Suez Canal Univ Med J

Vol. 3 No. 2, October, 2000

193-201.

Evaluation of Percutaneous Kirschner Wire Fixation and Early Wrist Joint Exercises in The Management of Displaced Unstable Colles' Fractures
Hamam Adel.
From the Department of Orthopedics and Tramatology Suez Cannel University

Introduction
Although Colles' fracture was described in 1814, yet controversy still exists regarding classification, treatment options including immobilization time and correlation between radiological and functional outcome(') The goal of treatment is restoration of joint congruency to produce maximum pain - free movements of the wrist and forearm (2). There is usually a little difficulty in achieving good closed reduction, but maintaining the reduction is often difficult(') Due to the inherent instability of the fracture with subsequent redisplacement occurring in 5- 60% (4), a wide variety of methods have been described for reducing and immobilizing Colles' fracture. These include percutaneous kirschner wire fixatiod5), External fixation , open reduction with internal fixation and primary bone grafting,c7) and finally arthroscopically assisted reduction @). Early wrist movements have been advocated to reduce the incidence of joint stiffness often with the calculated risk of some loss of reduction (9).

Kirschmer wire (K. wire) pinning offers the advantage of a minimally invasive procedure with the ability to move the wrist early while radio-carpal alignment is being achieved (lo). The current study aims at evaluation of the results of percutaneous K. wire fixation and early joint exercises in the management of displaced unstable Colles' fracture.

Material and Method

Twenty four consecutive patients with displaced unstable Colles' fracture treated by percutaneous kirschner wire fixation constitute the material for the current work. There were 16 females and 8 males. The right side was affected in 14 wrists. The age ranged from 23 - 66y with a mean of 52.5 years. The mechanism of injury was fall in 19 patients and traffic injury in 5. Inclusion criteria included unstable Colles' fractures according to sarmiento classification(ll) fig.
(1).

According to this classification, there were 8 patients type 11, 2 type I11 and 14 type IV. Exclusion criteria included patients with associated fractures in the same wrist or limb, previous injury in the same wrist and inability whether physically or mentally to perform the functional exercises program.

TYPE 3

Fig. (1): Sarmiento Classification for Distal Radius Fractures. Standard antero - posterior and lateral radiographs were taken on admission. In the operating theatre closed reduction was done under general anesthesia and fluoroscopy control. Once anatomical reduction was achieved, the stability was checked by observing the effect of flexion and extension on the fracture site. If no motion is seen at the fracture site, it was considered stable. If motion was seen whatever minimal, the fracture was considered unstable and stabilization by two smooth K. wire 1.6-1.8mm in diameter drilled percutaneously through the radial styloid process using K. Wire power drill. The first wire was inserted at the dp of the radial styloid process in the anatomical snuff box, driving the wire through this cortex across the fracture line just through the proximal ulnar cortex of the radius. The second wire was inserted similarly but slightly ventral to the first, so that the stability of non parallel or crossed K. wire was achieved across the fracture with no risk of distraction. The accuracy of reduction and position of wires were again checked by fluoroscopy. The stability was finally evaluated as done before. The exposed length of the wire was then bent to 90" and the excess was cut off. Sterile dressing and a complete well - padded below - the - elbow cast was applied in neutral position. Standard A. P. and lateral radiographs were taken. Post - operatively the arm was elevated and the patient was discharged from the hospital mostly on the second day. The patient was instructed to move his fingers, elbow and shoulder, stressing the value of exercises to prepare the patient for the early mobilization program. The patient was seen at 10 days where checked X-ray was done and the cast was changed if loose. At 3 weeks the patient was seen again where another check

