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ORIGINAL ARTICLE
Year : 2018  |  Volume : 18  |  Issue : 1  |  Page : 32-35

Functional outcomes of percutaneous pinning augmented by Joshi's clamp in displaced extra-articular distal radius fractures


1 Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Orthopedic Surgery, Cairo Fatemic Hospital, Cairo, Egypt
3 Department of Orthopedic Surgery, Ahmed Maher Teaching Hospital, Cairo, Egypt
4 Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication15-Feb-2018

Correspondence Address:
Abdulrahman D Algarni
King Saud University, Riyadh
Saudi Arabia
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DOI: 10.4103/sjsm.sjsm_32_17

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  Abstract 


Aim: Fractures of the distal radius in adults are a common injury, particularly in the elderly people. Closed reduction of displaced extra-articular fractures and percutaneous pinning is a well-established treatment option. The aim of the study was to assess the functional outcomes of percutaneous pinning augmented by Joshi's clamp in patients with displaced extra-articular distal radius fractures.
Materials and Methods: Twenty adult patients with displaced fractures requiring manipulation were recruited prospectively over a 1-year period. There were 13 (65%) females and 7 (35%) males, with a mean age of 36.45 years (range; 20–55 years). All the procedures were performed in the operating room by a single surgeon. External plaster support was not needed. Immediate postoperative active wrist mobilization was started. The patients were followed at 2, 6, and 8 weeks, and then monthly for a minimum of 6 months, looking for clinical and radiological union, Cooney's wrist score, and any complication.
Results: None of the patients was lost to follow-up. According to the Cooney's score, 9 patients (45%) had good results, 9 patients (45%) had fair results, and poor results in 2 patients (10%). Fracture consolidation was achieved at an average of 43 days (range; 36–50). With regards to complications, 2 patients (10%) had a painful scar and 2 patients (10%) had a pin-tract infection.
Conclusion: This technique is a viable alternative option. It allowed minimal soft-tissue injury, adequate stability, and early rehabilitation in our patients. Long-term comparative randomized studies are still warranted.

  Abstract in Arabic 

الخلفية: كسور عظم القطر البعيدة إصابة شائعة في البالغين، وخاصة في كبار السن. إن الجبر المغلق للكسور المفصلية الإضافية والتثبيت بالمساميرعن طريق الجلد هو خيار علاج راسخ. وكان الهدف من هذه الدراسة تقييم النتائج الوظيفية من التسمير عن طريق الجلد يضاف اليها مشبك جوشي في المرضى الذين يعانون من الكسور النازحة البعيدة لعظم القطر.
المواد والطرق: تم تجنيد 20 مريضا بالغين يعانون من كسور نازحة تتطلب التلاعب وعلى مدى سنة واحدة. كان هناك 13 (65٪) من الإناث و7 (35٪) من الذكور، متوسط ا​​عمرهم 36.45 سنة (المدى؛ 20-55 سنة). تم إنجاز جميع الإجراءات في غرفة العمليات من قبل جراح واحد. لم يكن هناك حاجة إلى دعم الجبص الخارجي. تم البدء فورا بالحركة النشطة للمعصم بعد العملية الجراحية. وقد توبع المرضى في 2 و6 و8 أسابيع، ثم شهريا لمدة لا تقل عن 6 أشهر، ويتم اثناء ذلك البحث عن الاتحاد السريري والإشعاعي، وتسجيل معيار "كوني"، وأي مضاعفات.
النتائج: لم يفقد أي من المرضى اثناء المتابعة. وفقا لنتيجة كوني، كان 9 مرضى (45٪) لديهم نتائج جيدة، وكان 9 مرضى (45٪) نتائج عادلة، ونتائج ضعيفة في مريضين (10٪). تم تحقيق تكامل الكسر في المتوسط ​​43 يوما (المدى؛ 36-50). فيما يتعلق بالمضاعفات، كان مريضين (10٪) لديهم ندبة مؤلمة وفي مريضين (10٪) عدوى المسالك المسمار.
الخلاصة: هذه الوسيلة العلاجية هي خيار بديل قابل للتطبيق. وصاحبها الحد الأدنى من إصابة الأنسجة الرخوة، والاستقرار الكافي، وإعادة التأهيل المبكر في مرضانا. ولا تزال هناك حاجة إلى دراسات عشوائية مقارنة طويلة الأجل في هذا المجال.

