Percutaneous pinning for treating distal radial fractures in adults

Intrafocal Pinning in Distal Extraarticular Radius Fracture: A Retrospective Study Based on Patient Age

Background

Percutaneous intrafocal pinning is one of the many surgical options for extraarticular distal radius fracture with minimal comminution. This study aims to describe the role and indications of intrafocal pinning.

Methods

This monocentric, retrospective study included 49 patients who underwent intrafocal pinning for distal radius fractures in 2013 in our French hand surgery department. All the patients underwent posteroanterior and lateral x-ray on days 2 and 45 to measure radial inclination, distal radioulnar index, and volar tilt.

Results

The mean age of the patients was 45.4 years, with women representing approximately 61.2% of the sample (n = 30). The patients were divided into three groups: group A (17-50 y), 26 patients; group B (50-70 y), 15 patients; and group C (>70 y), eight patients. We documented on x-ray images, 21 secondary displacements, including seven in group C. There were three displacements (all in group C) and one surgical revision within 15 days for a previous displacement. The distal radioulnar index increased in all three groups.

Conclusions

The percutaneous intrafocal pinning fixation technique exposes a high risk of complications, especially for those older than 50 years, for whom this technique should be avoided. Overall, due to the frequency of secondary displacements encountered, our first-line treatment favors plate osteosynthesis for all patients. Pinning fixation should only be considered with caution in younger patients if plate osteosynthesis is not possible, but it requires a strict 6-week immobilization. The fracture morphology must also be considered.

Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial

Aims

The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury.

Methods

Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed.

Results

Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury.

Conclusion

For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Pull-out resistance of connected K-wires for osteosynthesis: development of a numerical model

A predictive finite element model was developed to investigate the best configuration of a fixation pins system consisting of two K-wires inserted in a synthetic model (Sawbones®) at different angles and secured to a connecting rod. Two key parameters were considered to determine the best configuration delivering the higher pull-out strength and lower pull-out length: the diameter and insertion angle. Results show that as the diameter and insertion angle increased, the pull-out force increased, while the pull-out length decreased. Results are successfully compared with available experimental data in literature. This model can be used as an alternative to experimental study.

Treatment of distal radius fractures using a cemented K-wire frame

BACKGROUND

This retrospective study included an alternative treatment for types A2, A3, and B1 distal radius fractures using percutaneous fixation with a cemented K-wire frame.

METHODS

From January 2017 to January 2020, 78 patients with distal radius fractures were treated with percutaneous internal fixation using a cemented K-wire frame. There were 47 male patients and 31 female patients. The fractures were classified into types A2 (n = 10), A3 (n = 46), and B1 (n = 22). X-rays were taken immediately after surgery and after the bone had healed. Wrist function was assessed using the Mayo Wrist Score (90-100, excellent; 80-90, good; 60-80, satisfactory; < 60, poor). Patient satisfaction was assessed using the 10-cm visual analog scale.

RESULTS

Neither fixation failure nor K-wire migration was found (P > 0.05). Osteomyelitis was not observed in this series. All patients achieved bone healing after a mean of 4.5 weeks (range, 4 to 8 weeks). Follow-up lasted a mean of 27 months (range, 24 to 33 months). The mean score of wrist function was 97 (range, 91 to 100). Among them, 66 results were excellent and 12 results were good. The mean patient satisfaction was 10 cm (range, 8 to 10 cm).

CONCLUSIONS

Percutaneous fixation with cemented K-wire frame is a safe and preferred choice for the treatment of types A2, A3, and B1 distal radius fractures. The frame provides support to prevent wire migration. The fixation technique is a minimally invasive procedure that is easy to perform.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures

BACKGROUND AND PURPOSE

National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions.

PATIENTS AND METHODS

In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines.

RESULTS

On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery.

INTERPRETATION

The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture: the DRAFFT 2 RCT

BACKGROUND

Patients with a displaced fracture of the distal radius are frequently offered surgical fixation. Manipulation of the fracture and moulded plaster casting is an alternative treatment that avoids metal implants, but evidence of its effectiveness is lacking.

OBJECTIVE

To compare functional outcomes, quality-of-life outcomes, complications and resource use among patients with a dorsally displaced fracture of the distal radius treated with manipulation and surgical fixation with Kirschner wires (K-wires) and those treated with manipulation and moulded cast.

