European Journal of Cardiovascular Medicine

Fractures of the distal radius are common.^1-3 The increasing incidence of these injuries may be attributed to an aging population (osteoporotic fractures) and the growing participation in outdoor pursuits (higher energy fractures).^4,5 The radius is one of two long bones that make up the human antebrachium, the other bone being the ulna. The radius has three borders, three surfaces, and has a prismoid shape in which the base is broader than the anterior border. The radius articulates proximally at the elbow with the capitulum of the humerus and the radial notch of the ulna. It articulates at its distal end with the ulna at the ulnar notch and with the articular surfaces of the scaphoid and lunate carpal bones.⁶

Currently, distal end of radius bone fracture is the most frequent fractures treated by orthopedic surgeons.^7-10 Seventeen percent fracture of distal end of radius bone out of total fracture occurred globally.¹¹ Distal radius fractures is found in 30% of the patients.¹² Distal radius fractures are injuries that can cause a loss of wrist function and disability and are most commonly seen in elderly patients.¹³ In young population, high-energy trauma by intra-articular component in distal radius fractures which leads to sharp and fixed fractures with displacement of the fracture fragments. Extra-articular fracture seen mostly in elder population and intra-articular in younger population. The radius initially fails in originally on the volar aspect, with the fracture leading dorsally where bending forces bring out compressive stresses, ensuing in dorsal comminution. Additional shearing forces control the injury pattern, leading towards articular surface involvement.¹⁴

Lots of fractures of the distal aspect of the radius are relatively uncomplicated and are effectively treated by closed reduction (CR) and immobilization in plaster of Paris (POP) cast. However, vast majority of fractures of the distal end of radius are articular injuries that result in disruption of either radiocarpal joint or distal radioulnar joint or both.^15,16 Intra‑articular fractures are inherently unstable, are difficult to reduce anatomically and immobilize in POP cast, and are associated with high rate of complications.¹⁷

The aim of the present study was to compare the efficacy of volar locking plate and K wire fixation with POP cast procedure in intra articular distal end radius fractures among elderly patients.

The Study was conducted at Maharishi Markandeshwar Medical College and Hospital (MMMCH), Kumarhatti, Solan, Himachal Pradesh, India from December 2020 to December 2022. All confirmed cases of stable and unstable distal radius fracture registered at the orthopedic department of MMMCH, Kumarhatti, Solan.

Study has included 60 confirmed cases of stable and unstable distal radius fracture diagnosed during study period. The study participants were divided into two groups: Group A (operated by volar locking plate): n=30 and Group B (operated by K wire fixation with POP cast): n= 30

Inclusion criteria :-

• Age > 50 years
• Displaced distal radius fracture
• Patient with both radius and ulna fracture(comminuted)
• Open fractures
• Injury upto 2 weeks.
• Patients who gave informed written consent

Exclusion criteria: -

• Age of patient ≤ 50 years.
• DRUJ injury
• Previous deformity or fracture
• Rheumatoid arthritis.
• Injury more than 2 weeks.
• Open Fracture
• Diabetes Mellitus

The study has been presented to Institutional Ethics Committee (IEC) for ethical clearance, after getting clearance from IEC the study has been started.

Detailed History and clinical examination were done. Demographic data including age, sex, socio-economic statutes, rural or urban background was obtained.

Routine blood investigations were done.

Study has evaluated the surgical procedures efficacy post op complications as well as implant failure, evaluated the time take for the patient rehabilitate and resume his/her functioning of day-to-day activities post immobilization via plaster cast. The patients has been followed up for a period of minimum 6 months postoperatively, and the result has been interpreted by comparison of both treatment modalities in terms of functional/clinical and radiographic outcomes.

Conservative management:

Closed reduction with cast immobilization.

Under regional or general anaesthesia, the patient was positioned supine with the effected forearm maintained parallel to the floor with flexion of the elbow at 90 degrees. Closed reduction was done manually by applying longitudinal traction and correcting the angulation by manipulating the distal fragment. The goal of reduction was to regain radial height and correct the radial and volar tilt of the distal radial epiphysis. The quality of reduction was checked with radiological AP and lateral projections.

Surgical technique:

Surgical procedures has been performed by various trauma surgeons with various levels of experience as well as supervised residents.

All patients has been given preoperative antibiotic prophylaxis (ceftriaxone 1gm intravenously), while surgery has been performed under loco-regional or under general anaesthesia. Use of tourniquet has been as per surgeon’s preference. A sterile exposure closed reduction has been done. Alignment and reduction checked under C-arm.

