Full text of DOI:10.1016/S0020-1383(99)00207-7

Injury, Int. J. Care Injured 31 (2000) 75±79
www.elsevier.com/locate/injury
Displaced intra-articular fractures of distal radius: a comparative
evaluation of results following closed reduction, external ®xation
and open reduction with internal ®xation
Harish Kapoor, Ashoo Agarwal*, B.K. Dhaon
B1 B/4, Janakpuri, New Delhi 110058 India
Abstract
Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist.
Management of these fractures has remained controversial as far as modality of treatment is concerned. In this study 90 adult
cases of acute displaced intra-articular fractures of the lower end of the radius were classi®ed according to Frykman's and AO
classi®cations after obtaining radiographs in antero-posterior and lateral planes. These were randomly treated by one of three
methods: (1) closed reduction and plaster immobilisation, (2) external ®xation and (3) open reduction and internal ®xation, and
were followed for an average of 4 yr. In the ®nal functional assessment (Sarmiento) the results were (1) plaster 43% good and
excellent, 50% fair and 7% poor, (2) external ®xator 80% good and excellent, 20% fair and poor results, (3) open reduction and
internal ®xation 63% good and excellent, 26% fair, 11% poor. We recommend that displaced severely comminuted intra-
articular fractures should be treated with an external ®xator. # 2000 Elsevier Science Ltd. All rights reserved.
1
. Introduction
Cooney et al. [2] had stressed the importance of ana-
tomical correction and chose various methods of exter-
nal ®xation to achieve it. Bradway et al. [3] had laid
emphasis on achieving and maintaining an anatomical
reduction of fracture fragments by open reduction and
internal ®xation. The study was undertaken to evaluate
the results of various modalities of treatment in dis-
placed intra-articular fractures of the distal radius.
Fractures of the distal end of the radius have often
been considered primarily extra articular injuries of
elderly female. The distal end of the radius is being
exposed to increasingly severe trauma in younger
patients. The carpus is drawn into the distal end of the
radius like a diepunch resulting in comminution of its
articular surface. The reports of treatment methods
and results are con¯icting. Treatment of such injuries
is often dicult and demanding, particularly when the
fracture is severely comminuted or displaced. Varying
patterns of intra-articular fractures are common in
adults. They are commonly referred to as Colle's Bar-
ton's or Smith's, depending upon the pattern of invol-
vement of the distal radio ulnar and radio carpal joint
surface and the displacement. Nonoperative manage-
ment often includes the acceptance of some degree of
displacement and emphasis is placed on function [1].
2
. Materials and methods
The study has been carried out in the department of
orthopaedic surgery, Maulana Azad Medical College
and associated LNJP and G.B. Pant Hospitals between
July 1991 and July 1996.
Ninety adults cases of acute displaced intra-articular
fractures of the lower end of the radius were included
in the study and were followed up for an average of 4
yr. Assessment of the fracture was based on Frykman's
and AO classi®cations [7] after obtaining anteroposter-
ior and lateral radiographs. The patients were treated
*
Corresponding author.
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
PII: S0020-1383(99)00207-7

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H. Kapoor et al. / Injury, Int. J. Care Injured 31 (2000) 75±79
at random by any one of the following three methods
see Figs. 1 and 2).
ments of both involved and normal wrists were made.
Range of motion was measured using a goniometer.
The data obtained were tabulated, analysed and sub-
jected to standard statistical methods. Results were
assessed based on the Sarmiento functional score.
The statistical tests included student t-test, p-value
(
1
2
3
. Closed reduction and plaster immobilisation.
. External ®xation.
. Open reduction and internal ®xation.
2
For closed reduction and plaster immobilisation X-
or w tests and coecient of correlation and ANOVA
test (Table 1).
rays were taken at 1 and 6 weeks. One more attempt
at closed reduction under anaesthesia was performed if
the reduction was unacceptable. The plaster was main-
tained for 6±7 weeks.
