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Internal Fixation of Distal Radius Fractures with Novel Intramedullary Implants

Brooks, Kenneth, R*; Capo, John, T*; Warburton, Mark; Tan, Virak*

Section Editor(s): Meals, Roy A MD, Guest Editor; Harness, Neil G MD, Guest Editor

Clinical Orthopaedics and Related Research: April 2006 - Volume 445 - Issue - p 42-50
doi: 10.1097/01.blo.0000205892.96575.d4
SECTION I: SYMPOSIUM: Problem Fractures of the Hand and Wrist
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Fracture of the distal radius is a common injury and treatment varies depending on the fracture, patient factors, and surgeon preference. Internal fixation has grown in popularity because it affords increased stability and early motion of the extremity. The desire to provide stable fracture support while minimizing soft tissue dissection and complications has led to the development of new intramedullary implants. These implants use distal screw divergence for subchondral support, fixed-angle screws locked to the implant, and minimally invasive technique to allow early patient rehabilitation. Early results of these intramedullary devices are promising but require longer followup.

Level of Evidence: Level IV (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

From the *Division of Hand and Microvascular Surgery, Department of Orthopaedics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey; and †High Point Orthopaedic Associates, Inc., High Point, North Carolina.

One or more of the authors (JTC, MW, VT) are consultants for and have received funding from Wright Medical Technology, Inc.

Each author certifies that his institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained. Correspondence to: Virak Tan, MD, Associate Professor of Orthopaedics, UMDNJ-New Jersey Medical School, DOC Suite 7400, 90 Bergen Street, Newark, NJ 07103. Phone: 973-972-0763; Fax: 973-972-5296; E-mail: tanvi@umdnj.edu.

Distal radius fractures are common injuries, representing 20% of all fractures leading to emergency room visits28,46 and 75% of all forearm injuries.11 There are diverse treatment strategies for these fractures. Methods range from nonoperative treatments to a multitude of operative techniques.1,2,4,7-13,15,16,19,21,23-31,33,34,36-38,41-44,47-50,52-55,57,59,61-63,65

Despite the plethora of options, the concept of internal fixation with an intramedullary (IM) device designed specifically for the distal radius has been applied only in limited fashion.47,51,53,59

In 1986, Tarr and Wiss64 discussed the basic concepts behind IM nailing of fractures. They defined the goals of internal fixation as increasing fracture stability, transferring load across the fracture, and maintaining anatomic alignment of the fracture to promote union. These authors noted an IM nail functions as an internal splint, allowing motion at the fracture site and healing through formation of peripheral callus. Furthermore, they suggested IM nails function in a load-sharing mode, reducing stress shielding, and minimizing disuse osteoporosis.

Street59 reported on IM fixation of forearm fractures, noting more rapid union through increased stability and improved periosteal circulation, smaller incisions with deceased surgical trauma and better cosmesis, less blood loss, and shorter operative time. The author developed a retrograde insertion technique for the radial nail with an entry point just radial to Lister's tubercle, between the extensor carpi radialis brevis and longus tendons. In the recent years, the concept of IM fixation, as defined by Tarr and Wiss64 and Street,59 has been expanded and adapted for periarticular fractures of the distal radius.

Using selected literature, we review the IM fixation techniques available for distal radius fractures. Specifically, we discuss the clinical application of two commercially available IM implants.

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Pathophysiology, Etiology, and Diagnosis

Fractures of the distal radius are common, accounting for approximately 300,000 cases in the United States annually.58 The injury typically is caused by a low-energy mechanism such as a fall onto an outstretched hand or by a high-energy mechanism such as a motor vehicle accident or fall from a height.11 Although distal radius fractures have been considered a homogeneous group of injuries, it is now recognized there are different and often complex fracture patterns.21,28,29,38,56 There are many classification systems that have been made to describe these fractures.29 The more commonly used systems include those of Melone,38 AO/ASIF,39 and Fernandez and Jupiter.29 The diagnosis and imaging of a distal radius fracture are well-defined in other publications and will not be elaborated in this article.

