Treatment of Distal Radius Fractures Using a Cemented K-Wire Frame

doi:10.21203/rs.3.rs-1354231/v1

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Research Article

Treatment of Distal Radius Fractures Using a Cemented K-Wire Frame

https://doi.org/10.21203/rs.3.rs-1354231/v1

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Background: This retrospective study introduced an alternative treatment of types A2, A3, and B1 distal radius fractures using percutaneous pinning with cemented K-wire frame.

Methods: From January 2017 to January 2020, 78 patients with distal radius fractures were treated with percutaneous pinning and cemented K-wire frame. There were 14 male patients and 4 female patients. There were types A2 (n=10), A3 (n=46), and B1 (n=22) fractures. X-rays were taken immediately after surgery and after bone healing. Wrist function was assessed with Mayo Wrist Score to assess wrist function (90–100, excellent; 80–90, good; 60–80, satisfactory; below 60, poor).Patient satisfaction on the upper limb was assessed using the 10-cm visual analog scale.

Results: The data showed the fragments were kept in place without significant redisplacment (P>0.05). No wire loosening was found. All K-wires were kept in place without bone lessening. Fixation failure or osteomyelitis was not observed in this series. Bone healing was achieved in all patients at a mean of 4.5 months (range, 4 to 8 months). Follow-ups lasted for a mean of 27 months (range, 24 to 33 months). The mean score of wrist function was 97 (range, 91 to 100), including 66 excellent and 12 good results. The mean patient satisfaction was 10 cm (range, 8 to 10 cm).

Conclusions: Percutaneous pinning with cemented K-wire frame is a safe and preferred choice for the treatment of types A2, A3, and B1 distal radius fractures. The frame provides support to prevent wire migration. The fixation is a minimally invasive technique that is easy to perform.

Level of Evidence: Therapeutic study, Level IVa.

Distal radial fracture

pining

K-wire

Distal radius fractures (DRFs) account for 8%−15% of all fractures ¹. Stable DRFs are commonly treated conservatively, and unstable DRFs are often treated surgically ². The fixation implants include plate and screw systems, K-wires, external fixators, etc. Selection is based on the fracture types, soft tissue envelop injuries, articular surface involvement, surgeon’s preference, patient’s health condition, etc. ³ Currently, the optimal technique remains controversial. K-wire fixation is a well-accepted treatment, but the optimal configuration is debated ⁴.

Clinical practice guidelines from the American Academy of Orthopaedic Surgeons (AAOS) moderately recommend stable surgical fixation, rather than cast fixation, followed by early wrist motion to treat displaced DRFs ⁵. Percutaneous pinning can aid reduction and stabilize the fragments in a minimally invasive manner. The usual indication for K-wire fixation is DRFs that cannot be stabilized in a plaster, such as DRFs located close to the wrist joint (AO types A2 and A3) and certain AO type C fractures. Ideally, the Kapandji wiring technique provides a high reactive torque to reduce and maintain the reduction ⁶. The K-wires are inserted from the anatomical windows. However, achieving an optimal wire position may be difficult due to tendon position, fracture patterns, intact cortical wall, and anatomical variation ⁷. The windows are limited in number and invisible on the skin. Those weaknesses may be associated with an unstable fixation and redisplacement ⁸. Adding more K-wires increases the risks of tendon irritation, tendon rupture, neurovascular injuries, and pin tract infection ⁹. Moreover, oblique Kapandji K-wires engaging a single cortical wall risk wire migration, especially in oblique and comminuted fractures. Its stability depends on the correct wire position, a good fracture pattern, intact cortical wall, and good bone quality, but these factors may be compromised due to the lack of direct visualization of the tissue and fracture site ¹⁰. These drawbacks prompted us to modify the fixation technique. The key points are introducing K-wires at safe places and providing support to prevent wire migration and fracture redisplacment.

This retrospective study introduced an alternative treatment of types A2, A3, and B1 DRFs using percutaneous pinning with cemented K-wire frame. We also report the effectiveness of the novel fixation technique.