DESIGN

Pragmatic, superiority, multicentre, randomised controlled trial with a health economic evaluation.

SETTING

A total of 36 orthopaedic trauma centres in the UK NHS.

PARTICIPANTS

Patients (aged ≥ 16 years) treated for an acute dorsally displaced fracture of the distal radius were potentially eligible. Patients were excluded if their injury had occurred > 2 weeks previously, if the fracture was open, if it extended > 3 cm from the radiocarpal joint or if it required open reduction, or if the participant was unable to complete questionnaires.

INTERVENTIONS

Participants were randomly assigned in theatre (1 : 1) to receive a moulded cast (i.e. the cast group) or surgical fixation with K-wires (i.e. the K-wire group) after fracture manipulation.

MAIN OUTCOME MEASURES

The primary outcome measure was the Patient-Rated Wrist Evaluation score at 12 months, analysed on an intention-to-treat basis. Health-related quality of life was recorded using the EuroQol-5 Dimensions, five-level version, and resource use was recorded from a health and personal social care perspective.

RESULTS

Between January 2017 and March 2019, 500 participants (mean age 60 years, 83% women) were randomly allocated to receive a moulded cast (n = 255) or surgical fixation with K-wire (n = 245) following a manipulation of their fracture. A total of 395 (80%) participants were included in the primary analysis at 12 months. There was no difference in the Patient-Rated Wrist Evaluation score at 1 year post randomisation [cast group: n = 200, mean score 21.2 (standard deviation 23.1); K-wire group: n = 195, mean score 20.7 (standard deviation 22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66); p = 0.87]. A total of 33 (13%) participants in the cast group required surgical fixation for loss of fracture position in the first 6 weeks, compared with one participant in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10). The base-case cost-effectiveness analysis showed that manipulation and surgical fixation with K-wires had a higher mean cost than manipulation and a moulded cast, despite similar mean effectiveness. The use of K-wires is unlikely to be cost-effective, and sensitivity analyses found this result to be robust.

LIMITATIONS

Because the interventions were identifiable, neither patients nor clinicians could be blind to their treatment.

CONCLUSIONS

Surgical fixation with K-wires was not found to be superior to moulded casting following manipulation of a dorsally displaced fracture of the distal radius, as measured by Patient-Rated Wrist Evaluation score. However, one in eight participants treated in a moulded cast required surgery for loss of fracture reduction in the first 6 weeks. After a successful closed reduction, clinicians may consider a moulded cast as a safe and cost-effective alternative to surgical fixation with K-wires.

FUTURE WORK

Further research should focus on optimal techniques for immobilisation and manipulation of this type of fracture, including optimal analgesia, and for rehabilitation of the patient after immobilisation.

TRIAL REGISTRATION

This trial is registered as ISRCTN11980540 and UKCRN Portfolio 208830.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 11. See the NIHR Journals Library website for further project information.

Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial

OBJECTIVE

To assess wrist function, quality of life, and complications in adult patients with a dorsally displaced fracture of the distal radius, treated with either a moulded cast or surgical fixation with K-wires.

DESIGN

Multicentre randomised clinical superiority trial, SETTING: 36 hospitals in the UK National Health Service (NHS).

PARTICIPANTS

500 adults aged 16 or over with a dorsally displaced fracture of the distal radius, randomised after manipulation of their fracture (255 to moulded cast; 245 to surgical fixation).

INTERVENTIONS

Manipulation and moulded cast was compared with manipulation and surgical fixation with K-wires plus cast. Details of the application of the cast and the insertion of the K-wires were at the discretion of the treating surgeon, according to their normal clinical practice.

MAIN OUTCOME MEASURES

The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) score at 12 months (five questions about pain and 10 about function and disability; overall score out of 100 (best score=0 and worst score=100)). Secondary outcomes were PRWE score at three and six months, quality of life, and complications, including the need for surgery due to loss of fracture position in the first six weeks.

RESULTS

The mean age of participants was 60 years and 417 (83%) were women; 395 (79%) completed follow-up. No statistically significant difference in the PRWE score was seen at 12 months (cast group (n=200), mean 21.2 (SD 23.1); K-wire group (n=195), mean 20.7 (22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66), P=0.87). No difference was seen at earlier time points. In the cast group, 33 (13%) of participants needed surgical fixation for loss of fracture position in the first six weeks compared with one revision surgery in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10).

