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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 49  |  Issue : 2  |  Page : 174-176

Unstable distal radius fractures in the elderly patients: does volar locking plating system prevent secondary displacement?


Damanhour National Medical Institute, Egypt

Date of Submission16-Jun-2014
Date of Acceptance10-Oct-2014
Date of Web Publication25-Nov-2014

Correspondence Address:
Salah A Zakzouk
MD Orthop, El-Rahman Mosque Street, Behind El Mohafza Built, Bohera Government
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1148.145407

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  Abstract 

Background
Osteoporosis characterizes the distal radial fracture in elderly patients. Primarily weakening metaphyseal bone, osteoporosis renders simple fractures unstable that necessitate proper internal fixation.
Aim
The aim of this study was to assess whether a secondary displacement could occur, despite using volar locking plating system in the elderly patients.
Patients and methods
Open reduction and internal fixation by volar locked plate was performed for 12 elderly patients with mean age of 67.2 years (range, 60-74 years), and these patients were followed for a mean period of 12 months (range, 6-20 months); standard radiographic and clinical fracture parameters were measured and final functional results were assessed.
Results
The functional outcome was excellent in seven cases (58.3%), good in three cases (25%), fair in two cases (16.7%), and there were no poor cases. Secondary displacement was detected in the final follow-up radiograph in only three cases, with respect to radial length (2-3 mm), radial inclination (2-5°), and volar tilt (4-12°).
Conclusion
Although secondary displacement may occur to some extent in elderly patients with distal radial fractures fixed by volar locked plate, it does not affect the end follow-up functional results.

Keywords: displacement, distal radius fracture, elderly patient, osteoporosis


How to cite this article:
Zakzouk SA. Unstable distal radius fractures in the elderly patients: does volar locking plating system prevent secondary displacement? . Egypt Orthop J 2014;49:174-6

How to cite this URL:
Zakzouk SA. Unstable distal radius fractures in the elderly patients: does volar locking plating system prevent secondary displacement? . Egypt Orthop J [serial online] 2014 [cited 2020 Apr 9];49:174-6. Available from: http://www.eoj.eg.net/text.asp?2014/49/2/174/145407


  Introduction Top


Distal radius fractures are the most common upper extremity fractures in individuals aged 60 years and above, with 15% of White women fracturing their distal radius after an age of 50 years [1]. The management of these fractures is beset with difficulties regarding osteoporosis that primarily weaken the metaphyseal segment of this bone and makes the fracture highly unstable, and finally internal fixation will be challenging [2.3]. Volar locking plates are increasingly used to fix these fractures after open reduction, and it is expected that, as the screws lock into the plate providing rigid support, this will prevent collapse at the fracture site during healing. This works well in normal dense bone but it is not known whether it works in patients with osteoporosis [4.5].

The purpose of this study was to assess whether there is a secondary displacement after fixation of unstable distal radial fractures by volar locked plate in these elderly patients at the end of follow-up.


  Patients and methods Top


The study was conducted in the Damanhour National Medical Institute. Twelve patients above 60 years (range, 60-74 years) with a distal radial fracture from January 2009 to February 2011 constituted the material of this study. All of them were treated surgically with volar locked plate system. The fractures were classified according to the direction of displacement and the comprehensive classification of long bone fractures [6]. There were six A 3 , two C l , three C 2 , and one C 3 . The sex distribution was seven men and five women. The mean age was 67.2 years (range, 60-74 years). The mechanism of injury was a fall on an outstretched hand in pronation in all cases. The time interval between injury and plate fixation averaged 5 days (range, 2-10 days). The mean follow-up period was 12 months (range, 6-20 months). All fractures, whether dorsally or volarly displaced, were managed through a volar flexor carpi radialis approach.

