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Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution
David S. Ruch, MD z1; T. Adam Ginn, MD1; Charles C. Yang, MD1; Beth P. Smith, PhD1; Julia Rushing, MStat1; Douglas P. Hanel, MD2
1 Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157. E-mail address for T.A. Ginn: tginn@wfubmc.edu
2 Section of Hand and Microvascular Surgery, Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 May 01;87(5):945-954. doi: 10.2106/JBJS.D.02164
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Abstract

Background: Distal radial fractures with extensive comminution involving the metaphyseal-diaphyseal junction present a major treatment dilemma. Of particular difficulty are those fractures involving the articular surface. One approach is to apply a dorsal 3.5-mm plate extra-articularly from the radius to the third metacarpal, stabilizing the diaphysis and maintaining distraction across the radiocarpal joint.

Methods: Twenty-two patients treated with a distraction plate for a comminuted distal radial fracture were included in the study. With use of three limited incisions, a 3.5-mm ASIF plate was applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, to the long-finger metacarpal, where it was fixed distally. The articular surface was anatomically reduced and was secured with Kirschner wires or screws. Eleven of the twenty-two fractures were treated with bone-grafting. The plate was removed after fracture consolidation (at an average of 124 days), and wrist motion was initiated. All patients were followed prospectively with use of radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores.

Results: All fractures united by an average of 110 days. Radiographs showed an average palmar tilt of 4.6° and an average ulnar variance of neutral (0°), whereas loss of radial length averaged 2 mm. Flexion and extension averaged 57° and 65°, respectively, and pronation and supination averaged 77° and 76°, respectively. The average DASH scores were 34 points at six months, 15 points at one year, and 11.5 points at the time of final follow-up (at an average of 24.8 months). According to the Gartland-Werley rating system, fourteen patients had an excellent result, six had a good result, and two had a fair result. Grip strength and the range of motion of the wrist at one year correlated inversely with the proximal extent of fracture comminution into the diaphysis. The duration of plate immobilization did not correlate with the range of motion of the wrist or with the DASH score at one year.

Conclusions: The use of a distraction plate combined with reduction of the articular surface and bone-grafting when needed can be an effective technique for treatment of fractures of the distal end of the radius with extensive metaphyseal and diaphyseal comminution. A functional range of motion with minimal disability can be achieved despite a prolonged period of fixation with a distraction plate across the wrist joint.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    T. Adam Ginn, M.D.
    Posted on June 08, 2005
    Dr. Ginn et al respond to Dr. Todkar
    Wake Forest University School of Medicine, Dept. Orthopaedic Surgery, Winston-Salem, NC 27157

    Dear Sir:

    Thank you for your input and your interest in our paper. We would like to respond to your letter at a point by point fashion. First, the technique has been applied in cases of infected nonunions of the radius. In the three cases which we treated in this cohort of patients, these were infections following management with more conventional techniques. These cases were managed with the basic principle of resection of the infected bone, placement of an antibiotic impregnated cement spacer when necessary and antibiotic beads when a smaller defect was present. The DCP plate was applied after debridement to maintain the radius at the appropriate length. The patient's received an eight week course of IV antibiotics. At approximately three months following placement of the spacer, the spacers were removed and either cancellous graft (one case) or tricortical graft (two cases) was placed. The plate was maintained in its position until the defect was felt to be consolidated and the plate was removed. In none of these cases did the plate continue to harbor the infected organism and all 3 healed uneventfully. It is difficult to assess whether the infection resulted in additional stiffness in the wrist as all of these cases were considered to be "salvage" cases and difficult to compare one to the other.

    In response to the question regarding bone grafting, there is some variation in the way in which these patients were managed. We feel that there are essentially two patient populations in which the technique is useful. One are those patients with extensive metaphyseal and diaphyseal involvement and the second are those in which there is extensive comminution of the articular surface and metaphyses where conventional plating would require both palmar, dorsal and radial plate placement. In the first group of patients, if the metaphyseal diaphyseal junction can be reconstructed with the patient's native bone, then additional graft was not used. The plate allowed for sufficiently rigid fixation to permit healing of the cortical bone of the forearm. In patients with extensive comminution involving the metaphysis, primary grafting was performed in order to allow for early union and removal of the implant. Finally, open fractures or previously infected fractures were not primarily grafted due to concerns over secondary infection.

    MANOJ S TODKAR
    Posted on May 07, 2005
    INFECTIONS AFTER DISTRACTION PLATING
    NUFFIELD ORTHOPAEDIC CENTRE, OXFORD

    To the Editor:

    I read the article "Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution" with great interest. The authors report that three wounds became infected after plating; the infection was controlled with debridement and antibiotics; and the plates were retained.

    I would ask the authors whether bone grafts were used in these patients? Was there a significant defect after debridement, and if there was, how did they manage the defect with the plate in situ? Also, did these infections lead to delayed union and stiffness of wrist and did they require secondary procedures.

    They also mention that bone grafts were used in only half of the patients with comminuted distal radius fractures.It would be interesting to know how they managed bone defects or comminution in patients in whom they did not use bone graft.

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