Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Marco Rizzo, MD*,
Mayo Clinic, Rochester, Minnesota
Posted September 2008
Years ago, during my fellowship, external fixation and
pinning was the predominant method of treating unstable dorsally angulated
distal radial fractures. The surgical management of these injuries has changed substantially
in the past decade. While the concept of open reduction and volar plating for
unstable dorsally angulated distal radial fractures is not new, previous
attempts at using nonlocking volar plates were associated with instances of
loss of reduction and hardware failure1. Thus, most surgeons used
this method only for volarly displaced fractures, such as a volar Barton or
Smith fracture. Locking technology affords a more stable construct, and, since
the landmark article by Orbay2, this technique has assumed a greater
role in the management of these injuries. In addition, the introduction of
fragment-specific fixation systems has allowed orthopaedic surgeons another
method of achieving successful open reduction and internal fixation3.
Finally, a newer generation of dorsal plates that have a lower-profile have
improved the outcomes in comparison with the outcomes of the previous
generation of hardware4. Is this trend scientifically warranted, or
is it hasty? I now use open reduction and internal fixation in the management
of many distal radial fractures that I would have previously managed with
external fixation and pins. Is it in the patient's best interest to proceed
with these newer treatments, or (in the words or Dr. Ronald Linscheid) "should
we stay a couple of fads behind?"
Koval and colleagues do an excellent job of analyzing this
trend in detail and in considering its justification. In more precisely
defining this trend, the authors benefited from the large database of
information collected by the American Board of Orthopaedic Surgery (ABOS). They
further propose explanations for this trend in the operative treatment of these
common fractures. (As an aside, I think this paper underscores the value of the
data collected by the ABOS and is a good example of how this information can be
beneficial.)
More than 12,000 distal radial fractures were surgically
treated between 1999 and 2007 by more than 3000 surgeons. The incidence of
surgical treatment increased over this nine-year period, from 3.2 to 5.2 per
surgeon. Forty-two percent of patients were treated with open reduction and
internal fixation in 1999. This number nearly doubled to 81% in 2007. The overall
reported complication rates were greater in the external fixation group. However,
more patients who underwent open reduction and internal fixation had nerve-related
complications. Infection rates were higher in the external fixation cohort. While
somewhat subjective, early term physician-perceived and patient-perceived
outcomes were superior in the ORIF group.
The authors speculate on reasons for the striking shift in
treatment. Since these surgeons are young, it appears that this trend is in
large part a reflection of their training. They correctly cite the lack of good
comparison studies. Nevertheless, I feel that this shift in treatment methods is
not unwarranted. Although most of the comparison studies are not Level-1
studies, there are data to support the use of locked volar plating for many of
these fractures. The authors do a good job of reviewing the current literature.
My experience has been similar: patients who undergo open reduction and
internal fixation have earlier restoration of range of motion and less
complicated rehabilitation; however, the long-term outcomes are very similar5.
I agree with the authors regarding the additional reasons
for moving away from external fixation. Pin-track infections can be a problem. However,
most of these can be avoided with proper patient education and compliance. I
also find that bracing to support the splint can help share the load on the
pins and that patients prefer not to see an external fixator across their
wrist. Moreover, even in cases where the fixators are not overdistracted, early
range of motion of the fingers appears to be more laborious for patients.
I believe that open reduction and internal fixation
(regardless of the preferred technique: volar plating, fragment specific, or
dorsal plating) is here to stay. One of the challenges that arises from this
shift in treatment lies in identifying the appropriate indications for open
reduction and internal fixation compared with those for external fixation. I
think it is important to remember that not all distal radial fractures are
equal and that these two methods are not mutually exclusive. Despite the fact
that, in my practice, many types of fractures that were previously treated with
external fixation are now treated with open reduction and internal fixation,
external fixation maintains a role in the treatment of some distal radial
fractures. The fracture pattern will determine the best treatment in my hands. Understanding
the strengths and limitations of the particular method and adhering to the fundamental
principles that we learned as residents will help us to continue to improve
treatment of these injuries and optimize patient outcomes.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family 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 author, or a member of his immediate family, is affiliated or associated.
References
1. Lacroix H, Jacobs PB, Keeman JN. Operative treatment of unstable distal radial fractures. Neth J Surg. 1987;39(2):59-64.
2. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000;5:103-12.
3. Medoff RJ, Kopylov P. Open reduction and immediate motion of intra-articular distal radius fractures with fragment specific fixation system. Arch Am Acad Orthop Surg. 1999;2:53-61.
4. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg [Am]. 2006;31:1061-7.
5. Rizzo M, Katt BA, Carothers JT. Comparison of locked volar plating versus pinning and external fixation in the treatment of unstable intraarticular distal radius fractures. Hand. 2008;3:111-7.
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