EDITOR'S NOTE: The authors were invited to respond to the letter but, to date, have not done so.
To the Editor:
We read with interest the July 2009 article by Wei et al. (1) entitled, “Unstable Distal Radial Fractures Treated with External Fixation,a Radial Column Plate, or a Volar Plate...” and would like to make the following points.
1. In the Materials and Methods, the authors define the three treatment arms of the study. The external fixator group incorporates “additional augmentation” that includes patients that required cancellous bone allograft and/or “the additional use of small buttress plates”. No detail is given to these additional surgical procedures, all of which can significantly influence clinical outcome (2). Subsequently, can the outcome in this group be solely attributable to external fixation as this study states?
2. Previous studies suggest a statistical correlation between instability of the distal radioulnar joint (DRUJ) and worse clinical outcomes (3-5). No assessment has been detailed in this study of DRUJ instability and indeed the Orthopaedic Trauma Association classification does clearly differentiate involvement of the DRUJ. Do the authors feel
that DRUJ instability is a possible confounding factor in the outcome of these fractures?
3. It is recognized that a correlation exists between functional outcome and the restoration of the radiocarpal and radioulnar relationships (6,7). Further, carpal alignment in relation to the distal radial articular surface after healing may also be an important factor in the outcomes of treatment of distal radial fractures (8). As this study provides no direct evaluation of carpal alignment following treatment, such as the scapholunate angle, do the authors consider carpal alignment a significant factor in wrist function?
4. The relative bone mineral density (BMD) of each of the three treatment arms studied is not provided in the results. Whilst the quantification of the BMD may be superfluous in routine clinical practice, for a clinical study evaluating three different surgical techniques,
including locking plates, the results should be matched for BMD (9). Specifically, should the reader assume all patients are osteoporotic by the nature of the fracture and their age, and if so is this assumption a valid one?
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.
References
1. Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1568-77.
2. Dodds SD, Cornelissen S, Jossan S, Wolfe SW. A biomechanical comparison of fragment-specific fixation and augmented external fixation for intra-articular distal radius fractures. J Hand Surg Am. 2002;27:953-64.
3. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;229-35.
4. Lindau T, Aspenberg P. The radioulnar joint in distal radial fractures. Acta Orthop Scand. 2002;73:579-88.
5. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioulnar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002;73:151-6.
6. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951;33-A:895-907.
7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59.
8. Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79:1290-302.
9. Nordvall H, Glanberg-Persson G, Lysholm J. Are distal radius fractures due to fragility or to falls? A consecutive case-control study of bone mineral density, tendency to fall, risk factors for osteoporosis,
and health-related quality of life. Acta Orthop. 2007;78:271-7.
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