Hand Surgery, Vol. 13, No. 2 (2008) 1–12 © World Scientific Publishing Company
THE TREATMENT OF DISTAL RADIUS ARTICULAR FRACTURES THROUGH LCP SYSTEM R. Adani,∗ L. Tarallo,∗ M. G. Amorico† and C. Tata† ∗Department of Orthopaedic Surgery †Department of Radiology, University of Modena and Reggio Emilia
Modena, Italy A. Atzei Hand Surgery Unit, Verona, Italy Received 22 July 2008; Accepted 22 July 2008 ABSTRACT We analysed LCP efficiency in type B and type C wrist fractures (according to the AO Classification). We treated 58 wrist fractures (19 B-type fractures and 39 C-type fractures) in 35 male and 23 female patients, aged 19 to 87 years. Forty-one cases were followed up for an average period of 13 months. We performed a volar approach on 32 patients, a dorsal approach on five, and a double approach on four (both volar and dorsal). Twenty-six cases were pre-operatively examined with CT. All patients were evaluated using the “Mayo modified wrist score”, with an excellent/good result in 76% of patients and a satisfactory/poor result in 24%. The LCP system proved to be adequately reliable and stable to keep the reduction in complex fractures (e.g. the C-type fractures in patients with low bone quality). Keywords: Distal Radius Fractures; Open Reduction Internal Fixation (ORIF); LCP System.
INTRODUCTION
technological research of new systems for osteosynthesis. The distal screws in this device do not need to grip the fracture fragments, as the conventional plates do. Due to their angular stability, the distal screws stabilise the system and form a sort of rake whose teeth keep the stability of the radius articular component. Therefore, the force applied on the distal part of the plate is transferred along the proximal part of the plate, where it is possible to achieve the best grip on the bone, just like an internal fixator.3
Distal radius fractures are the most frequent fractures of the upper limb: they represent one-sixth of all fractures in patients over 50 years.1 Fractures of B- and C-type show an articular involvement according to AO classification2 and represent about 60% of the fractures which need surgical treatment. These fractures generally require surgical treatment using plates, sometimes in association with K wires or an external fixator. The introduction of fixed angle LCP is an innovation in the
Correspondence to: Dr. Roberto Adani, Clinica Ortopedica e Traumatologica, Policlinico di Modena, Largo del Pozzo no. 71, 41100 Modena, Italy. Tel: (+39) 059-422-2549, Fax: (+39) 059-422-4313, E-mail:
[email protected] 1
2
R. Adani et al.
Most of the distal radius fractures present a dorsal displacement, therefore for a long time surgeons considered the plate as a back-up. As a consequence, the fixed angle plate helped the development of the use of the dorsal approach with encouraging results.5,6 In cases of dorsally displaced fractures the volar approach is used in order to avoid the extensor tendons rupture. However to control the ulnar volar fragment which is that is the key for a good reduction of the distal radio-ulnar joint.7,8 B- and C-type articular wrist fracture treatment aims at rebuilding the anatomy of the articular surface, reducing the fracture fragments so that the radiographic aspect is similar to the normal anatomy. CT is generally used to study and classify correctly the fractures in order to choose the best surgical choice.9,10 The aim of this paper is: (1) Evaluation of the fixed angle LCP system efficiency in articular wrist fractures (B- and C-type of AO classification). (2) Establishing whether CT should be definitively considered necessary in the pre-operative assessment of articular wrist fractures.
