External fixation of Smith's fracture. 16 patients followed for 2 years

Volar Barton's fractures with concomitant dorsal fracture in older patients

PURPOSE

To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex.

METHODS

This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius.

RESULTS

All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35).

CONCLUSIONS

Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.

The operative treatment of intraarticular Smith fractures

Twenty-one intraarticular palmar displaced fractures of the distal radius operated on between 1990 and 1995 were reviewed with a mean follow-up of 27.3 months (range, 8-54). Fifteen fractures were treated with palmar T-plates, two in combination with an external fixator. Five fractures were treated with external fixators and K-wires, and one fracture was treated with percutaneous K-wires and a cast. In six patients cancellous bone graft from the iliac crest was used. The most satisfactory clinical and radiological results were obtained by anatomical reconstruction of the articular surface. The favoured method remains stabilization with palmar T-plates. K-wires with a cast should only be used in simple articular fractures with a large palmar fragment.

Operative treatment of volar intra-articular fractures of the distal end of the radius

We retrospectively reviewed the results of operative treatment of forty-nine volar marginal intra-articular fractures of the distal end of the radius. According to the Comprehensive Classification of Fractures, there were two B3.1 fractures (characterized by a small volar fragment, with the sigmoid notch intact), three B3.2 fractures (characterized by a large volar fragment that included the sigmoid notch), and forty-four B3.3 fractures (characterized by comminution of the volar fragment). Although all fractures healed and only nine patients had evidence of osteoarthrosis on follow-up radiographs, there were six early and fourteen late complications, some of which adversely influenced the over-all outcome. After an average of fifty-one months (range, twenty-four to 117 months), there were thirty-one excellent, ten good, and eight fair results according to the system described by Gartland and Werley, and thirty-two excellent, nine good, five fair, and three poor results according to the modified system of Green and O'Brien. Two factors were found to have a significant association with a fair or poor outcome: evidence of osteoarthrosis on the most recent follow-up radiographs and reversal of the normal volar tilt of the distal end of the radius. The age of the patient, the interval from the injury to the operation, a concomitant injury of the ipsilateral upper extremity, an associated fracture of the ulnar styloid process, the radio-ulnar index, ulnar angulation, the classification of the fracture, comminution of the volar fragment, and articular incongruity were not significantly associated with the outcome.

Twelve years follow-up of fractures of the distal radius treated with the AO external fixator

From 1977 to 1982 a total of 55 patients suffering comminuted fracture of the distal radius were treated with the external fixator. Fifty of these were followed up in 1983/85 and 32 of them were available for assessment in this study (1992). The follow-up period was 11.6 years on average. All patients had suffered an intra-articular fracture (91% a C-fracture, 9% a B-fracture according to the AO classification), 27 patients had also fractured the ulnar styloid process and in 11 a dye-punch fragment was present. Both wrists were assessed on the basis of case history, clinical examination, radiographs in two planes and visual analogue scales (VAS). The results were evaluated using established scoring systems. On the Gartland and Werley scale 75% of the results were good or very good, 63% according to Castaing. In general, there was no statistically significant difference between the results of this study and those of 1983/85. It could be demonstrated that there was a relationship between arthritis as a late complication and the existence of an intra-articular step-off of at least 2 mm at implant removal. This also has a negative influence on the range of motion and strength. Radial shortening affects the functional result whereas a die-punch fragment does not. On VAS patients identified performance restriction and disability as the worst consequences of the accident; these criteria correlated best with the results of objective evaluations. In contrast, patients were more satisfied with the result of treatment than would be expected from the objective analyses. The overall results indicate that exact reduction was extremely important. Long-term follow-up showed that the use of the external fixator in the treatment of comminuted intra-articular fractures of the distal radius was an adequate method. Prospective and possibly multicentric studies would be required to investigate more detailed relationships between treatment and long-term results.