Comparison between functional outcomes of close reduction versus K-wire fixation in fracture distal end radius

Karuna Shankar Dinkar; Rajat Kapoor; Vivek Mittal; Brijesh Sharma; Sushil Kumar Saini; Ashutosh Verma

doi:10.4103/jbjd.jbjd_19_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 37 | Issue : 3 | Page : 114-118

Comparison between functional outcomes of close reduction versus K-wire fixation in fracture distal end radius

Karuna Shankar Dinkar, Rajat Kapoor, Vivek Mittal, Brijesh Sharma, Sushil Kumar Saini, Ashutosh Verma
Department of Orthopaedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India

Date of Submission	24-Aug-2022
Date of Acceptance	22-Oct-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Sushil Kumar Saini
Department of Orthopaedics, S.N. Medical College, Agra, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_19_22

Abstract

Background: Fracture of distal radius usually occurs as a result of high energy trauma in younger individual with good bone density and is associated with substantial articular and periarticular tissue injury. The fracture of distal radius was previously known for being common in elderly with low function demand who sustained a low energy trauma. Purpose of study was to compare the functional and radiological outcomes between percutaneous K-wiring and close reduction with below elbow cast application in treatment of distal end radius fracture. Methodology: 30 cases of closed reduction and casting and 30 cases of percutaneous K-wire fixation were included in the study. The data obtained from the two groups was analysed by using unpaired student’s t-test for continuous variables. All cases were followed up after 2 weeks, 4 weeks, and 6 weeks and were functionally and radiologically assessed for re-displacement. Results: There was no statistically significant difference in the range of movement outcomes between the two groups. The unpaired student’s t-test on the values obtained from both groups yielded a P-value of 0.9816. Conclusion: Closed reduction with percutaneous K-wiring and below elbow cast application is a simple, minimally invasive technique that provides additional stability and better radiological outcome in the treatment of extra-articular distal radius fracture as compared to closed reduction and below elbow cast application.

Keywords: Close reduction, fracture distal end radius, K-wire

How to cite this article:
Dinkar KS, Kapoor R, Mittal V, Sharma B, Saini SK, Verma A. Comparison between functional outcomes of close reduction versus K-wire fixation in fracture distal end radius. J Bone Joint Dis 2022;37:114-8

How to cite this URL:
Dinkar KS, Kapoor R, Mittal V, Sharma B, Saini SK, Verma A. Comparison between functional outcomes of close reduction versus K-wire fixation in fracture distal end radius. J Bone Joint Dis [serial online] 2022 [cited 2023 May 27];37:114-8. Available from: http://www.jbjd.in/text.asp?2022/37/3/114/363846

Introduction

Fracture of the distal end of the radius represents the most common fracture of the upper extremity. There are three main peaks of fracture distribution: children aged 5–15, men below 50 years of age, and women over 40 years of age. The treatment of the distal radial articular fracture is still controversial despite continued refinement in the treatment. Fractures of distal end radius represent approximately 16% of all fractures treated by orthopedic surgeons. ^[1] It is a common injury of the upper extremity. Fractures of the distal radius usually occur as a result of high-energy trauma in the younger individual with good bone density and are associated with substantial articular and periarticular tissue injury. ^[2] In addition, these fractures are also reported in elderly osteoporotic patients. ^[3] The fracture of the distal radius was previously known for being common in elderly with low function demand who sustained a low energy trauma. But the incidence of this fracture is increased due to the increasing number of elderly population along with the increasing number of road traffic accidents and other high-energy traumas in all age groups who end up sustaining this fracture ^[2].

If these fractures are not assessed properly and not treated on time, angulation, shortening, and articular incongruity may lead to permanent deformity and loss of function. Degree of disability later correlates with the degree of residual deformity. Management of this fracture has undergone extraordinary evolution over the preceding few years. ^[4] There are numerous treatment modalities available to orthopedic surgeons in the treatment of a distal radius fracture; these include closed reduction and casting, closed reduction and percutaneous pinning by different methods such as Kapandiji intrafocal pinning, trans-radial styloid pinning, pinning via the Lister’s tubercle, or trans-ulnar pinning. Other modalities of treatment include closed reduction and external fixation by means of ligamentotaxis to realign fracture displacement, open reduction by volar or dorsal approach, and internal fixation by different implants such as screws, plates, or screws with locking plates ^[2],[3],[4].