MATERIALS AND METHODS Between June 2003 and April 2005 we treated through ORIF (Open Reduction Internal Fixation) 58 patients affected by intra-articular fractures of the distal radius using the 2.4 mm fixed angle LCP system for the distal radius (Synthes). Thirtyfive patients were male and 23 female; they were aged 19 to 87 (average age: 48 years). The fractures were classified according to AO classification: 19 B-type fractures (B1 = 3, B2 = 1, B3 = 15) and 39 C-type fractures (C1 = 6, C2 = 23, C3 = 10). We used metaphiseal comminution (involving articular surface) for highly unstable fractures and fractures that did not achieve a good reduction after a conservative treatment. In five C-type fractures a cancellous bone graft was employed, associated to hydroxyapatite in two cases. A Pennig external fixator in association with a plate was used in three C-type fractures and K wires in 18 cases (four B-type and 14 C-type). Thirty-six patients were studied through CT (General Electric Medical System, Milwaukee, USA, light speed 16) with the following technical parameters: collimation 1.25 mm, overlapping 0.6 mm and bone filter; this allowed the acquisition of thin layers and the execution of electronic multiplane 3D reconstruction.
In 56 cases, the time between trauma and surgical treatment ranged from 0 to 32 days (average: 14 days), while in two cases surgery was performed 52 and 70 days after the initial trauma. Forty-one patients (29 males, 12 females) out of 58 were re-evaluated; the average age was 44 years (range 19–87 years), the elapsed time between trauma and surgical treatment was 10.7 days on average (range 1–70); 12 patients belonged to the B group (B1 :2, B2 :1, B3 :10) while 29 were in the C group (C1 :3, C2 :19, C3 :7). All cases were followed-up four to 28 months after the surgical treatment (average period: 13 months). The post-operative evaluation was based on both subjective and objective results. The objective evaluation implied the measuring of the range of movement in flexion/extension and in pronation/supination, expressed both in degrees and in percentage of the contralateral arc of movement. We evaluated the grip strength measured by Jamar dynamometer as a percentage of the contralateral limb. The subjective evaluation in the postoperative period was made by examining the patient through a questionnaire about the presence of pain and the capability to return to work. These four parameters (pain, functional state, range of motion and grip strength) were grouped in a resuming scheme using the “Mayo modified wrist score” (Table 1). X-rays were made both in antero-posterior and latero-lateral projections in order to evaluate the degree of the post-operative alterations.
RESULTS All fractures perfectly healed in six to eight weeks (average time of consolidation: 4.8 weeks) and no radiographic sign of necrosis was found on the fracture fragments. In 41 followed-up cases the average wrist extension was 57◦ (range 30◦ –70◦ ) while average flexion was 60◦ (range 25◦ –90◦ ); the average total mobility was 116.5◦ (B-type fractures average ROM = 136.6◦ , C-type fractures average ROM = 104.6◦ ). The average total pronation was 78◦ (range 54◦ –90◦ ), while the average total supination was 80◦ (range 49◦ – 90◦ ); the total pronation-supination was 157.9◦ (B-type fractures = 170.75◦ , C-type fractures 147.93◦ ). The average force hold resulted in 30.3 kg (range 9–51 kg), i.e. 77% (range 42%–100%) of contralateral hand force (B-type fractures average force hold = 36.58 kg, C-type fractures average force hold = 27.72 kg) (see Table 2).
The Treatment of Distal Radius Articular Fractures Through LCP System
Table 1 Mayo Modified Wrist Score. Pain
Points 25 20 15 0
Functional Status
Range of Motion
No pain Mild, occasional Moderate, tolerable Severe to intolerable
0 1–4 5–7 8–10
(healed in about two weeks). All patients returned to their normal working activities, suffering no pain. Final results according to the “Mayo Modified Wrist Score”: excellent in 19 cases, good in 12, fair in six, poor in four; 76% of patients obtained an excellent/good result and 24% patients had a fair/poor result.
Points 25 20 15 0
Return to regular employment Restricted employment Able to work, unemployed Unable to work, pain
Total Motion
Percentage of Normal (%)
≥ 20◦
90–100 80–89 70–79 50–69 25–49 0–24
25 20 15 10 5 0
100◦ –119◦ 90◦ –99◦ 60◦ –89◦ 30◦ –59◦ 0◦ –29◦
Grip Strength
Percentage of Normal (%)
25 15 10 5 0
90–100 75–89 50–74 25–49 0–24
91–100 — Excellent; 80–90 — Good; 65–79 — Fair;