3
. Frykman's classi®cation
We used the Roger and Anderson type of external
xator. Patients treated with the external ®xator were
®
The three groups were also similar in the fracture
taught daily pin track dressings and also encouraged
to use the limb for activities of daily living like writing,
eating, etc. Radiographic and clinical examinations
were done at one, two and 6±7 weeks. The ®xator was
removed as an outpatient procedure after 6±7 weeks
and a splint applied for 2 days after which mobilis-
ation was begun.
distribution according to Frykman's classi®cation.
Frykman's type VII and type VIII formed 67% of the
study.
The dominant side was involved in 65% of cases.
The three groups were followed up for an average of 4
yr. On comparing loss of dorsi¯exion and palmar¯ex-
ion we found the least loss with the ®xator following
by open reduction and internal ®xation and then plas-
ter (Fig. 3).
Patients treated with open reduction and internal
xation by means of Kirschner wires, small T plates or
®
both. Mobilisation began at 2 weeks. Active hand,
elbow and shoulder exercises were carried out through-
out: wax bath, wrist exercises and grip strengthening
exercises were done regularly. Grip strength measure-
3
.1. Grip strength
For restoration of grip strength, the ®xator was sig-
ni®cantly better than plaster immobilisation ꢀp ˆ 0:05).
Fig. 1. Preoperative Radiograph showing fracture lower end radius.
Postoperative radiograph with external ®xator in situ.
Fig. 2. Full range of pronation and supination in the same patient.

H. Kapoor et al. / Injury, Int. J. Care Injured 31 (2000) 75±79
77
Table 1
w ˆ 2:33, df 2, p ˆ 0:31 (not signi®cant)
Mode of treatment
Male
Female
Total cases
Type VIII
VII
III
IV
Plaster
Fixator
26
20
7
33
28
29
90
17
15
13
8
4
3
2
2
5
6
7
8
8
10
Open reduction
Total
19
65 (72.2%)
25 (27.8%)
3.2. Dorsal tilt
3.3. Radial length
Correction of dorsal tilt was achieved best by open
Radial length was best restored with ®xator, fol-
lowed by open reduction and internal ®xation and
then plaster immobilisation.
reduction and internal ®xation and ®xator technique.
Increase in dorsal tilt due to late collapse was seen as
follows:
3
.4. Articular step o€
Plaster: eight cases
Fixator: four cases
ORIF: two cases
Open reduction and internal ®xation is better than
plaster immobilisation for reducing articular step o€
while ®xator is also better than plaster immobilisation
for reducing the articular step o€. The maximum per-
centage of excellent and good anatomical results are
seen with open reduction followed by external ®xation
then plaster application.
There were 11 cases of volar angulation of the distal
fragment
Plaster: three cases
Fixator: three cases
ORIF: ®ve cases
3
.5. Functional score
It includes residual deformity, subjective evaluation,
objective evaluation and complications. The maximal
percentage of excellent and good functional results
were seen with the external ®xator followed closely by
open reduction and internal ®xation. These ®ndings
are not statistically signi®cant. (Table 2).
3
3
.6. Complications
.6.1. Plaster
Four patients had severe ®nger sti€ness after plaster
removal which gradually resolved with physiotherapy.
One patient had carpal tunnel syndrome which
resolved spontaneously without operative treatment.
3
.6.2. Fixator
One case of pin track infection controlled with anti-
septic dressings and antibiotics. Two cases of residual
cosmetic deformity, one case of sympathetic dystrophy
resolved by physiotherapy.
Table 2
Optained results
Excellent
Good
Fair
Poor
PLASTER
FIXATOR
Open reduction
2
6
7
8
8
5
11
2
2
2
2
Fig. 3. Full range of dorsi¯exion and palmar¯exion in the same
patient.
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H. Kapoor et al. / Injury, Int. J. Care Injured 31 (2000) 75±79
3
.6.3. ORIF
One case of super®cial infection subsided with
Emphasis has been given to restoration of radial
length and its relationship with the functional ability
of patients [7]. Out study supports this concept. The
radial length was best restored and maintained with
external ®xation. Aro and Koivenum [7] in a study on
axial shortening of radius had reported similar ®ndings
and suggested that external ®xation should always be
considered if there are any signs of persistent axial
shortening. We ®nd in our study, persistence of some
residual radial shortening in the three treatment
groups. Aro and Koivenum [7] had suggested that
complete restoration of the original radial length inevi-
tably calls for the need of bone grafting to ®ll the cre-
ated diastasis between with fracture fragments. Since
we did not perform primary bone grafting, some radial
shortening persisted. Radial shortening was strongly
correlated with the ®nal functional outcome in out
study. Jupiter [4] had also found a similar correlation
between the ultimate functional outcome and radial
shortening.
antibiotics and antiseptic dressings. The ®xation was
not rigid in four cases with severe comminution
and all these cases had fair and poor functional
results.
