written consent was obtained from the patients The subjects were randomly allocated to the two
different surgical treatment groups by the randomization envelop system
The patients were referred to hand therapy 2 days after operation following standardized rehabilitation intervention
Pre-op (case 1)
Pre-op (case 2)
Post-op (case 1)
Post-op (Case 2)
MethodologyDemographic information
Ext Fix Int Plate
Number 17 (M:14 F:4) 22 (M:18 F:4)
Mean age 37.6 42.6
R hand dominance
17 (100%) 22 (100%)
R side injury 8 (47%) 9 (41%)
MethodologyOccupation
Ext Fix Int Plate
Sedentary 7 (41%) 11 (50%)
Manual 10 (59%) 11 (50%)
Methodology
Ethnic distribution (int. plating): Chinese: 16 (72%) Malay: 2 (5%) Indian: 3 (14%) Others: 1 (5%)
Methodology
Ethnic distribution (Ext. fixation): Chinese: 13 (76%) Malay: 0 (0%) Indian: 3 (18%) Others: 1 (6%)
Methodology
Functional evaluation:outcomes were collected at 2 month, 3 month, 6
month and 1 year post injury active range of motion of the wrist and
forearm grip and pinch strength patient rated wrist evaluation (PRWE) modified Green and O'Brien scoring system.
Methodology
Standardized rehabilitation protocols were followed after both surgical interventions
Ext Fix Int Plate
0-4 weeks Finger AROM; C-bar splint if necessary
Interval wrist splint 2 weeks; gentle wrist AROM
4-6 weeks Wrist splint for 2 weeks after R/O ext fixator; gentle wrist AROM
Continue wrist AROM & PROM; gentle strengthening
Methodology
Ext Fix Int Plate
6-8 weeks Continue wrist AROM & PROM
Continue strengthening
8-12 weeks Start stretching & Strengthening
Work conditioning
12 weeks onwards
Work conditioning
Results
00.10.20.30.40.50.60.7
2 months 3 months 6 months 12 months
int plating
ext f ixation
Mean PRWE Score Over Time
Results
60
65
70
75
80
85
6 months 12 months
int plating
ext f ixation
Mean Modified Green and O'Brien Score Over Time
Results
Pearson Chi-square test were used, and showed no significant differences between groups with regards to age, hand dominance, fracture side, cause of injury, occupation and associated injuries (P>.05)
One-way ANOVA test were used to compare the functional outcomes between the two groups (P<.05) Dorsi-flexion at 2-month post injury (P=.029) Radiual deviation at 2-month post injury (P=.002) Radiual deviation at 3-month post injury (P=.001)
No statically significant deference was detected from other variables
Discussion
Both internal plating and external fixation showed good functional results for treating unstable extra-articular distal radius fracture
Internal plating provides earlier active rehabilitation and earlier return of certain range of motion of the wrist as compared with external fixation
Further data analysis is need to look into radiographic characteristics and complications between these two groups