Although management of distal end radius in elderly is controvertial the two techniques used here for surgical intervention are K- wire fiaxation with POP cast and the other being Volar Locking Plate. Patients has been receiving a dorsal blocking slab for 2 weeks after either procedures.

Postoperative treatment:

Patients has been receiving a cast for immobilisation for a period of 4 weeks. Conventional radiographic images has been performed post-operatively at day 2. Patients has been assessed at 2nd, 4th, & 6th week in OPD follow-up. Passive ROM has been initiated after 2-3 days under supervision and active ROM has been initiated after removal of the cast at 2 weeks. Patients has been referred to a specialised hand physiotherapist for guided mobilisation if full function does not occur within 2 weeks after cast immobilisation. During follow up radiographic, functional and wound control has been performed in the OPD. Patients has been released from the OPD follow up after full recovery. Therefore, each patient has been clinically followed up for a minimum of 6 months. All inserted K- Wires has been removed after 6 weeks, if no complications occur.

Clinical evaluation:

Clinical evaluations have been performed independently. Which includes ROM of the injured wrist joint, VAS for injured wrist joint pain. Active ROM for patients with injured DRUJ and TFCC integrity has been evaluated. Also, PRWE has been evaluated, and pain during daily activity has been accessed using a VAS in which 0 indicated no pain and 10 indicated the most severe pain.

Radiographic evaluation:

Radiographic assessments have been performed using a post-operative x-ray which includes radiological patterns mostly in AP and lateral view at wrist have generally used the following criteria for acceptable alignment.

<_ 10-to-15-degree dorsal angulation, <_20-degree volar angulation, <_2 to 4 mm ulnar variance, >_ 15-degree radioulnar inclination angle and <2 mm step off or gap on the joint line at 6 weeks postoperatively or after conservative management. Shortening to be measured on the AP view by subtracting the length of the injured wrist from that of the non-injured wrist preoperatively and at 6 weeks after surgery or after conservative management.

Statistical method: Collected data has been entered in the excel data sheet and data analysis has been done with the help of Epi. Info.7.2 software.

Ethical issue:- The study has been presented to Institutional Ethics Committee for ethical clearance. A written informed consent has been obtained from the subjects after full explanation of the requirement of the study. There is no any interference or influence of research process on the treatment of the patient. The treating team has been free to administer the treatment as it consider appropriate based on clinical requirement of the patient. All the information collected has been strictly used for study purpose and confidentiality has been strictly maintained. This was also ensuring to study participants before staring study.

Table 1: Demographic data

13.3%, 30.0%, 40.0%, 16.7% participants of ‘VLP’ group and 16.7%, 23.3%, 43.3%, 16.7% participants of ‘K wire’ group were belonged to age group 50-60, 61-70, 71-80, >80 years respectively. The distribution of participants according to age was statistically not significant (p>0.05). The mean age of participants of ‘VLP’ & ‘K wire’ group was 73.8 years with 6.1 SD & 74.1 years with 9.7 SD respectively. 76.7%, 23.3% participants of ‘VLP’ group and 80.0%, 20.0% participants of ‘K wire’ group were male & female respectively. 56.7%, 43.3% participants of ‘VLP’ group and 46.7%, 53.3% participants of ‘K wire’ group were noted with left & right side fracture respectively. The distribution of participants was statistically not significant (p>0.05). 43.3%, 56.7% participants of ‘VLP’ group and 36.7%, 63.3% participants of ‘K wire’ group have mode of injury was Fall on outstretch hand & RTA respectively. 30.0%, 53.3%, 16.7% participants of ‘VLP’ group and 26.7%, 60.0%, 13.3% participants of ‘K wire’ group were belonged to AO class C1, C2, C3 respectively. The difference between mean age participants, gender wise, fracture side wise, mode of injury wise and AO fracture wise distribution of participants was statistically not significant (p>0.05).

Table 2: Type of injury, mean dash score distribution of study participants

93.3%, 6.7%, 0.0% participants of ‘VLP’ group and 90.0%, 0.0%, 10.0% participants of ‘K wire’ group were noted with close, Open (GA1), open (GA2) type of injury respectively. The distribution of participants according to type of injury was statistically not significant (p>0.05). The mean DASH score was 17.9 ± 2.2, 12.5 ± 1.4, 6.81 ± 1.0 in ‘VLP’ group and 22.4 ± 4.1, 14.3 ± 3.1, 9.7 ± 2.2 in ‘K wire’ group at postoperative duration 2, 4, 6 months respectively. The difference between mean DASH score at post-operative duration 2, 4, 6 months of participants of VLP & K wire group was statistically significant (p<0.05).