Keywords: Distal radius, extra-articular, fracture, Joshi, pinning


How to cite this article:
Mostafa IA, El-Sebaey IM, Ahmed AA, Zayed EM, Elbeshbeshy A, Algarni AD. Functional outcomes of percutaneous pinning augmented by Joshi's clamp in displaced extra-articular distal radius fractures. Saudi J Sports Med 2018;18:32-5

How to cite this URL:
Mostafa IA, El-Sebaey IM, Ahmed AA, Zayed EM, Elbeshbeshy A, Algarni AD. Functional outcomes of percutaneous pinning augmented by Joshi's clamp in displaced extra-articular distal radius fractures. Saudi J Sports Med [serial online] 2018 [cited 2018 Jul 22];18:32-5. Available from: http://www.sjosm.org/text.asp?2018/18/1/32/225290




  Introduction Top


Fractures of the distal radius comprise almost one-sixth of all fracture cases encountered in the emergency department. They are a common injury, particularly in the elderly population.[1],[2] These fractures are limited between the radiocarpal joint and up to 3 cm toward the proximal portion. They are usually closed and the overlying skin is intact.[3] They are considered complex as they usually entail accompanying injuries to the adjacent ligamentous and cartilaginous structures. Hence, an ideal treatment which can provide preferable anatomical reduction and fixation of fracture fragments is necessary to prevent long-term dysfunction.[4],[5],[6]

Several options exist for the treatment. Nonoperative management consists of closed reduction and casting. Operative treatment options include pinning with Kirschner wire (K-wire), nonbridging and bridging external fixation, and various methods of open reduction-internal fixation. When operative intervention is indicated, considerations should be given to the characteristics of the fracture and the surgeon's experience with the various treatment modalities.[1],[7],[8]

Closed reduction and percutaneous pinning is a well-established treatment method that involves the insertion of pins through the skin to hold the reduced fragments until union.[3] This usually requires an external support of cast or slab. We aimed to assess the functional outcomes of the patients with displaced extra-articular distal radius fractures treated with closed reduction and percutaneous pinning augmented by an external fixator clamp devised by Joshi that hold the pins together without application of cast or slab.


  Materials and Methods Top


In this prospective study, 20 patients with distal radius fractures were recruited over a 1-year period. All adult patients with displaced extra-articular distal radius fractures requiring manipulation were included in the study. Patients with intra-articular fracture, pathological or open fracture, other fracture in the ipsilateral upper extremity and those with associated neurovascular injuries were excluded from the study. All the fractures were of Type A2 or A3 according to the AO classification system of distal radius fractures. Among the 20 patients, there were 13 (65%) females and 7 (35%) males, with a mean age of 36.45 years (range; 20–55 years). The dominant wrist was involved in 12 (60%) patients. The right side was involved in 12 patients, whereas the left one was involved in 8 patients. Falling on the outstretched hand was the most common mode of injury.

All the procedures were performed by a single surgeon using a standardized technique. The procedure was performed with the patient under general anesthesia in a supine position. With the elbow at 90° flexion, the fracture was reduced by manual traction aiming to restore the normal radial height, inclination, and volar tilt. The quality of the reduction is checked intraoperatively under fluoroscopy in anteroposterior and lateral projections by rotating the C-arm while the patient's hand is steadily held. Three K-wires, generally of caliber 2.0 mm, 1.8 mm in patients with a small radius, and 2.2 mm in patients with a large radius, were utilized for osteosynthesis. They were introduced in a distal-proximal direction in a combined manner if possible, i.e., intramedullary, intrafocal, and/or bicortical depending on the fracture configuration and surgeon's preference. The K-wire was inserted by a power drill unless it is used for an intramedullary technique where the tip was bent, and the K-wire was manually inserted by the hand with a chuck. The first intramedullary wire was inserted at the apex of the radial styloid allowing the curved peak of the wire to lean against the diaphyseal cortex of the ulnar side of the radius. The second wire was inserted in an intrafocal manner in accordance with the Kapandji technique.[9],[10] The third wire was inserted in a bicortical technique to allow greater stability. Joshi's clamp was always used to lock externally the wires, and they were suitably folded toward a convergence point above the wrist. External support of a cast or slab plaster was not necessary [Figure 1].
Figure 1: Clinical postoperative photograph showing Kirschner wires connected together by Joshi's clamp

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Postoperatively, radiographs were obtained and immediate active wrist mobilization was started. The patients were instructed to clean the wire sites daily with alcohol swabs, and any pin-tract infection was treated accordingly.