The study was approved by the Institutional Review Board of the hospital involved. Informed consent was obtained from all participants and their legal guardian(s) for the participants of age 16. All methods were performed in accordance with the relevant guidelines and regulations

From January 2017 to January 2020, 78 patients with DRFs were treated with percutaneous pinning and cemented K-wire frame. The eligibility criteria for the study were as follows: age ≧ 16 or < 70 years old; closed DRFs; AO/OTA (AO Foundation and Orthopaedic Trauma Association) Classification types A2, A3, and B1 fractures. We excluded type A1 fractures because the fractures did not involve distal radius; we excluded types B2 to C3 fractures because the fractures are too complex to be treated with percutaneous pinning. Patients were also excluded if they had one of the following: patients < 16 years because the displacement could be corrected with growth; decline to participate; open fractures; fixation with screws alone; fixation with an external fixator; combined carpal fractures, dislocations, or ulna fracture-dislocations; old fractures over 14 days; multiple fractures; pathological fractures; the need for the aid of arthroscope; uncooperative adults, such as dementia patients; or an associated infection or underlying diabetes, rheumatoid arthritis, or gout. Patients with combined ligament injuries shown on preoperative magnetic resonance images were also excluded. Preoperative radiographs and CT images were obtained in all patients. All operations were performed by the same senior surgeon and using the same surgical technique.

Surgical Technique

The operation was performed under brachial plexus anesthesia and without the need for tourniquet control. First, we tried to reduce the fracture with axial traction and maneuver. If there was remaining displacement, we percutaneously reduced the fracture by leveraging using a K-wire.

For a type B1 fracture (Fig. 2A, B), we introduced one or more 1.5- to 2.0-mm K-wires from distally to proximally (Fig. 2A). Then, we introduced one or two transverse bicortical K-wires into the proximal fragment (Fig. 2B). Acceptable reduction and wire position were confirmed using fluoroscopy. The K-wires were bent about 1.5 cm distal to the skin toward the fracture site (Fig. 2C). We mixed Monomer (liquid) and polymer (powder) of bone cement (Single dose 40 g US$170; PALACOS®, Hanau, Germany). When the bone cement viscosity changed over time from a runny liquid into a dough-like state, we applied it to the bent K-wires ends and waited for it to harden into a solid material (Fig. 2D). Thus, we created a cemented K-wire frame to prevent wire migration. Acceptable reduction and wire position were confirmed using fluoroscopy (Fig. 3A, B).

For a type B1 fracture with a small fragment, we performed the same procedure (Fig. 4A). For types A1 and A2 fractures, we obliquely introduced one or two bicortical K-wires into the proximal fragment; Then, we introduced one oblique K-wire passing across the fracture site into the distal fragment, and another transverse bicortical K-wires into the proximal fragment. The wire ends were bent and mounted with bone cement as mentioned above (Fig. 4B, C; Fig. 5A, B). Similar treatment was done in type A2 (Fig. 6A-F) and A3 fractures (Fig. 7A, B and Fig. 8A, B, C, D, E, F).

We performed ballottement test with the wrist in neutral, supination, and pronation. If there was any injury to the distal radioulnar joint, the ligament was repaired or reconstructed under arthroscopy (n = 0).

Postoperative Management

After surgery, the wrist and forearm were placed in a splint that permitted active range of motion exercises. The splint was completely removed after 4 weeks, and a progressive joint motion was continued until bone union was solid. The K-wires were cut off and removed when bone healing had been achieved.

Outcome Evaluation

Radiographic evaluation was performed on day 1 and every two weeks until bone healing had occurred. Palmar tilt was measured on the lateral view. Radial inclination, scapholunate gap, and ulnar variance were measured on posteroanterior radiograph ¹¹. Pin tract infection was assessed according to clinical symptoms ¹². Pain intensity of the wrist was assessed using the visual analog scale (VAS) ¹³.