CONCLUSIONS

Among patients with a dorsally displaced distal radius fracture that needed manipulation, surgical fixation with K-wires did not improve patients' wrist function at 12 months compared with a cast.

TRIAL REGISTRATION

ISRCTN registry ISRCTN11980540.

Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients

BACKGROUND

Surgical site infections (SSI) after distal radius fracture (DRF) surgery have not previously been studied as the primary outcome in a large population with comparative data for different surgical methods. The aims of this study were 1) to compare SSI rates between plate fixation, percutaneous pinning and external fixation, and 2) to study factors associated with SSI.

METHODS

We performed a nation-wide cohort study linking data from the Swedish national patient register (NPR) with the Swedish prescribed drug register (SPDR). We included all patients ≥18 years with a registration of a surgically treated DRF in the NPR between 2006 and 2013. The primary outcome was a registration in the SPDR of a dispensed prescription of peroral Flucloxacillin and/or Clindamycin within the first 8 weeks following surgery, which was used as a proxy for an SSI. The SSI rates for the three main surgical methods were calculated. Logistic regression was used to study the association between surgical method and the primary outcome, adjusted for potential confounders including age, sex, fracture type (closed/open), and a dispensed prescription of Flucloxacillin and/or Clindamycin 0-8 weeks prior to DRF surgery. A classification tree analysis was performed to study which factors were associated with SSI.

RESULTS

A total of 31,807 patients with a surgically treated DRF were included. The proportion of patients with an SSI was 5% (n = 1110/21,348) among patients treated with plate fixation, 12% (n = 754/6198) among patients treated with percutaneous pinning, and 28% (n = 1180/4261) among patients treated with external fixation. After adjustment for potential confounders, the surgical method most strongly associated with SSI was external fixation (aOR 6.9 (95% CI 6.2-7.5, p < 0.001)), followed by percutaneous pinning (aOR 2.7 (95% CI 2.4-3.0, p < 0.001)) (reference: plate fixation). The classification tree analysis showed that surgical method, fracture type (closed/open), age and sex were factors associated with SSI.

CONCLUSIONS

The SSI rate was highest after external fixation and lowest after plate fixation. The results may be useful for estimation of SSI burdens after DRF surgery on a population basis. For the physician, they may be useful for  estimating the likelihood of SSI in individual patients.

Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator

Background

Conservative treatment remains the preferred choice for distal radius fracture in children. However, loss of reduction is problematic, especially in an older child. Crossed Kirschner-wires is widely used to treat distal radius fracture in adolescents. This study aimed to compare the application of crossed Kirschner-wiring (KW) and non-bridging external fixator (EF) for the treatment of delayed distal radial fracture involving metaphyseal diaphyseal junction (MDJ) in adolescents.

Methods

Between January 2012 to January 2017, 146 (male = 101, female = 45) patients in EF group and 117 (male = 76, female = 41) in KW group, were reviewed retrospectively. Preoperative data were collected from the hospital database, and postoperative clinical outcomes data were collected during the follow-up visits. We used SPSS for data analysis.

Results

There existed no significant difference between EF and KW regarding sex, body weight, fracture side, duration from injury to surgery. The duration of surgery was significantly shorter in EF (30.5 ± 6.1 min) than the KW group (44.6 ± 9.4 min), P < 0.001. The number of intraoperative X-ray images was significantly lower in EF (6.5 ± 1.1) than KW (11.8 ± 2.3), P < 0.001. The incidence of tendon irritation is significantly higher in the KW (19.7%) than the EF group (0%), P < 0.001. The residual angulation on the AP view was higher in KW (3.8 ± 2.3, degrees) than the EF group (2.5 ± 1.6, degrees), P < 0.001. The volar tilting is better in EF (6.6 ± 1.1, degrees) than the KW group (1.0 ± 1.5, degrees), P < 0.001. However, the functional outcomes of the wrist showed no significant difference between EF and KW group, P = 0.086.

Conclusion

The EF was superior to KW in the treatment of radial MDJ fractures in adolescents. The EF displayed shorter duration of surgery, less tendon irritation, and better radiographic outcomes than the KW. However, the cost-effect analysis remains to be investigated, because the EF is more expensive than KW.