4
. Discussion
The three groups were similar in age, sex and de-
formity. The average age was 39 yr. In other reported
series the average age was 63 [2], 27.6 [4] and 37 [5].
The mode of injury was road trac accident in sev-
enty percent of cases. This is similar to the ®ndings of
Jupiter and Knick [4].
The average loss of the arc with plaster was 378 in
comparison with 198 by external ®xator. Cooney et al.
[
2] reported an average loss of 178 by external ®xator
with loss of 108 if pronation and supination and loss
of 148 of radial and ulnar deviation. With the external
®
Cooney et al. [2] had 87% good and excellent results
with the use of the Roger Anderson frame external
®xator with a follow up 204 yr. With the same ®xator
assembly, we achieved 82% similar results in an aver-
age of 4 yr follow-up. The results are quite similar.
Saunders et al. [8] reported 68% good and excellent
results with the use of an external ®xator.
xator loss of pronation and supination was 238 and
radial and ulnar deviation 138. Our results tally with
the work of Cooney et al. [2]. With the use of a plaster
case, the average loss of dorsi¯exion and palmar ¯ex-
ion was 378, radial and ulnar deviation was 168 and
pronation±supination was 408. This is in conformity
with the work of Kongsholm and Olerud [6] who in
their comparative study between plaster cases and ®xa-
tor found a similar high loss of range of motion with
the use of a cast. With open reduction and internal ®x-
ation, the average loss of dorsipalmar ¯exion was 308,
radio-ulnar deviation was 158 and pronation±supina-
tion was 308. Similar loss of motion was seen in the
study by Bradway et al. [3] on open reduction and in-
ternal ®xation of displaced intra-articular fractures of
the distal radius.
5. Conclusion
We conclude that primary operative treatment gen-
erates signi®cantly better anatomical and functional
results than closed reduction and casting. Plaster case
is insucient to maintain the reduction in the majority
of displaced intra-articular fractures. Remanipulation
is required in a large percentage of cases, reduction
slips often, cosmetic deformity persists and there are a
large number or associated complications.
Pronation and supination was best restored with the
use of an external ®xator. Frykman had pointed out in
1967 that increased range of pronation and supination
is due to better alignment of the distal radio-ulnar
joint. The realignment of the distal radio-ulnar joint is
best achieved with a ®xator. Hence a better range of
motion is observed with the ®xator. Patients were also
encouraged to perform pronation and supination as
this motion is not restricted by this device.
The average grip strength (in comparison with the
normal side) in our groups was ®xator 70%, open re-
duction and internal ®xation 68% and plaster 63%.
The better grip strength in the wrist treated by exter-
nal ®xation is probably due to a combination of
decreased pain and better joint and muscle mechanics
as explained by Kongsholm and Olerud [6]. In their
comparative study, average grip strength in the ®xa-
tor group was 90% while in the plaster group was
Open reduction and internal ®xation provides the
best articular anatomy and therefore patients treated
by this method have the least change of developing
secondary osteoarthritis as suggested by the literature.
It is the treatment of choice if there is a residual
articular stepo€ > 2 mm. It should preferably be
avoided in severely comminuted fractures as the ®x-
ation is not stable and functional results are not good.
Good results are seen with the use of external skel-
etal ®xation in displaced intra-articular fractures. It
maintains the radial length best due to sustained coun-
ter-traction utilising the principle of ligamentotaxis.
Best results in severely comminuted fractures are seen
with a ®xator. The complications with this procedure
are minimal with meticulous pin insertion and pin site
care.
65%.

H. Kapoor et al. / Injury, Int. J. Care Injured 31 (2000) 75±79
79
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