Patients were followed at 2, 6, and 8 weeks, and then monthly for a minimum of 6 months, looking for clinical and radiological union, Cooney's wrist score,[11],[12] and any complication. Removing K-wires and Joshi's clamp was performed in the clinic, usually 5–7 weeks after surgery, when radiographs show fracture consolidation.

The data were analyzed using Statistical Package for Social Sciences (SPSS), version 16.0 (IBM SPSS Statistics, Armonk, NY, USA). Descriptive data were expressed as percentages, mean, standard deviation and range.

The study was approved by the Institutional Review Board, and all patients gave their informed consent before their inclusion in the study.


  Results Top


The minimum follow-up period was 6 months (range; 6–12 months). None of the patients was lost to follow-up. Postoperative radiographs showed the mean radial height of 11.15 mm (±1.31), mean radial inclination of 22.4° (±2.33), and mean volar tilt of 10.95° (±1.83). Postoperatively, immediate active wrist range of motion exercises was started. Physical therapy was required in nine cases (45%).

Functional outcomes were assessed according to the Cooney's modification of the Green and O'Brien score. At the last follow-up, 9 patients (45%) had good results, 9 patients (45%) had fair results, and poor results in 2 patients (10%) [Figure 2].
Figure 2: Clinical photograph showing functional results in a 48-year-old female at 6-month follow-up

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Fracture consolidation was achieved at an average of 43 days (range; 36–50) at which time the removal of wires and clamp was performed in the clinic. With regards to complications, 2 patients (10%) had a painful scar which was managed by local ointments and 2 patients (10%) had a pin-tract infection which was managed by dressing and oral antibiotics.


  Discussion Top


Several methods have been described to maintain the position after closed reduction of unstable distal radius fractures. These include immobilization in a cast alone, percutaneous K-wire fixation with cast, bridging external fixator, and formal open reduction and internal fixation.[13],[14],[15],[16] Immobilization in cast alone is usually not sufficient and is associated with a high rate of redisplacement.[17],[18],[19] Einsiedel et al. described a significant redisplacement in 70% of patients managed with cast immobilization only.[17]

Percutaneous pinning with K-wires is a standard method to maintain reduction and offers additional stability as compared to cast alone.[20] Several authors have described more favorable outcomes and lower risk of redisplacement in cases treated with percutaneous pinning, and therefore, it is considered superior to casting alone.[21],[22],[23],[24] However, its disadvantage is the need for external support of a cast or slab; although shorter in duration than casting alone; until fracture healing is attained which results in delay of wrist mobilization, and subsequently, a higher rate of wrist stiffness.[25]

In this study, the patients underwent closed reduction and stabilization using percutaneous K-wires connected together by a Joshi's clamp forming one construct in the way described by Mantovani et al.[26] We are in agreement with the authors' proposal that this technique might offer further stability; however, biomechanical studies are required to validate this assumption. It also obviates the need for cast immobilization allowing immediate wrist mobility. All patients in our study received the treatment under a single exposure to anesthesia as no manipulation was performed in the emergency room before the procedure which helped in decreasing the morbidity.

As compared to a bridging external fixation, this technique is of low-cost, light-weighted construct, and uses K-wires which are readily available and are less traumatic to soft-tissues than external fixator's pins. In addition, a bridging external fixator involved wrist immobilization. Open reduction and plating entails a more extensive approach and required a second procedure to remove the implants. It is more appropriate for cases in which closed manipulation has failed to achieve an adequate reduction.

The current study has some limitations. These include the small number of patients participated in the study, the lack of a control group and the short-term follow-up.