There are numerous factors that decide the treatment modality; these include the patient’s age, lifestyle, associated injuries, comorbidities, functional demands, dominance of hand, type of fracture, alignment of fracture, condition of soft tissues, whether the fracture is open or closed and economic constraints of the patient. All these factors play a paramount role in the final decision in the treatment of the distal radius fracture ^[3],[4]. Owing to the poor quality of bones in elderly patients, reduction of fracture is difficult to maintain by simple external splintage. To prevent collapse, additional support is needed. In these patients, percutaneous pinning adds the extra support needed to maintain the fracture in desired alignment and reduction ^[5],[6]. Percutaneous pinning is considered as a simple way of providing additional stability to immobilization in a cast in extra-articular fracture of the distal radius in which anatomical reduction is obtained by closed reduction ^[6],[7].

Materials and Methods

This prospective randomized control study was conducted on 60 patients attending as outpatient or in-patient at the Department of Orthopaedics in our tertiary care center from December 2013 to May 2015 who have been found to have extra-articular fractures of the distal radius and fulfill all the inclusion and exclusion criteria.

Inclusion criteria

All patients with radiologically confirmed extra-articular fractures of the distal radius (AO types 23-A2, 23-A3), are medically fit, willing for the procedure and consented to be part of the study, are above the age of 18 years, and presenting with injuries not older than 3 weeks.

Exclusion criteria

Patients with intra-articular fractures,

Distal radius fractures with neurological involvement,

Fractures in children with epiphyseal involvement,

Patients with poor anesthetic risk are excluded.

Method

Thirty cases of closed reduction and casting and 30 cases of percutaneous K-wire fixation were included in the study. Of which, five patients of each group were lost in the study. The data obtained from the two groups were analyzed by using an unpaired Student’s t test for continuous variables. The results were analyzed by Statistical Package for the Social Sciences (SPSS) software program, version 20.0.

Approximately 60 patients were between the ages of 21 years and 78 years with a mean age of 47.45 years. Patients were allocated randomly into two equal groups of 30 patients. The first group was treated by closed reduction and cast application and the second group was treated by closed reduction and percutaneous K-wire fixation and cast application. In follow-up, five patients of each group were lost; hence, the final study was conducted with 25 patients in each group. Hence, a total of 50 patients were included in the study.

All fractures were classified by AO Classification and only AO type 23-A2 and 23-A3 fracture patterns were included in the study.

All the patients of the study were admitted from emergency and OPD of the orthopedic department. After admission complete history of every patient was noted regarding the mode of injury, severity of trauma, and duration of injury. In all patients, swelling, tenderness, deformity, and any bony irregularities of the distal radius were examined and the relative position of radial and ulnar styloid processes were elicited. The wrist and hand movements of each patient and distal neurovascular status were evaluated. Below the elbow, plaster of paris slab was applied and the limb was elevated. Anti-inflammatory and analgesics were given for pain and inflammation control. All routine investigations were done as per anesthetic checkup.

Radiographs of the involved extremity were taken from wrist to forearm in the neutral position in anteroposterior and lateral view [Figure 1]. The radiographic parameters that were noted were radial inclination in postero-anterior (PA) view, radial length in PA view, and palmar tilt in lateral view [Figure 2].

Figure 1: X-ray showing fracture distal end radius

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Figure 2: Preop X-ray showing fracture distal end radius

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The fracture reduction was carried out under general anesthesia or wrist block. Reduction was achieved by firm longitudinal traction to the hand against the counter traction by an assistant who grasped the arm above the flexed elbow, whereas the distal fragments were pushed into palmar flexion and ulnar deviation using the thumb of the other hand; the patient’s hand was brought into pronation, palmar flexion, and ulnar deviation [Figure 3]. A plaster cast was applied extending from below the elbow to the metacarpal heads, maintaining the wrist in palmar flexion and ulnar deviation (Colles’ Cast) in the closed reduction group.