Table 3: Distribution of study participants according to mean range of motion and radiological evaluation at 6 months

The mean ‘range of motion’ like ‘Palmer flexion’, ‘Dorsiflexion’, ‘Supination’, ‘Pronation’, ‘Radial deviation’, ‘Ulnar deviation’ was 78.1 ± 1.9, 67.0 ± 1.9, 81.2 ± 2.3, 78.4 ± 2.2, 21.8 ± 1.7, 23.0 ± 0.9 in ‘VLP’ group and 70.1 ± 4.6, 64.9 ± 4.8, 71.3 ± 2.4, 70.6 ± 2.3, 20.0 ± 1.8, 21.8 ± 1.7 in ‘K wire’ group respectively. The difference between mean range of motion of participants of VLP & K wire group was statistically significant for all parameters (p<0.05). The mean of parameters for radiological evaluation like Volar tilt, Radial Inclination , Ulnar Variance, Radial Length was 12.4 ± 0.69, 23.5 ± 1.7, -1.18 ±0.49, 12.4 ± 0.33 in ‘VLP’ group and 11.4 ± 0.86, 22.3 ± 1.74, -1.28 ± 0.37, 12.2 ± 0.6 in ‘K wire’ group respectively. The difference between mean parameters for radiological evaluation participants of VLP & K wire group was statistically significant for all parameters (p<0.05) except ulnar variance (p>0.05).

Table 4: Post-operative Complication distribution of study participants

3.3%, 0.0%, 10.0%, 6.7%, 10.0% participants of ‘VLP’ group and 0.0%, 13.3%, 16.7%, 3.3%, 6.7% participants of ‘K wire’ group have noted with complication like Infection, Pin site infection , Wrist Stiffness, Hand shoulder syndrome, Superfiial nerve neuropraxia respectively. The distribution of participants according to complication were statistically not significant (p>0.05).

Table 5: Distribution of study participants according to mean modified demerit score, duration of procedure and VAS score

The mean modified demerit score was 4.7 ± 2.0, & 7.1± 2.5, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean modified demerit score of participants of VLP & K wire group was statistically significant (p<0.05). The mean duration of surgery was 40 min ± 8.6, & 36 min ± 7.4, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean duration of surgery among participants of VLP & K wire group was statistically not significant (p>0.05). The mean VAS score was 3 ± 1.0, & 4 ± 0.8, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean VAS score among participants of VLP & K wire group was statistically not significant (p>0.05).

The radius is one of two long bones that make up the human antebrachium, the other bone being the ulna. The radius has three borders, three surfaces, and has a prismoid shape in which the base is broader than the anterior border. The radius articulates proximally at the elbow with the capitulum of the humerus and the radial notch of the ulna. It articulates at its distal end with the ulna at the ulnar notch and with the articular surfaces of the scaphoid and lunate carpal bones.⁵

13.3%, 30.0%, 40.0%, 16.7% participants of VLP group and 16.7%, 23.3%, 43.3%, 16.7% participants of ‘K wire’ group were belonged to age group 50-60, 61-70, 71-80, >80 years respectively. The distribution of participants according to age was statistically not significant (p>0.05). The mean age of participants of ‘VLP’ & ‘K wire’ group was 73.8 years with 6.1 SD & 74.1 years with 9.7 SD respectively. The difference between mean age participants was statistically not significant (p>0.05). A similar study done by Shukla R et al¹⁹ and Raj H et al²⁰ noted overall mean age was 36 years and (44 in VLP, K wire group both), which is lower than the present study because present study did not include below 50 years age group. 76.7%, 23.3% participants of ‘VLP’ group and 80.0%, 20.0% participants of ‘K wire’ group were male & female respectively. The gender wise distribution of participants were statistically not significant (p>0.05). These findings are correlate with the study done by Mishra AK et al.²¹

56.7%, 43.3% participants of ‘VLP’ group and 46.7%, 53.3% participants of ‘K wire’ group were noted with left & right side fracture respectively. The fracture side wise distribution of participants was statistically not significant (p>0.05). A another similar study done by Yu X et al²² noted left & right side fracture in 48.7% & 51.3% and 43.5% & 56.5% in group ‘VLP’ and ‘K wire’ respectively. 30.0%, 53.3%, 16.7% participants of ‘VLP’ group and 26.7%, 60.0%, 13.3% participants of ‘K wire’ group were belonged to AO class C1, C2, C3 respectively. The distribution of participants according to AO classifcation was statistically not significant (p>0.05). 93.3%, 6.7%, 0.0% participants of ‘VLP’ group and 90.0%, 0.0%, 10.0% participants of ‘K wire’ group were noted with close, Open (GA1), open (GA2) type of injury respectively. The distribution of participants according to type of injury was statistically not significant (p>0.05). These findings are correlate to study done by Mishra AK et al²¹ and Yu X et al.²²