Standard posteroanterior and lateral radiographs were obtained for these patients before surgery and postoperatively at every visit; these were scheduled at 2 weeks after surgery, at 4-6 weeks after surgery, at monthly intervals as needed, and at the time of final follow-up. The following parameters were measured: volar tilt, radial inclination, and radial length. These parameters were compared with previous follow-up films to assess the correction of the original deformity and to recognize any postoperative loss of reduction. A goniometer was used to obtain measurements of wrist and forearm motions. The grip strength was measured according to the McRae technique [7]. Assessment of the functional end results was performed using the Sarmiento modification of Gartland and Werley functional scoring system of the wrist [8].


  Results Top


The overall functional results were determined using the Sarmiento modification of Gartland and Werley score [8]; in this study, the functional outcome scores were as follows: excellent, 58.3% (seven patients); good, 25% (three patients); fair, 16.7% (two patients); and poor, 0%. In this study, all fractures united radiographically at an average time of 7.1 weeks (range, 5-10 weeks); fracture union was established by the presence of bone continuity or bridging callus on both the posteroanterior and lateral views.

Full reduction was achieved in all patients intraoperatively and was confirmed by immediate postoperative radiography in all patients; at the end of follow-up, secondary displacement was detected in only three patients: radial length (2, 2, and 3 mm, respectively), radial inclination (2, 4, and 5°, respectively), and volar tilt (4, 4, and 12°, respectively) [Figure 1] and [Table 1].
Table 1: Patients demographics

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Figure 1: (a and b) Posteroanterior and lateral preoperative radiographs of a 74-year-old man showing unstable extra-articular fracture of the distal radius. (c and d) Immediate postoperative radiographs showing excellent radiological alignment after fi xation with a volar locking plate. (e and f) Six weeks follow-up radiographs showing mild displacement of radial length, radial inclination, and volar tilt. (g and h) End follow-up radiographs at 9 months showing secondary displacement of radial length, radial inclination, and volar tilt (patient 7, Table 1).

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Complications

Wound infections, tendon ruptures, and nerve injuries were not reported in this study. Only one patient in this study complained of stiffness of the fingers due to reflex sympathetic dystrophy, which necessitated prolonged postoperative physiotherapy program, and he showed complete improvement after 12 weeks. The overall incidence of secondary displacement was reported in three patients.


  Discussion Top


Distal radial fractures in elderly patients are special, as casts that were sufficient treatment for the younger age group proved to be insufficient for elderly patients [9.10]. However, even pinning was ineffective due to osteoporosis [11]. Conventional butters plating provides poor distal screw purchase and often requires bone grafting [12]. Dorsal plate fixation is associated with soft tissue problems and external fixation carries the risk for pin tract infections, is objected by patients, and encourages stiffness of the wrist [13.14].

Osteoporosis, the skeletal hallmark of advanced age, is a ubiquitous condition that primarily weakens metaphyseal bone by decreasing trabecular volume [15]; this entity is a widely recognized risk factor for patients to sustain fractures with lower-energy trauma and also changes the character of the fracture, because trabecular bone is mostly affected and cortical subchondral bone and ligaments maintain a relative greater strength. Fractures usually occur by compressive failure of metaphyseal bone; this is unlike the failure mechanism of healthy bone and frequently results in extra-articular fracture patterns with a low incidence of associated ligamentous injuries. Compression failure of the metaphysis produces a defect or void [2,16]. The introduction of volar locking plating system for the treatment of these fractures is an established line of treatment, which has a less likelihood for loosening and toggling [17].

In this study, secondary displacement was found in three patients as shown in the results.

Although the locked plate screw system maintains its rigidity all over the course of treatment of unstable distal radial fractures in elderly patients, the distal fragment still can toggle around the distal fixation screw may be because of osteopenia, and slight loosening around this screw may be due to osteoporosis, despite that the recorded secondary displacement was found to be minimal and did not affect the end follow-up functional results.

The final results in this study are comparable with those entailing the same subject.

Orbay et al. [18] recorded that three cases of 24 fractures lost 1 or 2 mm of radial length.