Figure 3: X-ray after close reduction in both AP and lateral

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However in the second group, after achieving acceptable reduction 1.5-mm K-wires were passed through the radial styloid process piercing the far medial cortex of the proximal fragment under image control [Figure 4]. In some cases, an additional K-wire was passed through the ulnar side of the radius engaging the opposite cortex. After that K-wires were bent and cut, sterilize dressing was done and below-elbow plaster was applied in the neutral position.

Figure 4: Postop X-ray after close reduction and fixation with K-wire

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Postoperatively in every patient analgesics and anti-inflammatory medications were given to control pain and inflammation. Patients who were treated by K-wire intravenous antibiotics were given for 3 days. In all patients, active finger movements, elbow, and shoulder movements were started from day 1.

Immediate postoperative check X-rays were taken in both PA and lateral view. The reduction of fracture was confirmed and any displacements were noted. All patients were discharged third day postoperatively with routine plaster of paris instructions with active finger, elbow, and shoulder exercises.

All cases were followed up after 2 weeks, 4 weeks, and 6 weeks and were radiologically assessed for re-displacement. K-wires and cast were removed after 6 weeks and patients were assessed clinically for fracture union, range of movements, and radiological parameters; physiotherapy was advised. After that regular follow-up was done at an interval of 3 months and 6 months, respectively.

Assessment of Outcome

Functional outcome assessment

Functional outcome of the patients was assessed at 6 months postoperatively by the demerit score system of Gartland and Werley and then scores compared with ascertain for any statistically valid difference in outcome by an unpaired Student’s t test.

Radiological assessment

The radiological outcome was assessed based on the values of radial height, radial inclination, and volar tilt in the PA and lateral radiographs of the treated wrists and was individually assessed by an unpaired Student’s t test to ascertain for any statistically valid difference between the radiological outcome between the two groups.

Results

This study was conducted with a total of 60 patients; 30 patients were each randomly divided into two groups. Thirty patients in the first group were treated with closed reduction and casting; thirty patients in group two were treated with closed reduction percutaneous pinning with K-wires and cast application.

The radiological parameters were assessed for pre-reduction, post-reduction, 6 weeks post-reduction, and at 3 months. There was a statistically significant difference in all three radiological parameters of the patient groups.

The mean radial height in the casting group was 8.033 mm, whereas the mean in the K-wiring group was 11.783 mm.

The unpaired Student’s t test on the values obtained in both groups revealed a P-value of 0.0001

The mean volar tilt in the Cast application group was 4.867° and in the k-wiring group was 7.5° the unpaired Student’s t test revealed a P-value of 0.0001.

The mean radial inclination in the Cast application group was 14.23° and that in the K-wiring group was 19.1°. Unpaired Student’s t test on the values revealed a P-value of 0.0001.

There was no statistically significant difference in the range of movement outcomes between the two groups. The functional scoring was done as per the Gartland and Werley demerit scoring system. The Cast application group had 10 excellent, 8 good, 6 fair, and 1 poor result; the mean outcome score of the group was 5.2. The K-wiring group had 12 excellent, 10 good, 2 fair, and 1 poor result; the mean score of the group was 5.17.

The unpaired Student’s t test on the values obtained from both groups yielded a P-value of 0.9816, indicating that there was no statistically significant difference in the functional outcome between the two groups.

Discussion

As the average life expectancy is increasing, fractures of the distal radius are also increasing. This fracture is most common, especially with low-energy fractures in elderly; the other contributing factor is due to road traffic accidents ^[2]. Owing to increasing life expectancy, orthopedic surgeons will need to focus on treating osteoporotic fractures, particularly those in postmenopausal women as noted by Young and Ryan.^[5] As per studies conducted by Jupiter^[2] and Cooney et al.,^[3] there is a direct relationship between anatomical result and functional outcome.