The mean DASH score was 17.9 ± 2.2, 12.5 ± 1.4, 6.81 ± 1.0 in ‘VLP’ group and 22.4 ± 4.1, 14.3 ± 3.1, 9.7 ± 2.2 in ‘K wire’ group at post- operative duration 2, 4, 6 months respectively. The difference between mean DASH score at post-operative duration 2, 4, 6 months of participants of VLP & K wire group was statistically significant (p<0.05). These findings are correlate with the study done by Mishra AK et al.²¹ A study done by Marcheix PS et al²³ did study among 103 patients aged 50 years with unstable extra- and intra-articular fractures to volar locking plates. At 3 and 6 months, the plated patients had better objective functional results and reported better DASH scores, which is in accordance with present study observations. The mean ‘range of motion’ like ‘Palmer flexion’, ‘Dorsiflexion’, ‘Supination’, ‘Pronation’, ‘Radial deviation’, ‘Ulnar deviation’ was 78.1 ± 1.9, 67.0 ± 1.9, 81.2 ± 2.3, 78.4 ± 2.2, 21.8 ± 1.7, 23.0 ± 0.9 in ‘VLP’ group an70.1 ± 4.6, 64.9 ± 4.8, 71.3 ± 2.4, 70.6 ± 2.3, 20.0 ± 1.8, 21.8 ± 1.7 in ‘K wire’ group respectively. The difference between mean range of motion of participants of VLP & K wire group was statistically significant for all parameters (p<0.05). A study done by Raj H et al²⁰ observed that the mean pronation in the first month for the volar plate group is 28.84±4.99 and for the k-wire group is 25.56±3.57 which is statistically significant.

The mean of parameters for radiological evaluation like Volar tilt, Radial Inclination , Ulnar Variance, Radial Length was 12.4 ± 0.69, 23.5 ± 1.7, -1.18 ± 0.49, 12.4 ± 0.33 in ‘VLP’ group and 11.4 ± 0.86, 22.3 ± 1.74, -1.28 ± 0.37, 12.2 ± 0.6 in ‘K wire’ group respectively. The difference between mean parameters for radiological evaluation participants of VLP & K wire group was statistically significant for all parameters (p<0.05) except ulnar variance (p>0.05). These findings are similar to study done by Lee SJ et al²⁴, Hollevoet N et al²⁵ and Mishra AK et al.²¹

3.3%, 0.0%, 10.0%, 6.7%, 10.0% participants of ‘VLP’ group and 0.0%, 13.3%, 16.7%, 3.3%, 6.7% participants of ‘K wire’ group have noted with complication like Infection, Pin site infection , Wrist Stiffness, Hand shoulder syndrome, Superficial nerve neuropraxia respectively. The distribution of participants according to complication were statistically not significant (p>0.05). These findings are similar to study done by Raj H et al²⁰ and Mishra AK et al.²¹ The mean modified demerit score was 4.7 ± 2.0, & 7.1± 2.5, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean modified demerit score of participants of VLP & K wire group was statistically significant (p<0.05). These findings are correlate to study done by Raj H et al²⁰ and a study done by Yu X et al²² noted that VLP group exhibited a better modified demerit score (2.5 ± 2.7 vs 3.7 ± .2.4) than EF group. The mean duration of surgery was 40 min ± 8.6, & 36 min ± 7.4, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean duration of surgery among participants of VLP & K wire group was statistically not significant (p>0.05). These findings are correlate to study done by Yu X et al.²² The mean VAS score was 3 ± 1.0, & 4 ± 0.8, in ‘VLP’ group and ‘K wire’ group respectively. The difference between mean VAS score among participants of VLP & K wire group was statistically not significant (p>0.05). Present study observed the lower VAS score noted among the participants of VLP group compare to participants of ‘K wire’ group (p>0.05).

Distal radius fractures are injuries that can cause a loss of wrist function and disability and are most commonly seen in elderly patients. A closed reduction and fixation with a plaster cast is the initial treatment used which is both simple and reliable Surgical intervention can be performed to obtain acceptable functional outcome and radiological values. The use of percutaneous pin fixation, Kapandji’s intrafocal pinning ext fix devices that permit distraction and palmar translation, low profile internal fixation plates, arthroscopically assisted reduction, and bone grafting techniques including bone‑graft substitutes, all have contributed to improved fracture stability and outcome

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