Surgical Treatment of Ipsilateral Fracture Lower Radius and Fracture Dislocation of the Carpal Bone: Case Series
Citation: Surgical Treatment of Ipsilateral Fracture Lower Radius and Fracture Dislocation of the Carpal Bone: Case Series. American Research Journal of Orthopedics and Traumatology. 2019; 4(1): 1-9.
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Background: Pathoanatomy & biomechanics of radiocarpal & radioulnar joints have pivotal role in maintaining wrist functions and movements. Problems associated with these fractures hamper strength of grip and early arthritis with carpal instability.
Patients and methods: Twenty four patients with unilateral distal radius fracture associated with intercarpal fractures and dislocations who were managed by treatment protocol of primary external fixation for ligamentotaxes until edema subsided, followed by secondary stage of plate fixation of distal radius, k-wire fixation of intercarpal ligamentous injury, and Headless compression screw fixation for carpal scaphoid fractures. The patients were evaluated according to standard objective and subjective criteria using demeritpoint system of Gartland and Werley & patient rated wrist evaluation score (PRWE).
Results: Fourteen patients (70%) had excellent to good outcome based on Gartland and Werley score, and six patients had fair outcome. Radiologically, excellent to good results were found in 80% of the patients with loss of radial inclination less than 10 degrees, average radial shortening (4mm) ranged from 3-6 mm. The average palmar tilt at final follow up was around 7 degrees (3-14).
Conclusion: The technique of primary external fixator, followed by plate osteosynthesis can be utilized in comminuted intra articular fractures lower radius associated with screw fixation for individual carpal bone fixation and k wire for intercarpal instability due to ligamentous injuries. The adequate surgical technique will minimize complications and an optimized rehabilitation regime can give the best possible result. Accurate anatomical reduction of the articular surface and stable fixation are mandatory for better functional outcome.
Keywords: fractures, lower radius, Carpal Bone, surgical treatment
The wrist is a complex joint consisting of bony structures, including the distal radius, distal ulna, and eight carpal bones and a ligament complex that divides extrinsic and intrinsic ligaments. Pathoanatomy & biomechanics of radiocarpal & radioulnar joints have pivotal role in maintaining wrist functions and movements [1-3]. Problems associated with these fractures hamper strength of grip and early arthritis with carpal instability . Therefore, the prognosis of wrist injuries can be affected by soft tissue injuries as well as fractures . Distal radial fractures (DRFs) are common injuries that occur in the upper limb and are treated using various methods, including closed reduction and cast immobilization, percutaneous K-wire fixation, external fixation, intramedullary fixation, and open reduction and internal fixation [6-9]. However, previous studies have been mostly limited to fractures that occur in the distal radius with associated fractures in the distal ulna. Some studies have reported that associated soft tissue injuries may affect the outcome of DRFs.
As soft tissue injuries may be accompanied by DRFs, carpal bone fractures (CBFs) may occur in association with DRFs. Avulsion fractures of carpal bones are commonly observed in patients with DRFs and may indicate injuries to the intrinsic or extrinsic ligaments of the wrist . Additionally, CBFs may be untreated, because CBFs are frequently missed on initial radiographs, which may lead to persistent pain or subsequent wrist dysfunction and eventually affect the outcome of DRF treatment [11-13]. If associated CBFs are misdiagnosed and left untreated, unsatisfactory DRF clinical outcomes may occur. Therefore, associated carpal injuries must be ruled out for DRFs. However, the frequency and distribution of CBFs associated with DRFs have not been reported, since cases of scaphoid fractures accompanying DRFs are usually reported .
The aim of this study was to evaluate the clinical and radiological results of 20 patients with associated fracture distal radius and ipsilateral intercarpal fracture dislocation of the wrist and intercarpal joints. The treatment protocol was immediate external fixation (5-7 days), followed by secondary stage open reduction and multiple angle anatomical locked plate fixation of distal radius with intercarpal k-wires and Headless 2.7 mm compression screws for scaphoid fixation and follow up of minimum period of one year.
PATIENTS AND METHODS
In the period from May 2014 to November 2018, twenty four patients with unilateral distal radius fracture associated with intercarpal fractures and dislocations who were managed by treatment protocol of primary external fixation for ligamentotaxes until edema subsided, followed by secondary stage of plate fixation of distal radius, k-wire fixation of intercarpal ligamentous injury, and Headless compression screw fixation for carpal scaphoid fractures.
At the end of 36 months follow up 20 of 24 patients underwent clinical evaluation of minimum 1 year follow up were finally included in this study. There were 16 males and 8 females, with an average age of 33 years (range 22-45 years). There were 6 dominant hands and 14 nondominant hands with fractures. Four fractures were due to fall on the ground and 16 fractures were due to road traffic accidents. All patients who underwent preoperative plain X-ray and computed tomography (CT).
According to the Müller-AO comprehensive classification , there were 3 fractures Type A, 5 were Type B, and 12 were Type C. The Type C fractures included 6 C1 fractures, 4 C2 fractures, and 2 C3 fractures. The operative procedure was started within 3 days of injury. The average time interval between injury and final surgery was 23 days (range 14 - 21 days). We used the Gartland and Werley scoring system  for assessment of functional outcome with modification based on Sarmiento et al.’s criteria of the minimum in range of motion (ROM) for normal function, which consisted of extension (45°), flexion (30°), radial deviation (15°), ulnar deviation (15°), pronation (50°), and supination (50°). Standard preoperative and postoperative postero-anterior and lateral wrist radiographs were obtained for each patient. We recorded radiographic parameters such as the degree of volar angulation, radial inclination (RI) angle, and radial height (RH). Routine follow-up radiographs were taken in the clinic at 4 weeks, 3 months, and 1 year after surgery.
Statistical analysis with a two-sample t-test was used to determine the significance of differences in radiographic parameters between postoperative radiographs and those of the 1-year follow up. A significant difference was defined as a P < 0.05
After the primary period of external fixation (5-7 days), the final operation was done after extraction of the fixator and sterilization. 12 operations were performed under regional anesthesia, and 8 patients under general anesthesia. Distal radius fractures were reduced and fixed temporarily by K-wire (K-wire) after realignment was confirmed using C-arm image intensifier. Two K-wires were used to secure the dorsal lunate facet fragment for correction of dorsal angulation. Another two were used to fix the radial styloid fragment for maintenance of radial height (RH). Volar plate through hennery approach was done in 14 cases and double plate technique was done in 6 cases. For intra articular fractures involving the scaphoid or lunate fossa, capsulotomy was performed through the same incision to allow direct visualization and facilitate restoration of articular congruity. Appropriate size plate selected and placed over volar surface of radius below the watershed line and temporarily fixed with cortical screw under radiological guidance. After confirming the desired reduction, remaining screws are fixed (Figure 1 & 2). Pronator quadratus was repaired using absorbable sutures. Subcutaneous and skin closure was done. Intravenous antibiotic was given for 5 days and then changed to oral post op dressing was done on 3rd post of day and stich removed after 14 days. Postoperatively radiographs were taken, the limb was kept elevated in below elbow plaster slab, active finger, forearm rotation and shoulder exercises were started at the earliest possible. The plaster slab was removed within 4 weeks, crepe bandage applied and active exercises of wrist, elbow and shoulder were started. Range of motion of fingers started immediately but wrist started after 15 days. Heavy lifting was not allowed until signs of fracture healing were radiographically confirmed. Patients were followed up at regular intervals clinically and radiologically. The patients were evaluated according to standard objective and subjective criteria using demerit-point system of Gartland and Werley & patient rated wrist evaluation score (PRWE).