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Treatment Options

The goal of treating distal radius fractures is restoration of function, with a secondary goal of preventing late complications such as arthritis and malunion. Restoring the extra-articular and intra-articular anatomy and preventing stiffness can best accomplish these goals.6,11,15,17,21,26,33,38,54 Many authors have described criteria for acceptable position.11,15,33,35,57 In 1981, Knirk and Jupiter33 recommended reduction of the radiocarpal articular step off to less than 1 mm, reduction of incongruity of the distal radioulnar joint, and anatomic restoration of any die punch fragments. In 1989, Lafontaine et al35 described criteria for determining initial stability of distal radius fractures, which had implications for operative fixation. These authors reported a dorsal angulation greater than 20°, dorsal comminution, intraarticular fracture extension, associated ulnar styloid fracture, and age older than 60 years indicated instability that may induce redisplacement of the fracture with nonoperative treatment.35 Other radiographic criteria have been established for operative intervention, including radial shortening greater than 4 mm,11 dorsal angulation greater than 20° from normal (apex volar angulation greater than 10°),15,35 and greater than 5° loss of radial inclination.57 Surgery also may be indicated after loss of reduction with closed treatment29 or for malunion.6,11,55 Contraindications to surgical intervention include medical comorbidities and patient refusal.

Surgical treatment options for distal radius fractures include percutaneous pinning, external fixation, internal fixation with plates, or combined techniques.1,2,4,7,9-13,15,19,21,23-31,33,34,36-38,41-44,47-50,52-55,57,59,61-63,65 Detailed discussion in this report is limited to IM fixation methods because they represent a new approach to operative treatment of distal radius fractures.

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Surgical Technique and Clinical Application - MICRONAIL®

The MICRONAIL® (Wright Medical Corporation, Memphis, TN) (Fig 1) is an IM device for fixation of distal radius fractures (Fig 1). It is used to provide stable support while minimizing soft tissue complications that can occur with other internal fixation implants.3,13,14,19,24,28,30,32,34,43,49 This device uses the principles of load sharing, fixed-angle divergent screws in the subchondral bone, and minimal surgical dissection to allow early patient rehabilitation. Indications for surgery include distal radial metaphyseal fractures where casting or external fixation are not tolerated by the patient, when reduction cannot be maintained by closed means, or where early motion and return to function are essential.63 Specific instances amenable to this form of fixation include extra-articular fractures (Fig 2) and intra-articular fractures with large fragments that can be adequately reduced with closed or percutaneous methods.63 Fractures with multiple comminuted articular fragments may not be suitable for IM fixation.

Fig 1

Fig 1

Fig 2

Fig 2

We used standard preparation of the arm and wrist for surgery. An image intensifier was used to confirm a near anatomic reduction was achievable by closed manipulation. After the tourniquet was inflated, a 2 to 3 cm longitudinal incision was centered over the radial styloid. We performed blunt dissection through the subcutaneous tissue, and branches of the radial sensory nerve were retracted from the surgical field. The dissection was continued to the periosteum between the first and second dorsal extensor compartments. The periosteum was elevated and retracted, and the fracture was provisionally reduced. Temporary placement of Kirschner wires (K-wires) can help maintain the reduction when there are large articular fragments, especially on the ulnar corner. A cortical window was made at the tip of the radial styloid 2 to 3 mm proximal to the radioscaphoid joint line. This can be accomplished with an awl or with a cannulated drill. The starter awl was then introduced into the radial styloid in a retrograde fashion under fluoroscopic guidance. The fracture was held in a reduced position as the awl was advanced across the fracture into the metaphysis.

The awl was removed and broaching of the bone was completed by hand. The broach followed the path established by the awl. It should be inserted to the shoulder of the broach to ensure proper depth below the radial cortex. Once the bone was broached to the appropriate size, the implant attached to the insertion jig was advanced into the bone until countersunk within the radial styloid. MICRONAIL® positioning was then confirmed with the image intensifier. Satisfactory depth can be determined by inserting a K-wire through the most distal hole of the device. The wire should pass within the subchondral bone just proximal to the articular surface. The distal locking buttress screws were inserted after hand drilling through the guides on the jig. This created a fixed-angle device and locked the distal bone fragment to the nail.

Minor adjustments in radial length, tilt, and inclination can be performed by manipulating the nail within the medullary canal. After this a temporary K-wire can be inserted through the jig and into the proximal fracture fragment to maintain the final reduction. The proximal interlocking screws were placed through stab incisions (or a single 2-3 cm longitudinal incision) on the dorsum of the wrist using the guide and sleeve provided. These bicortical interlocking screws secured the distal fragment-nail construct to the shaft fragment. After the jig was disassembled, final fluoroscopic images confirmed the position of the implant and fracture alignment. The tourniquet was deflated, the wounds were irrigated, and the skin was closed.

