Use of A Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution

Author(s): Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP.

Source: The Journal of Bone and Joint Surgery 87-A(5): 945-954, 2005.

Summary:

This study reviews the use of a spanning “bridge-type” distraction plate for comminuted comminuted distal radius fractures with metaphyseal and diaphyseal comminution. Twenty-two patients were treated with a     3.5 mm compression plate through three separate incisions.  These included one over the metacarpal to apply three screws, an incision over the midforearm to secure the plate to the radius and the third incision at Lister’s tubercle to facilitate passage of the plate under the extensor tendons and to ensure that the plate did not impinge on the EPL.  The plate was first applied distally  followed by distraction and proximal fixation. The diaphyseal fragments were then reduced and fixed with interfragmentary screws when possible.  Allograft was placed to support the articular surface when necessary and if instability was noted at the distal radioulnar joint, the forearm was placed in supination for three weeks.  All fractures were found to be united at 110 days.  Hardware was generally removed two to three weeks after union was confirmed radiographically with an average time from application to removal of the plate of 124 days (range, 68 to 240 days).

The average loss of radial length was 2 mm compared to the contralateral extremity and the mean palmar tilt was 4.6 degrees.  The capitolunate angle was neutral in twenty-one patients.  At one year follow up, flexion and extension averaged 57 degrees and 65 degrees, pronation and supination averaged 77 degrees and 76 degrees and grip strength averaged 69% that of the contralateral side.  Three patients developed an infection at the surgical site, all of whom had a Grade III-A open fracture.  The infections were treated with irrigation and debridement followed by antibiotic therapy without the need for hardware removal.  No cases developed osteomyelitis or extensor tendon rupture. The average DASH score at the time of final follow-up was 11.5 points at an average of 25 months.  According to the rating system of Gartland-Werley at one year post-operatively, fourteen results were rated as excellent, six were rated as good, and two were rated as fair.  Fifteen patients were able to return to their previous jobs in an average of 6.4 weeks postoperatively, whereas two patients were unable to return.  There was no significant correlation between the duration of internal fixation with the plate and wrist flexion/extension or forearm pronation/supination at six months or one year.  There was a significant relationship between the extent of the fracture and wrist motion as well as grip strength.

This study confirms the potential use of a bridge plate for the management of severe metaphyseal and diaphyseal comminuted distal radius fractures.  These fractures often require prolonged time to healing and are less ideally treated with an external fixator due to the potential for pin tract infections over the prolonged time required for their use and the diminished stability imparted by the external fixator.  The use of the distraction plate allows the soft-tissue envelope to mature allowing incorporation of the bone graft while maintaining the reduction.  The internal plate fixation allows the patients to use the upper extremity for light activities and in fact fifteen of the seventeen patients who had been working before the injury were able to return to work during their treatment. The main disadvantage of the use of a bridge plate is its requirement for removal after fracture healing is obtained.

 

 

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Journal of Bone and Joint Surgery