  Conclusion Top


This technique is a viable alternative option for the treatment of unstable extra-articular distal radius fractures. It allowed minimal soft-tissue injury, adequate stability, and early rehabilitation. However, further, long-term comparative randomized studies are still required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Liporace FA, Adams MR, Capo JT, Koval KJ. Distal radius fractures. J Orthop Trauma 2009;23:739-48.  Back to cited text no. 1
    
2.
Grewal R, Perey B, Wilmink M, Stothers K. A randomized prospective study on the treatment of intra-articular distal radius fractures: Open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation. J Hand Surg Am 2005;30:764-72.  Back to cited text no. 2
    
3.
Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev 2007;3:CD006080.  Back to cited text no. 3
    
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7.
Gofton W, Liew A. Distal radius fractures: Nonoperative and percutaneous pinning treatment options. Orthop Clin North Am 2007;38:175-85, v-vi.  Back to cited text no. 7
    
8.
Handoll HH, Madhok R. WITHDRAWN: Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2009;3:CD003209.  Back to cited text no. 8
    
9.
Kapandji A. Internal fixation by double intrafocal plate. Functional treatment of non articular fractures of the lower end of the radius (author's transl). Ann Chir 1976;30:903-8.  Back to cited text no. 9
    
10.
Kapandji A. Intra-focal pinning of fractures of the distal end of the radius 10 years late. Ann Chir Main 1987;6:57-63.  Back to cited text no. 10
    
11.
Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987;214:136-47.  Back to cited text no. 11
    
12.
Cooney WP 3rd, Dobyns JH, Linscheid RL. Complications of Colles' fractures. J Bone Joint Surg Am 1980;62:613-9.  Back to cited text no. 12
    
13.
Clancey GJ. Percutaneous kirschner-wire fixation of Colles fractures. A prospective study of thirty cases. J Bone Joint Surg Am 1984;66:1008-14.  Back to cited text no. 13
    
14.
Ring D, Jupiter JB. Percutaneous and limited open fixation of fractures of the distal radius. Clin Orthop Relat Res 2000;375:105-15.  Back to cited text no. 14
    
15.
Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am 1991;73:461-9.  Back to cited text no. 15
    
16.
Cooney WP 3rd, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. J Bone Joint Surg Am 1979;61:840-5.  Back to cited text no. 16
    
17.
Einsiedel T, Freund W, Sander S, Trnavac S, Gebhard F, Kramer M, et al. Can the displacement of a conservatively treated distal radius fracture be predicted at the beginning of treatment? Int Orthop 2009;33:795-800.  Back to cited text no. 17
    
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Collert S, Isacson J. Management of redislocated Colles' fractures. Clin Orthop Relat Res 1978;135:183-6.  Back to cited text no. 18
    
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20.
McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus non-bridging external fixation. J Bone Joint Surg Br 1998;80:665-9.  Back to cited text no. 20
    
21.
Naidu SH, Capo JT, Moulton M, Ciccone W 2nd, Radin A. Percutaneous pinning of distal radius fractures: A biomechanical study. J Hand Surg Am 1997;22:252-7.  Back to cited text no. 21
    
22.
Dixon S, Allen P, Bannister G. Which Colles' fractures should be manipulated? Injury 2005;36:81-3.  Back to cited text no. 22
    
23.
Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: A prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br 2005;87:837-40.  Back to cited text no. 23
    
24.
Stein AH Jr., Katz SF. Stabilization of comminuted fractures of the distal inch of the radius: Percutaneous pinning. Clin Orthop Relat Res 1975;108:174-81.  Back to cited text no. 24
    
25.
Obert L, Rey PB, Uhring J, Gasse N, Rochet S, Lepage D, et al. Fixation of distal radius fractures in adults: A review. Orthop Traumatol Surg Res 2013;99:216-34.  Back to cited text no. 25
    
26.
Mantovani A, Trevisan M, Cassini M. Osteosintesi percutanea con fili di kirschner e morsetto di joshi delle fratture extra articolari instabili del radio distale. [Percutaneous osteosynthesis of unstable extra-articular fractures of the distal radius using Kirschner wires and a Joshi clamp]. Riv Chir Mano 2009;46:25-39.  Back to cited text no. 26
    


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