When using the MICRONAIL® the surgeon should be comfortable with mobilization of the dorsal radial sensory nerve. It can be bluntly dissected and gently retracted, usually dorsally. Excessive retraction or inadvertent surgical trauma can result in sensory disturbance in the hand. Provisional reduction and stabilization of the fracture (including intraarticular fragments) with K-wires may be helpful during instrumentation of the distal radial medullary canal.43,63 The K-wires should be placed away from the eventual path of the MICRONAIL®. Undersizing the implant in the canal is preferred to overstuffing because it prevents iatrogenic fractures and allows more room for final fracture reduction after insertion of the distal locking screws. One of us (VT) found it useful to have a starting point at the radial margin of the second dorsal compartment tendons for dorsally displaced fractures, and at the ulnar margin of the first dorsal compartment tendons for volarly displaced fractures. This was to position the distal buttress locking screws to resist redisplacement.

There are some potential drawbacks to using the MICRONAIL®. Although designed to reside entirely within the medullary canal, placement of excessively long screws can still result in soft tissue irritation. Screw penetration into the distal radioulnar joint (DRUJ) and radiocarpal joint can be avoided by fluoroscopic confirmation of screw length and position. If the most distal screw enters the radiocarpal joint, the implant can be repositioned more proximally. Another concern is difficult observation of sagittal alignment during insertion of the nail because the jig overlies the bone. Therefore, this alignment should be established during initial reduction and broaching. Alternatively, the jig may be disconnected from the MICRONAIL® to check the images but remounting may be slightly cumbersome.

Tan et al63 presented a prospective analysis of 23 consecutive patients treated for isolated unstable distal radius fractures using the MICRONAIL®. The mean age of the patients in this group was 59 years (range, 31-83 years). Twenty of the 23 patients were older than 60 years. Criteria for operative treatment included initial dorsal angulation greater than 20º with dorsal comminution, initial shortening greater than 5 mm, displaced intra-articular component, or loss of reduction with closed immobilization techniques. Exclusion criteria included inability to achieve near-anatomic reduction of the fracture fragments by closed or percutaneous means. Fractures were classified according to the ASIF/AO Comprehensive Classification system.39 There were 10 A2 (Figs 3-5), three A3, four B3, one C1, and five C2 fracture types. Four of the fractures had a Grade 1 open wound on the volar-ulnar side of the wrist, and the remaining 19 were closed fractures. The time interval between the injury and surgery averaged 11 days (range, 0-31 days). Outcome was assessed with standard radiographic parameters, wrist motion, grip strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Fig 3A

Fig 3A

Fig 4A

Fig 4A

Fig 5A

Fig 5A

All patients had a followup of at least 6 months. The average time of complete splint immobilization was 11 days (range, 0-23 days). The overall outcomes regarding active range of motion (ROM) and DASH scores were highly satisfactory even at the early time points. At one month, active wrist motions were: flexion 28º (range, 10-50º), extension 44º (range, 20-70º), radial deviation 12º (range, 5-20º), ulnar deviation 20º (range, 10-30º), supination 61º (range, 30-80º) and pronation 72º (range, 60-90º). Grip strength was 40% (range, 18-71%) of the un-injured side, and DASH score was 29 (range, 19-47).

These measures steadily improved, and at the 6-month followup flexion averaged 58º (range, 25-75º), extension 73º (range, 55-90º), radial deviation 22º (range, 15-30º), ulnar deviation 28º (range, 20-35º), supination 78º (range, 50-90º) and pronation 87º (range, 80-90º). The mean grip strength was 80% (range, 68-100%) of the uninjured side, and the DASH score averaged 8 (range, 0-23).

