BACKGROUND: Distal radial fractures with extensive comminution involving the metaphyseal-diaphyseal junction present a major treatment dilemma. Of particular difficulty are those fractures involving the articular surface. One approach is to apply a dorsal 3.5-mm plate extra-articularly from the radius to the third metacarpal, stabilizing the diaphysis and maintaining distraction across the radiocarpal joint.
METHODS: Twenty-two patients treated with a distraction plate for a comminuted distal radial fracture were included in the study. With use of three limited incisions, a 3.5-mm ASIF plate was applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, to the long-finger metacarpal, where it was fixed distally. The articular surface was anatomically reduced and was secured with Kirschner wires or screws. Eleven of the twenty-two fractures were treated with bone-grafting. The plate was removed after fracture consolidation (at an average of 124 days), and wrist motion was initiated. All patients were followed prospectively with use of radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores.
RESULTS: All fractures united by an average of 110 days. Radiographs showed an average palmar tilt of 4.6° and an average ulnar variance of neutral (0°), whereas loss of radial length averaged 2 mm. Flexion and extension averaged 57° and 65°, respectively, and pronation and supination averaged 77° and 76°, respectively. The average DASH scores were 34 points at six months, 15 points at one year, and 11.5 points at the time of final follow-up (at an average of 24.8 months). According to the Gartland-Werley rating system, fourteen patients had an excellent result, six had a good result, and two had a fair result. Grip strength and the range of motion of the wrist at one year correlated inversely with the proximal extent of fracture comminution into the diaphysis. The duration of plate immobilization did not correlate with the range of motion of the wrist or with the DASH score at one year.
CONCLUSIONS: The use of a distraction plate combined with reduction of the articular surface and bone-grafting when needed can be an effective technique for treatment of fractures of the distal end of the radius with extensive metaphyseal and diaphyseal comminution. A functional range of motion with minimal disability can be achieved despite a prolonged period of fixation with a distraction plate across the wrist joint.
1 Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157. E-mail address for T.A. Ginn: email@example.com
2 Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710
3 Section of Hand and Microvascular Surgery, Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104