At the final follow-up, active range of motion of the wrist was measured using a goniometer ¹⁴. All measurements were compared to those on the opposite side. Grip strength of the hand was assessed using a Baseline hydraulic hand dynamometer (Fabrication Enterprises Inc., White Plains, NY) ¹⁵. Isometric testing of pronation torque was assessed using McConkey method at 5 positions of rotation (90° of supination, 45° of supination, neutral, 45° of pronation, and 80° of pronation) ¹⁶. To exclude any discrepancy between dominant and nondominant hand strength, we based the scores for analysis on the premise that the grip strength was 15% higher at dominant sides compared to the nondominant sides ¹⁷. No correction was required for left-handed individuals. These measurements were compared to the opposite side. The patients rated their wrist pain and hand numbness using the 10-cm visual analogue scale ¹⁸. We used the Mayo Wrist Score to assess wrist function (90–100, excellent; 80–90, good; 60–80, satisfactory; below 60, poor) ¹⁹. Aesthetics and patient satisfaction on the upper limb were assessed using the 10-cm visual analog scale ²⁰.

Statistical Analysis

Quantitative variables were described as mean and standard deviation for symmetric distribution or median and interquartile range for asymmetric distribution. We used Pearson’s chi-square test to compare categorical variables, and Mann-Whitney U test to symmetric and asymmetric distribution. A P < 0.05 was considered statistical significance. The collected data were analyzed with the Statistical Package for Social Sciences 20.0 (SPSS, Inc., Chicago, Ill).

The mean age of 78 patients was 37 years (range, 16 to 64 years). There were 14 male patients and 4 female patients. There were types A2 (n = 20), A3 (n = 36), and B1 (n = 22) DRFs (Table 1). We compared the X-rays taken immediately after surgery and bone healing, and the results showed the fragments were kept in place without significant redisplacment (Table 2) (P > 0.05). No wire loosening was found. Fixation failure or osteomyelitis was not observed in this series. Bone healing was achieved in all patients at a mean of 4.5 months (range, 4 to 8 months).

Table 1

Demographic data on 78 patients.
Age (mean, range, yr)	37 (16–64)
Sex (m:f)	47 : 31
Dominant hand (n)	39
Cause (n)
Fall	49
Road traffic accident	13
Sports	11
Others	5
AO/OTA (n)
A2	10
A3	46
B1	22
Ulnar styloid fracture (n)	32
AO/OTA, AO Foundation and Orthopaedic Trauma Association.

Table 2

Reduction maintenance measured immediately after surgery vs bone healing.
	Immediately after surgery	Bone healing	P value
Radial height (mm)	12.51 ± 3.22	12.45 ± 3.24	0.441
Palmar tilt (°)	11.19 ± 0.95	11.14 ± 0.94	0.069
Radial inclination (°)	18.7 ± 3.12	18.68 ± 3.12	0.159
Scapholunate gap (mm)	1.46 ± 0.16	1.45 ± 0.157	0.058
Ulnar variance (mm)	0.35 ± 0.53	0.364 ± 0.54	0.06
Articular stepoff > 2mm (n)	0	1	-
Data are shown as mean ± standard deviation.

Table 3

Outcomes at the final follow-up.
	Mean	Range
TBIO (day)	4	0–13
Operative time (minutes)	23	18–41
Number of K-wire (n)
Oblique	2.6	2–4
Transverse	1.3	1–2
Time of bone healing (week)	4.5	4–8
Wrist pain (VAS; day 10 postop)	1	0–2
Follow-up time (month)	27	24–33
Active ROM (°)
Flexion	74	61–89
Extension	67	52–72
Radial deviation	30	25–38
Ulnar deviation	17	7–26
Pronation	80	67–95
Supination	85	74–97
Grip strength (%) *	98	94–103
Supination torque (%) †
90° of supination	92	83–98
45° of supination	95	92–98
Neutral	94	81–98
45° of pronation	94	87–97
80° of pronation	96	90–102
Wrist pain (MWS)	0	0–1
Numbness (VAS)	0	0–1
Wrist function (VAS)	97	91–100
Aesthetics (VAS)	10	8–10
Satisfaction (VAS)	10	8–10
TBIO, time between injury to operation; SD, standard deviation; ROM, range of motion; VAS, visual analogue scale; *, 15% higher at dominant sides compared to the nondominant sides discrepancy, in which percentages show involved limb compared with opposite normal side; †, Supination torque based on McConkey method; DASH, disabilities of the arm, shoulder and hand scores; MWS, Mayo Wrist Score.