Initial postoperative radiographs showed average volar tilt was 5º (range, 5º dorsal tilt-12º volar tilt), radial inclination was 22º (range, 15-25º), radial height was 12 mm (range, 8-16 mm), and ulnar variance was 0 mm (range, −2-3 mm) (Table 1). Comparison of the initial postoperative radiographs with those taken at the latest followup showed complete reduction was maintained in all but three patients. One patient (AO type C2) had a 1-mm settling of a die-punch fragment, a second patient (AO type C2) settled to 14º dorsal angulation, and a third patient (AO type B3) failed treatment because the fracture collapsed around the implant within the initial followup period. This failure occurred in a patient with diabetes who had a dialysis shunt in the ipsilateral forearm. The patient had revision surgery to remove the MICRONAIL® with conversion to a locked volar plate 2 weeks after the initial procedure. The change in alignment these cases was attributed to the limitation of the first generation device. In the first-generation design, the dorsal-volar splay of the distal locking screws was less divergent and did not adequately secure the fracture fragments.

TABLE 1

TABLE 1

Three patients had temporary minor radial sensory nerve disturbance that resolved within two months of surgery. There were no cases of infection, complex regional pain syndrome, hardware breakage, or soft tissue irritation.

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Surgical Technique and Clinical Application-Dorsal Nail Plate®

The Dorsal Nail Plate® (Hand Innovations LLC, Miami, FL) is a hybrid plating and IM device for distal radius fractures (Fig 2). Its distal aspect functions as a fixed angle plate that affixes on the dorsal surface of the distal radius, and its proximal portion is locked within the medullary canal. This device is intended for fractures with minimal articular involvement in which reduction may be achieved by closed techniques. Contraindications include displaced intraarticular fractures, comminution involving the diaphysis, and nascent malunions.44

The surgical technique is well described in the technique guide60 and a recent technical report.44 After tourniquet inflation, a 3 to 4 cm longitudinal incision was made on the dorsum of the wrist in line with Lister's tubercle. The tendon sheath of the extensor pollicis longus was then released. Branches of the dorsal radial sensory nerve were identified in the distal aspect of the field and protected. The extensor pollicis longus (EPL) tendon was retracted radially. Next, subperiosteal exposure of Lister's tubercle was performed and carried proximally to expose the fracture site. The distal aspect of the Dorsal Nail Plate® will lie 4 mm proximal to the joint line. Lister's tubercle was removed with a ronguer, and the proximal fragment was notched in line with the floor of the third dorsal compartment. The proximal medullary canal was then entered with an awl. The Dorsal Nail Plate® was inserted and advanced into the medullary canal of the proximal fragment. The neck of the implant should lie against the edge of the notch created in the dorsal cortex. The head of the implant was then reduced to rest flush against the dorsal cortex of the distal fragment. The position of the implant and the fracture fragments was checked under fluoroscopy.

The implant was then secured to the bone by first inserting the most distal buttress peg. Next, the implant was fixed to the proximal fragment with three unicortical screws. After this the insertion jig was removed and the two remaining distal pegs were inserted. The final fluoroscopic images assessed the reduction and the position of the Dorsal Nail Plate® within the bone.

A surgical pearl noted in the technique guide addresses the insertion of the distal buttress pegs.60 To ensure the head of the Dorsal Nail Plate® remains flush with the dorsal cortex of the distal fragment during drilling of the peg holes, the surgeon should push the distal fragment dorsally against the implant. This will help with accurate drilling of the holes and measurement of peg lengths to prevent peg protrusion volarly.

In a recent report on the Dorsal Nail Plate®, Orbay et al44 noted complications were “relatively infrequent” and functional results were satisfactory in a series of over 200 patients. There were few clinical data presented in the article, but the authors did report cases of wound hematoma that required drainage, implant removal due to persistent surgical site discomfort, loss of fixation, and hypertrophic scarring.

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DISCUSSION

Because of the variation in distal radius fracture presentation, a diverse number of treatment options exist for these injuries.1,2,4,7-13,15,16,19,21,23-31,33,34,36-38,41-44,47-50,52-55,57,59,61-63,65 Intramedullary fixation of these fractures is an emerging concept.44,47,51,53,59,63 Until recently, no IM device specifically designed for the distal end of the radius had been available. The MICRONAIL® and Dorsal Nail Plate® now provide such an option for certain fracture patterns.44,63

