Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Jesse B. Jupiter, MD*,
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
Posted July 2009
Perhaps my more than thirty years of involvement as a
clinician, investigator, and student of the distal radial fracture allow me to
have somewhat of a broad perspective on the data presented in the prospective
study by Wei et al. This outcome study is based primarily on the Disabilities
of the Arm, Shoulder and Hand (DASH) scoring. In comparing the results of volar
plate application, radial column plate application, and bridging external
fixation, Wei et al. found that the mean DASH scores for the volar plate group were
significantly better (although still a mean and standard deviation of 41 ± 23) at
six weeks when compared with the scores of the external fixation group (p =
0.037), that they differed little from those of the other two groups at six
months, and that they differed little from those of the external fixation group
at one year. They also reported that the external fixation group had significantly
better recovery of grip strength at six months when compared with that attained
by the radial column plate group (p = 0.042) but that there were no significant
differences among the groups with regard to ulnar variance or volar tilt at any
follow-up period. A limitation of the study was that the three cohorts were
reduced in number because of substantial loss to follow-up.
One could justifiably ask whether DASH scoring is really the
best outcome-assessment tool for this injury as compared with wrist function (i.e.,
grip strength), which has been shown to be a significant predictor (p < 0.01)
of the patient-rated wrist evaluation score1. The DASH has become
the most widely used subjective questionnaire, yet I believe it may not be
sensitive to region-specific injury outcomes in the upper limb.
Secondly, it should come as no surprise that allowing a
patient to use his or her hand and upper limb, without additional support,
within ten to fourteen days after treatment with plates will produce a more
favorable subjective perspective by the patient than will treatment with a
cumbersome and uncomfortable external fixation device. Cassidy et al.
documented this clearly in a very large prospective study in which
Norian SRS and early motion were compared with alternative treatments that required six
weeks of immobilization2. Furthermore, it must be emphasized that by
three months, and certainly by six months, in the current study as well as in
many others3-10, overall function and motion begin to equalize.
Beyond the association between internal plate fixation and a
transitory improvement in function and DASH score, why has there been such wide
enthusiasm and utilization of this technique? The development of anatomically
shaped plates that can be applied to the flatter volar surface and that
incorporate angular stable screw-fixation technology has permitted, with a
reasonable degree of predictability and safety, stable fixation and early use
of the hand and wrist for the most affected group of patients—that of the older
individual who is otherwise healthy, active, and independent. It is a technique
that can be applied by most orthopaedic surgeons without the need for a
specialist, which means that this care can be provided to patients at almost
every hospital or clinic. The need for multiple follow-up visits and protracted
periods of therapy, which were so commonplace when most patients were treated with
cast immobilization (first above-the-elbow, then below-the-elbow), has been
substantially minimized, and the prevalence of deformity is equally less
commonly observed.
Yet, along with increased enthusiasm for volar plate surgery
have come recent reports of complications and the need for revision surgery11.
The technique is not immune to the tendon problems that are so often seen with
dorsal plate application and that can cause deformity, neurologic dysfunction,
and hand and forearm contracture.
Will this technology be the optimal treatment for years to
come? I do not think so. There is much interest in the development of minimally
invasive techniques of treating skeletal fractures, and I envision that we will
be seeing and using percutaneous methods of fracture reduction and even newer
cementing techniques. While it is less likely that there will be a return to
external skeletal fixation regardless of its proven efficacy, every surgeon in
training should nevertheless become familiar with its application because it
will remain useful in the treatment of special fractures or fractures associated
with major soft-tissue trauma.
*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.
References
1. Karnezis IA, Fragkiadakis EG. Association between objective clinical variables and patient-rated disability of the wrist. J Bone Joint Surg Br. 2002;84:967-70.
2. Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, Husband J, Ladd A, Seitz WR, Constanz B. Norian SRS cement compared with conventional fixation in distal radial fractures: a randomized study. J Bone Joint Surg Am. 2003;85:2127-37.
3. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. J Bone Joint Surg Br. 1996;78:404-9.
4. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3):CD003209. Update.
5. 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.
6. Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury. 2000;31:75-9.
7. Kreder HJ, Hanel DP, Agel J, McKee M, Schemitsch EH, Trumble TE, Stephen D. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87:829-36.
8. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg [Am]. 2005;30:1185-99.
9. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am]. 2005;30:289-99. Erratum in: J Hand
Surg [Am]. 2005;30:629.
10. Zamzuri Z, Yusof M, Hyzan MY. External fixation versus internal fixation for closed unstable intra-articular fracture of the distal radius. Early results from a prospective study. Med J Malaysia. 2004;59:15-9.
11. Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21:316-22.
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