Follow-ups lasted for a mean 27 months (range, 24 to 33 months) (Table 3). Active range of motion of the wrist and grip strength of the hand were similar to the opposite side. The mean score of wrist function was 97 (range, 91 to 100), including 66 excellent and 12 good results. The mean patient satisfaction was 10 (range, 8 to 10).

We found the percutaneous pinning with cemented K-wire frame could prevent radioproximal redisplacment of the fragment and radioproximal wire shift in type B1 DRFs; and prevent fragment rotational redisplacement in the sagittal plane in types A2 and A3 DRFs. Moreover, the system effectively maintains the radius height. The minimally invasive technique is reliable with minimal complications, resulting in satisfied outcomes.

DRFs are often caused by falling and landing on an outstretched hand ²¹. The treatment strategies for DRFs are generally debated ²². Surgeons’ preferences, fracture types, combined injuries and morbidity, complications, and patient factors (lifestyle, age, mental attitude, social support, comorbid conditions, and compliance with treatment) influence the options ²³. Usually, types A2, A3, B1, and B2 (AO/OTA classification) fractures can be treated with a splint, cast, plate and screw system, external fixator, or K-wires, or combined these ^{3, 24, 25}. A splint or plaster cast is commonly used for up to 4 to 6 weeks to immobilize the fracture in place while healing occurs ²⁶. For unstable fractures, open reduction and internal fixation may be indicated ²⁷. The reported complication (loss of fixation, tendon irritation and rupture caused by implants, and wound infection) rates of plating are as high as 3–27% depending on the fixation techniques used ²⁸.

DRFs can be treated with percutaneous screw fixation ²⁹. Transverse fractures can be fixed with cross screws ³⁰. However, for oblique fractures, the crews should be positioned perpendicular to the fracture line ³¹. Otherwise, screw compression generates a shifting force, resulting in redisplacment. For comminuted fractures, screw compression may shorten the radius.

Franceschi et al ³² performed a systematic review on plating versus pinning for the treatment of DRFs. They found plating is associated with higher rates of tendon irritation (wrist pain, carpal tunnel syndrome, endonitis, and tenosynovitis) caused by the plates. In comparasion, pinning is associated with higher rates of tendon and neurovascular injuries (temporary paraesthesia, nerve irritation, superficial infections, wire migration, and loss of reduction) due to improper wire placement. However, the comparison based on types A1 to C3 DRFs may not reflect the actual outcomes because plating is more likely used in complex fractures (types B3 to C3). Nevertheless, decreasing the complications of pinning is a laudable goal.

There are many percutaneous pinning techniques (e.g., two wires, three or more wires, and Kapandji-technique) for DRFs ⁴. Typically, one or two K-wires are introduced from the tip of the radial styloid (radial styloid window). More K-wires can be added through 1,2 tendon interseptum (between 1 and 2 compartments on the dorsal wrist), 2,3 interseptum, and 4,5 interseptum. However, identifying the tendon intersepta and achieving optimal wire position are difficult ⁶. Moreover, oblique and cross pinning can effectively stabilize transverse fractures because stability depends on the intact of the proximal fragment ³². However, the support is compromised in oblique and comminuted fractures ⁷. According to the early anatomical studies, there are no important structures in the radial aspect of distal 1/3 radius, where K-wires can be safely introduced ²⁹. A cement block connects all K-wires to form a frame, preventing wire migration. Thus, a relatively rigid fixation can be achieved, which allows an early range of motion exercise in a splint.