Walton et al.^[8] in their study presented a method of holding unstable distal radius fractures with blunt-ended K-wires via intrafocal and intramedullary insertion; therefore, modifying the Kapandji technique 102 patients were treated with unstable distal radius fractures in this way and according to clinical need and scored radiologically and functionally using modified Lidstrom scoring system. They presented this as a reliable and useful method in the treatment of these common fractures particularly in osteoporotic bones.

A study conducted by Kurup and Madalia^[9] on 56 patients found that distal radius fractures when treated by percutaneous K-wire fixation fracture reduced in position after removal of the pins regardless of age, sex, and fracture pattern.

Although anatomical reduction can usually be achieved by closed manipulation, there is still no clear consensus on the most appropriate method of maintaining the fractures. Studies by Walton et al.,^[8] Hashmi and Rafi,^[10] and Kurup and Madalia^[9] have been conducted with the use of percutaneous K-wiring for stabilization of distal radius have been published. All claimed good results, but with the lack of controlled trials; no clear consensus can be drawn.

A study conducted by Azzopardi and Coultan^[11] on cast versus supplementary percutaneous pinning concluded that by percutaneous k-wiring there was only a marginal improvement in radiological parameters as compared with immobilization in cast alone but there was no improved functional outcome in the elderly population.

In a study conducted by Das et al.^[12] on32 patients aged between 18 to 70 years with extra-articular distal radius fracture by closed reduction and percutaneous pinning using two to three K-wires concluded that by percutaneous pinning followed by immobilization of the wrist in the neutral position is a simple and effective method to maintain reduction and prevent stiffness of wrist and hand.

A study by Bagul and Deshmukh^[13] on 30 cases where comparative evaluation in the measurement of the radial height, radial inclination, and ulnar variance in fracture distal end of radius treated with closed reduction and casting and closed reduction K-wire fixation and casting was done. They concluded from the study that percutaneous pining had better results than casting alone with respect to the near anatomical restoration of radial height, radial inclination, and ulnar variance.

Our prospective randomized control study compared closed reduction and below-elbow cast immobilization and closed reduction with percutaneous K-wiring and below-elbow cast immobilization of extra-articular fractures of the distal radius (AO class 23-A2 and 23-A3). Both groups were immobilized for a period of 6 weeks in well-molded below-elbow cast. Studies by Jupiter^[2] and Sahin and Tasbas^[14] have shown no advantage of above elbow casting.

There was a statistically significant difference in all three radiological parameters of the patient groups. The mean radial height in the Cast application group was 8.033 mm, whereas the mean in the K-wiring group was 11.783 mm; the unpaired Student’s t test on the values obtained in both groups revealed a P-value of 0.0001. The mean volar tilt in the Cast application group was 4.867° and that in the K-wiring group was 7.5°; the unpaired Student’s t test revealed a P-value of 0.0001. The mean radial inclination in the Cast application group was 14.23° and that in the K-wiring group was 19.1°. Unpaired Student’s t test on the values revealed a P-value of 0.0001; this was in line with other studies of similar nature conducted by Azzopardi and Coultan,^[11] Das et al.,^[12] and Bagul and Deshmukh,^[13] which also concluded the same.

The functional outcome in our study was assessed by the demerit score system of Gartland and Werley unlike other studies like the one by Wong and Chiu,^[6] which used activities of daily life or Azzopardi and Coultan,^[11] who used Mayo wrist score. In this study, there was no statistically significant difference in the functional outcome between the two groups.

Limitations

The limitations of the study are as follows:

Number of patients, that is, only 25 patients in each group and a total of 50 patients were included in the study.

Short follow-up, as it was limited to 6 months.

Conclusion

Closed reduction with percutaneous K-wiring and below elbow cast application is a simple, minimally invasive technique that provides additional stability and better radiological outcome in the treatment of extra-articular distal radius fracture as compared with closed reduction and below elbow cast application.

But the functional outcome between the two treatment modalities is not statistically significant.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

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