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Unstable Distal Radial Fractures Treated with External Fixation, a Radial Column Plate, or a Volar PlateA Prospective Randomized Trial
David H. Wei, MD1; Noah M. Raizman, MD2; Clement J. Bottino, MD1; Charles M. Jobin, MD1; Robert J. Strauch, MD1; Melvin P. Rosenwasser, MD1
1 The Trauma Training Center, 622 West 168th Street, PH 11, Room 1164, New York, NY 10032. E-mail address for D.H. Wei: ttc@columbia.edu
2 Department of Orthopaedic Surgery, George Washington University School of Medicine, 2150 Pennsylvania Avenue, N.W., 7th Floor, Washington, DC 20037
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Doris Duke Clinical Research Fellowship. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Biomet EBI). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at Columbia University Medical Center, New York Presbyterian Hospital, New York, NY

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jul 01;91(7):1568-1577. doi: 10.2106/JBJS.H.00722
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Abstract

Background: Optimal surgical management of unstable distal radial fractures is controversial, and evidence from rigorous comparative trials is rare. We compared the functional outcomes of treatment of unstable distal radial fractures with external fixation, a volar plate, or a radial column plate.

Methods: Forty-six patients with an injury to a single limb were randomized to be treated with augmented external fixation (twenty-two patients), a locked volar plate (twelve), or a locked radial column plate (twelve). The fracture classifications included Orthopaedic Trauma Association (OTA) types A3, C1, C2, and C3. The patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at the time of follow-up. Grip and lateral pinch strength, the ranges of motion of the wrist and forearm, and radiographic parameters were also evaluated.

Results: At six weeks, the mean DASH score for the patients with a volar plate was significantly better than that for the patients treated with external fixation (p = 0.037) but similar to that for the patients with a radial column plate (p = 0.33). At three months, the patients with a volar plate demonstrated a DASH score that was significantly better than that for both the patients treated with external fixation (p = 0.028) and those with a radial column plate (p = 0.027). By six months and one year, all three groups had DASH scores comparable with those for the normal population. At one year, grip strength was similar among the three groups. The lateral pinch strength of the patients with a volar plate was significantly better than that of the patients with a radial column plate at three months (p = 0.042) and one year (p = 0.036), but no other significant differences in lateral pinch strength were found among the three groups at the other follow-up periods. The range of motion of the wrist did not differ significantly among the groups at any time beginning twelve weeks after the surgery. At one year, the patients with a radial column plate had maintained radial inclination and radial length that were significantly better than these measurements in both the patients treated with external fixation and those with a volar plate (all p < 0.05).

Conclusions: Use of a locked volar plate predictably leads to better patient-reported outcomes (DASH scores) in the first three months after fixation. However, at six months and one year, the outcomes of all three techniques evaluated in this study were found to be excellent, with minimal differences among them in terms of strength, motion, and radiographic alignment.

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

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    References

    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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    Benedict A. Rogers
    Posted on July 28, 2009
    Unstable Distal Radial Fracture Treatment
    St George's Hospital, London, United Kingdom

    EDITOR'S NOTE: The authors were invited to respond to the letter but, to date, have not done so.

    To the Editor:

    We read with interest the July 2009 article by Wei et al. (1) entitled, “Unstable Distal Radial Fractures Treated with External Fixation,a Radial Column Plate, or a Volar Plate...” and would like to make the following points.

    1. In the Materials and Methods, the authors define the three treatment arms of the study. The external fixator group incorporates “additional augmentation” that includes patients that required cancellous bone allograft and/or “the additional use of small buttress plates”. No detail is given to these additional surgical procedures, all of which can significantly influence clinical outcome (2). Subsequently, can the outcome in this group be solely attributable to external fixation as this study states?

    2. Previous studies suggest a statistical correlation between instability of the distal radioulnar joint (DRUJ) and worse clinical outcomes (3-5). No assessment has been detailed in this study of DRUJ instability and indeed the Orthopaedic Trauma Association classification does clearly differentiate involvement of the DRUJ. Do the authors feel that DRUJ instability is a possible confounding factor in the outcome of these fractures?

    3. It is recognized that a correlation exists between functional outcome and the restoration of the radiocarpal and radioulnar relationships (6,7). Further, carpal alignment in relation to the distal radial articular surface after healing may also be an important factor in the outcomes of treatment of distal radial fractures (8). As this study provides no direct evaluation of carpal alignment following treatment, such as the scapholunate angle, do the authors consider carpal alignment a significant factor in wrist function?

    4. The relative bone mineral density (BMD) of each of the three treatment arms studied is not provided in the results. Whilst the quantification of the BMD may be superfluous in routine clinical practice, for a clinical study evaluating three different surgical techniques, including locking plates, the results should be matched for BMD (9). Specifically, should the reader assume all patients are osteoporotic by the nature of the fracture and their age, and if so is this assumption a valid one?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1568-77.

    2. Dodds SD, Cornelissen S, Jossan S, Wolfe SW. A biomechanical comparison of fragment-specific fixation and augmented external fixation for intra-articular distal radius fractures. J Hand Surg Am. 2002;27:953-64.

    3. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;229-35.

    4. Lindau T, Aspenberg P. The radioulnar joint in distal radial fractures. Acta Orthop Scand. 2002;73:579-88.

    5. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioulnar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002;73:151-6.

    6. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951;33-A:895-907.

    7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59.

    8. Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79:1290-302.

    9. Nordvall H, Glanberg-Persson G, Lysholm J. Are distal radius fractures due to fragility or to falls? A consecutive case-control study of bone mineral density, tendency to fall, risk factors for osteoporosis, and health-related quality of life. Acta Orthop. 2007;78:271-7.

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