Dynamic vs static external fixation of distal radial fractures: A randomized study

Abstract

Objectives: The present randomized study is conducted to compare the functional and anatomical outcomes of dynamic multiplanar external fixation against that of static external fixation in the management of displaced unstable comminuted fractures of the distal radius.

Materials and methods: Sixty adult patients with displaced unstable comminuted fractures of the distal radius were randomly allocated either to the dynamic (n=30) or static (n=30) fixator groups. Patients in the dynamic fixator group were managed with closed reduction and application of Penning-type articulated fixator (Orthofix, Srl, Italy); the injured wrist was partially dynamized at 3 weeks. Patients in the static group were managed with monoplanar static external fixator of Joshi's external stabilizing system (JESS) type fixator. In both groups, the fixator was maintained for 6-8 weeks. The patients were followed-up over 2 years. The primary outcome measures were the functional outcome as measured using the Gartland and Werley and DASH scores and anatomical outcome as measured using the Lindstrom score. The secondary objective was to correlate anatomical and functional outcomes and to look at overall local complications.

Results: Palmar tilt was better restored in the Penning fixator group (P<0.0001). There was reduced loss of ulnar tilt (P=0.05) and radial height (P=0.04) in the Penning fixator group. Gartland and Werley score was better in the Penning fixator group at each time point of the follow-up. The DASH score was similar in the two groups at 2 years (P=0.14). There was poor correlation (0.19) between functional outcome and anatomical restoration at 2 years.

Conclusions: In the management of displaced unstable comminuted fracture of the distal radius, use of an articulated multiplanar external fixator, allowing partial dynamization of the injured wrist at 3 weeks, resulted in improved early functional and anatomical outcome as compared to static external fixation. However, there was no significant difference in functional outcome at 2 years.

Keywords: Comminuted fracture; distal radius; dynamic external fixation.

Figure 1

(a) X-ray of wrist joint anteroposterior and lateral view showing AO type A fracture of distal end radius. (b and c) Postoperative radiographs after application of JESS fixators. (d) Radiographs at removal of fixator

Figure 2

(a) X-ray of wrist joint anteroposterior and lateral view showing AO type C intra-articular fracture of the distal radius. (b) Penning fixator applied, additional fragment fixation screws used in a crossed fashion to stabilize the fracture. (c) Clinical picture of the patient with fixator in situ. (d) Radiograph of the wrist at 2 years follow-up

Figure 3

(a) X-ray of wrist joint anteroposterior and lateral view showing AO type A unstable extra-articular fracture of the distal radius in a young soldier. (b) Closed reduction done followed by application of Penning fixator. (c) Penning fixator applied using a T-clamp in a radio-radial (periarticular) fashion. (d) Radiographs taken at 2 years

Figure 4

(a) X-ray of wrist joint anteroposterior and lateral view showing comminuted intra-articular fracture of distal radius; AO type C. (b) Penning fixator applied, fracture reduced, and unstable radioulnar joint stabilized using ulnar outrigger. (c) Radiographs taken at 6 months

Figure 5

Box plots showing anatomical outcome in the two cohorts

Figure 6

Graphics showing numerical and categorical Gartland and Werley scores and DASH score in the two cohorts

Figure 7

Two way scatter plot showing the correlation between functional and anatomical outcomes in the two cohorts at 2 years

Figure 8

Box plots of Gartland and Werley and DASH scores at 2 years in the AO type A fractures as per treatment (transarticular vs periarticular external fixation)