Radiological outcomes of AO type B and C distal radius fractures managed with 2.7 mm volar locking plate fixation in geriatric population: a retrospective analysis

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INTRODUCTION

Distal end radius fractures are one of the most common fractures encountered by the orthopaedic surgeon with a bimodal age distribution. Compared to younger patients, elderly with distal radius fractures have usually poorer bone quality and higher comminution which may compromise the treatment outcome. Management for distal radius fractures has evolved significantly over the years. Closed manipulative reduction and below elbow cast application has been the main treatment especially for the elderly people.¹ However, the outcomes are often less than satisfactory with loss of reduction, limitation of function and disabilities. Several studies have shown that after a distal radius fracture, patients function more effectively when the anatomy is restored.² So, anatomic reduction with stable fixation is usually the choice treatment for displaced intra-articular fractures. While osteoporosis and poor bone quality hamper fracture stabilization, locking compression plates (LCPs) provide enhanced stability and axial loading force as compared to conventional plates.^3-5 The current study retrospectively analysed the post-operative radiological outcomes in a 2.7 mm volar LCP system used for internal stabilisation of distal radius fractures based on the Sarmiento’s modification of Lindstorm criteria.⁶

METHODS

This is a retrospective study conducted at Sanjay Gandhi institute of trauma and orthopaedics, Bangalore. The sample comprised of 25 patients. All patients aged 60 years and over with closed, intraarticular distal radius fractures (AO type B and C) treated with 2.7 mm volar locking plate fixation between June 2018 to July 2020 were included in study.⁷ The exclusion criteria were distal radius AO classification type A, bilateral distal radius fractures, poly-trauma patients with an injury severity score of more than 16, concomitant distal ulna fractures with metaphyseal involvement, same-side upper limb injury that affected the overall functional outcome or an open fracture, patients in whom bone grafting or bone substitute was used were excluded from the study to eliminate surgical-related bias.⁸ A proforma was used to collect data pertaining to patient demographics, procedure details, mode of injury, type of fracture, duration and type of immobilisations and complications once they have provided their written informed consent.

The radiographic assessment was the prime outcome. So, X-ray of the wrist in the anteroposterior and true lateral views taken pre-operatively, immediate post-operative, six weeks and three months were assessed (Figure 1-4).

Radiographic measurements were performed by two independent observers on digital radiographs with the help of a computer software according to the methods of Medoff and mean values were obtained.⁹ The radiological outcome was scored based on the Sarmiento’s modification of Lindstorm criteria which comprised of recording and grading palmar tilt, radial angulation, articular congruency and radial length.⁶ Analysis was done using descriptive statistics. Difference between data of follow up intervals was estimated by student’s paired t test. A statistical package SPSS version 17.0 and MS excel was used to do the analysis. A p value <0.05 was considered as significant with a 95% confidence interval.

RESULTS

All 25 patients underwent the surgical procedure under regional anaesthesia and within a week after the injury.

The modified Henry’s approach was used. The limb was immobilised in a below elbow plaster splint until suture removal on the eleventh or the twelfth post-operative day. Active finger movements were initiated early followed by wrist mobilisation after three to four weeks, check X-rays of the wrist in the anteroposterior and true lateral views were taken in the immediate post-operative, six weeks and three months. The study comprised of sixteen (64%) females and nine males (36%). The mean age was 70.28±6.39 with range being 60 to 84 years. Slip and fall on an out stretchered hand from standing height (72%) was the most common mode of injury. With AO type B3 (60%) being the most common type of fracture pattern.

Post-operative check X-ray were analysed at immediate post-operative, six weeks and three months. The mean immediate post-operative radial shortening, loss of radial deviation and decrease in palmar tilt were 3.80±1.03, 4.38±1.05and 3.97±1.02, respectively. The corresponding values at last follow up were 4.31±1.12, 6.19±1.02 and 4.76±0.99, respectively (Table 1). No statistically significant difference (p=0.949; p=1.0; p=0.996) in radial shortening, decrease in palmar angulation and loss of radial deviation was seen at the final follow up. These parameters were then graded and scored using the Sarmiento’s modification of Lindstorm criteria to assess the radiological outcome which showed that majority had a good outcome (80%, N=20) and excellent in 20% (N=5) (Table 2).

DISCUSSION

We all know that fracture of the distal radius especially intra articular ones requires accurate restoration of the anatomy and articular congruity. Failure to restore radiographic parameters can have a negative effect on the functional outcome. This is assessed by radiographic parameters. The late post-operative complications such as post traumatic arthritis, reduced grip strength, loss of range of motion, instability has been noted due to misalignment and failure to restore the articular congruity.^6,10

The main impact parameters reported are volar tilt of less than 5^◦, radial inclination less than 20^◦, radial height loss greater than 6 mm and positive ulnar variance greater than 5 mm.^11-16 Moreover, maintaining these in geriatric osteoporotic fractures is a challenging task. Internal stabilisation with locking plates provides a better restoration of the radial length as well as the volar tilt in comparison to external fixation in osteoporotic bones.¹⁷ This study has proved clearly that there is an insignificant difference in the radial height, radial inclination and the palmar tilt in the immediate post-operative and the last follow up. This highlights the fact that the fracture reduction that was achieved in the immediate post-operative period is maintained throughout the follow up duration.

The results are in concordance with other studies conducted using a volar LCP fixation although not the 2.7 mm volar LCP or in geriatric population. Rozental et al and Konstantinidis et al found good post-operative radiological outcomes with use of LCP for distal radius fracture.^18,19 A few studies in the Indian subcontinent such as Pradhan et al in their study concluded that treatment with open reduction and internal fixation for intra articular fractures of distal end of radius provides good radiological results and Khan MS et al found that the use of volar LCPs for intra-articular distal radius fracture shows good results especially in comminuted distal radius fractures.^20,21

The limitations of the current study were that it was retrospective, selection bias due to lack of randomization, the number of patients were low and the follow up time was short.

CONCLUSION

In conclusion, this study found that volar locking plate fixation for displaced intra-articular distal radius fractures in elderly patients was an effective procedure to maintain the radiographic parameter and in turn to obtain successful functional outcomes. Although reduction loss in volar tilt and radial height occurred within four first months, volar plate was able to maintain fracture stabilization with radiographic parameters within functional range over the time in most patients of these elderly patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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