In type B1 DRFs, the distal fragment tends to redisplaced radioproximally, and the distal K-wires tend to shift radioproximally due to a single cortical wall being engaged (Fig. 4A). In type A2 and A3 DRFs, the distal fragments tend to redisplaced due to oblique fracture lines or comminuted patterns. The two proximal K-wires not only prevent redisplacement of the fragment and wire shift, but also reinforce the fixation (Fig. 4B, C). Similar to an external fixator, the frame the loss of radius height.

Our technique is a minimally invasive procedure. The wire insertion is relatively safe. The procedures are easy to perform, and the fixation is relatively rigid. It can prevent bone shortening and allow early range of motion exercises of the wrist. The disadvantage is the risks of iatrogenic injuries to the tendons, nerves, and vessels, even though the incidence is very lower than the conventional pinning technique according to our experience.

Indications for our technique are AO/OTA classification types A2, A3, B1, and B2 DRFs. Contraindications are more complex fractures, combined tendon, nerve, artery, or ligament injuries, which need to be extensively exposed, and old fractures that require open reduction and grafting. However, the technique combined with other techniques may be a choice for complex DRFs.

The limitation of the study is the fixation kinematics that needs further studies. Surgeons’ preferences, experience, and ability may influence wire configuration and position. The operations and assessments were done at different times, and surgeons’ experience improved with time, which may affect ascertaining the effects of the techniques.

Percutaneous pinning with cemented K-wire frame is a safe and preferred alternative for the treatment of types A2, A3, and B1 DRFs. The frame provides support to prevent redisplacment and wire migration. The technique is a minimally invasive procedure and easy to perform.

-Ethics approval and consent to participate

Administrative permissions (NO 2020-055-1) were acquired by our team to access the clinical patient data used in our research, which was granted by the Committee on Ethics and the Institutional Review Board of the Third Hospital of Hebei Medical University. Informed consent was obtained from all participants and their legal guardian(s) for the participants of age 16.

-Consent for publication

Not Applicable.

-Availability of data and materials

Data is available on a supplementary file entitled “rare data Distal Radius Fractures” and also datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Supplementary file legend: Patients’ preoperative and postoperative data.

-Competing interests

The authors declare that they have no competing interests.

-Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

-Authors' contributions (This statement must exactly match on Editorial submission system and in the manuscript)

H.M. Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Data Curation, Writing – Original Draft, Writing – Review & Editing, Visualizaion, Supervision, Project Administration, Funding Acquisition. B. X. Conceptualization, Methodology, Investigation, Writing – Review & Editing. Y.X. Conceptualization, Methodology, Software, Validation, Formal Analysis, Investigation, Data Curation, Writing – Review & Editing. H. N. Conceptualization, Methodology, Investigation, Writing – Review & Editing. N.L. Conceptualization, Methodology, Investigation, Writing – Review & Editing, Formal Analysis, Investigation, Funding Acquisition, Figures 1-8, Tables 1-3. D.S. Conceptualization, Methodology, Investigation, Writing – Review & Editing, Supervision. All authors reviewed the manuscript.

-Acknowledgements

The authors have no acknowledgement to report.

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No competing interests reported.

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You are reading this latest preprint version

Treatment of Distal Radius Fractures Using a Cemented K-Wire Frame

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Version 1

Abstract

Figures

Introduction

Materials And Methods

Surgical Technique

Postoperative Management

Outcome Evaluation

Statistical Analysis

Results

Discussion

Conclusion

Declarations

-Ethics approval and consent to participate

-Consent for publication

-Availability of data and materials

-Competing interests

-Funding

-Authors' contributions (This statement must exactly match on Editorial submission system and in the manuscript)

-Acknowledgements

References

Competing Interests

Supplementary Files

Status:

Version 1