Figl et al. [3] did not report any loss of reduction in the volar tilt or radial inclination in their work, but on radiography taken at the time of follow-up only five of 58 patients (9%) had a mean radial shortening of 1.3 mm (range, 1-2 mm).

In contrast, Tawfik et al. [5] demonstrated no significant change in radial length, radial inclination, and volar angulations immediately after surgery and at 3 months.

In this study, it was proved that secondary displacement could occur in radial length, radial inclination, and volar tilt.


  Conclusion Top


Volar locking plating system still proved to be a viable option for distal radial fractures in elderly patients. Although secondary displacement was reported at the end of follow-up, the functional results were not affected.


  Acknowledgements Top


 
  References Top

1.
Gummings SR, Black DM, Rubin SM. Lifetime risks of hip, colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med 1989; 149:2445-2448.  Back to cited text no. 1
    
2.
Fernandez DL, Jupiter JB. Fractures of the distal radius. New York: Springer-Verlag; 1996. 24-26.  Back to cited text no. 2
    
3.
Figl M, Weninger P, Jurkowitsch J, Hofbauer M, SchauerJ, Leixnering M. Unstable distal radius fractures in the elderly patient - volar fixed - angle plate osteosynthesis prevents secondary loss of reduction. J Trauma 2010; 68:992-998.  Back to cited text no. 3
    
4.
Makhni EC, Ewald TJ, Kellys Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to non operative treatment. J Hand Surg Am 2008; 33:1301-1308.  Back to cited text no. 4
    
5.
Tawfik J, Powell Smith E, Bremner-Smith A. Efficacy of locking plate fixation in stabilizing distal radius fractures in patients aged 50 years or over. J Hand Surg Eur Vol 2012; 37:80-81.  Back to cited text no. 5
    
6.
Müller MR, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990.  Back to cited text no. 6
    
7.
McRae R. The hand, clinical orthopedic examination 2nd ed. Edinburgh, London, Melbourne, New York: 1987. 56-70.  Back to cited text no. 7
    
8.
Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles' fractures. Functional bracing in supination. J Bone Joint Surg Am 1975; 57-A:311-317.  Back to cited text no. 8
    
9.
AnZarut A, Johnson JA, Rowe BH. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am 2004; 29:1121-1127.  Back to cited text no. 9
    
10.
Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients. Closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand 2003; 74:98-100.  Back to cited text no. 10
    
11.
Greatting MD, Bishop AT. Intrafocal (kapandji) pinning of unstable fractures of the distal radius. Orthop Clin North Am 1993; 24:301-307.  Back to cited text no. 11
    
12.
Liporace FA, Gupta S, Jeong GK. A biomechanical comparison of the dorsal 3.5-mm T-plate and a volar fixed-angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma 2005; 19:187-191.  Back to cited text no. 12
    
13.
Leung F, Tu YK, Chew WY, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radius fractures. J Bone Joint Surg Am 2008; 90:16-22.  Back to cited text no. 13
    
14.
Knox J, Ambrose H, McCallister W, Trumble T. Percutaneous pins versus volar plates for unstable distal radius fractures: a biomechanics study using a cadaver model. J Hand Surg Am 2007; 32:813-817.  Back to cited text no. 14
    
15.
Barret JA, Baron JA, Karagas MR Beach ML Fracture risk in the US Medicare population. J Clin Epidemiol 1999; 52:243-249.  Back to cited text no. 15
    
16.
Abbaszadegan H, Jonsson U, von sivers K. Prediction of instability of Colles' fractures. Acta Orthop Scand 1989; 60:646-650.  Back to cited text no. 16
    
17.
Kwan K, Lau TW, Leung F. Operative treatment of distal radial fractures with locking plate system: a prospective study. J Hand Surg Am 2012; 21:31-39.  Back to cited text no. 17
    
18.
Orbay JL, Miami FL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg 2004; 29A:96-102.  Back to cited text no. 18
    


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    Tables

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  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
Acknowledgements
References
Article Figures
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