Despite the growing popularity of surgical treatment for distal radius fractures, closed reduction and casting remains the standard of care for most fractures with minimal metaphyseal comminution and derangement of the articular surface.1,2,4,8,11,16,21,28 In 1951, Gartland and Werley21 reported on patients treated with closed reduction and splinting and determined 68.3% of the patients had satisfactory results. However, they noted residual dorsal (apex volar) angulation negatively impacted the final clinical result.21 Bacorn and Kurtzke2 also noted increased residual deformity after healing with nonoperative management led to increased disability. Loss of reduction with manipulation and casting for up to 30 days after the initial injury has been reported to cause substantial disability.1,7,11,12,14,26,30 Casting has also been associated with compressive neuropathies and reflex sympathetic dystrophy, now referred to as complex regional pain syndrome (CRPS).21,26,57 Casting does not allow wrist mobilization until the course of cast treatment has concluded, which may lead to stiffness, muscle atrophy, or disuse osteopenia.1,12,17,45,51,53 However, for patients in whom a stable and acceptable reduction can be maintained, nonoperative procedures remain the first treatment.1,2,4,8,11,16,21,28

Percutaneous techniques can be used for patients with unstable extraarticular patterns or with intraarticular fragments that cannot be adequately reduced and maintained by closed methods.4,7,10-12,15,20,23,26,28,33,40,41,47,48,50,51,53-55,57,62,65,67 External fixation with or without K-wires is widely used and reliable. The external fixator can maintain those fractures that are axially unstable, but only in the context of a competent soft tissue envelope.65,67 Overdistraction across the carpus often is required to maintain reduction, which may lead to finger stiffness and CRPS.4,7,14,15,28,55,57,65,67 The addition of percutaneous K-wires may address this problem by directly maintaining the reduction of particular fracture fragments.11,18,48,55,57,67 However, there is a risk of pin track infection and soft tissue irritation.14,15,28,33,41,55,65,66 Because most fixators are transarticular, the patient cannot mobilize the wrist and may experience problems with finger motion secondary to tendon adhesion. Attempts to reestablish volar tilt by securing the fixator with the wrist in flexion leaves the extremity in a position of weakness for the finger flexors, reducing the patient's ability to use the hand for gripping activities and potentially causing compression of the median nerve.57

Open reduction and internal fixation is becoming a more widely used technique.4,9,11,13,18,19,22,24,25,27-31,34,36,37,42,43,45,46,48-50,57,61 Exposing the fracture site through a dorsal or volar approach allows direct visualization and manipulation of the fracture fragments. This can help to assure an accurate reduction, especially in patients with more extensive articular involvement.32,34,37 There are plate and screw constructs available for dorsal and volar fixation.4,9,11,13,18,19,22,24,25,27-31,34,36,37,42,43,45,46,48-50,57,61 Dorsally applied implants have well known complications, such as tendon irritation or rupture and the possible need for removing the hardware after fracture healing.4,11,13,32,43,57,61 Therefore, the volar approach has increased in popularity.11,19,42,43 Newer plating systems incorporate distal locking screws or pegs to establish a fixed angle construct for improved resistance to bending forces.18,24,36,42,43,45,47,49 The rigid nature of the hardware allows the patient to engage in early therapy to regain and maintain wrist and finger motion17,26,56 and to use the extremity for light gripping activities. However, the amount of soft tissue dissection and the placement of an extramedullary implant still pose some disadvantages in treating wrist fractures.3,19

Intramedullary implants are intended to minimize some of the disadvantages noted above. These devices reside either partially or completely within the medullary canal and, therefore, may eliminate or substantially reduce the complications related to hardware prominence, tendon irritation, and pin track infection. There are two IM devices that currently are available commercially, the MICRONAIL® and the Dorsal Nail Plate®.

We have clinical experience with the MICRONAIL®63 but no experience with the Dorsal Nail Plate® and therefore cannot specifically comment on the latter device. We found the IM position of the MICRONAIL® makes hardware prominence and tendon complications negligible. Unlike the volar approach, no muscle mobilization is required, thus maintaining fracture fragment vascularity56,58 and muscle integrity. The minimally invasive technique along with the construct stability allowed early wrist ROM and patient satisfaction.

The MICRONAIL® and the Dorsal Nail Plate® represent a new class of devices designed for fixation of distal radius fractures. These unique implants offer treating physicians a minimally invasive approach to internal fixation of certain types of these fractures. Our early results with the MICRONAIL® have been encouraging, especially for AO fracture Types A and B. As reported in the literature,44 the Dorsal Nail Plate® also has promising early results for patients with similar fracture patterns. Longer followup is necessary to determine whether these good early results will be maintained with time.

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