X-ray was don . If pain and tenderness at the fracture site were absent or minimal, the patient was instructed regarding gradual wrist exercises in the pain - free range. The patient was provided a wrist brace worn all the time, and advised to remove the brace, do the exercises 3 -4 times a day and to report any pain at the fracture site. At 6 weeks visit, X-ray was done for the injured and sound wrists for comparison. The pins were usually removed at the out - patient clinic mostly without anesthesia. The patient was instructed to continue the exercises and physiotherapy was started to hasten recovery. The patients were followed-up every three month whenever possible where radiological and functional evaluation was done. Follow-up period ranged from 42-9 months with a mean of 22 months. Clinical assessment was done using a geniometer to measure flexion, extension, pronation and supination, radial and ulnar deviation expressing the results as a percentage of the normal side. Grip strength was measured using bulb dynamometer and expressed as a percentage of the normal side allowing 30% less for the non- dominant side. Complications were reported. Radiological assessment included measurement of radial shortening, radial angle and dorsal angle Fig. (11). Angle measurements were done for the admission X-ray and follow up visits. Over-correction was expressed by negative values. Radial shortening was measured as the difference between the distal ulnar surface and the ulnar part of the distal radial surface and not from the tip of the ulnar stylolid process as the later may be fractured causing false measurement^.('^)

Evaluation of Percutaneous Kirschner wire fixation

195

Fig. (2): Radiological angles measurement. Functional end results were graded modifying the sarmiento modifications of the point system of Cartland and Werley (I3) (I4)for more simplification utilizing the percentile loss of motion compared to the sound wrist thus avoiding the detailed point system with its many subgroups. The functional out-come was considered: Statistical evaluation was done utilizing t- test for matched pairs to test for differences between pre and post operative radioanatomic measurements. Binomial (Z) test was used for differences in proportions. A P-value <0.05 was considered a level of significance in both statistical tests.

I - Excellent:: No pain, no disability, no deformity or loss of movement in any direction not exceeding 10% of the uninjured side.
2- Good: Occasional pain, limitation of movement at any direction not exceeding 15% uninjured side. Function is unimpaired.

Results
The results of radiological evaluation comparing preoperative immediate post operative and at final follow up is shown in table (I). As seen from the table radial shortening increased mainly up to 6 weeks with no marked increase at final follow-up. This was statistically significant. The dorsal angulation showed increase also up to 6 weeks with no change at final follow UP6 weeks

3- Fair: Pain on effort, limitation of movement more than 15-25%, function impaired on strenuous effort and extreme movement.
4Bad: Pain at rest, limitation of movement more than 25%, disability or function impaired on usual daily life activities.

Table I : Radiological evaluation: Angle Time Dorsal Axial shortening Radial Angle Table I1 : wrist function. Wrist functions Percentage Dorsi - flexion Palmar dlexion Radial deviation Ulnar deviation Supination Pronation Less than
10%

Pre operative 23 12 (10 - 18)

16

Post operative
-3.6 (- 14 to 8)

Final follow-up

- 2.5
2.8
22

- 2.5
3.2
20

2
24

1 0 - 15%

15 - 25%

More than
25%
0 0

21 19 22 18
20 1 9

4 3 5 4
3 3

2 2

2 2
I
2

0 0
0 0

196

Hamarn Adel.

The radial angle showed no significant change as at follow up it was within the normal range all through the treatment period. Secondary displacement occurred in 2 patients, one with severe comminution although the initial reduction was good resulting in dorsal angulation of nearly 15 degrees and radial shortening of 14 mm. The other patient was due to severe osteoporosis. In both the deformity was not severe enough with restriction of the wrist movements. They were graded as fair. Depending on the criteria of anatomical reduction, the reduction was excellent in 18 patients, good in 4, fair in 2 with no bad cases.
Clinical Evaluation:

Discussion

The treatment of displaced unstable Colles' fracture remains controversial with the wide variety of treatment options. Although earlier reports suggested that satisfactory functions can be obtained despite poor anatomical alignment,(15) yet most studies have demonstrated that maintenance of accurate anatomical reduction positively correlates with good functional outcome(16)(I7) (I8).This correlates with the current series as non of the fair reduction got excellent final outcome. In the current series 5 cases were due to traffic injuries. Four of them were males bellow 35 years age, which means that in younger patients considerable forces are necessary to cause this fracture. Above 40 ycars there is an increased incidence which correlated to post menopausal and age related osteopenia (I9) (20). In effect, both the cortical comminution and metaphyseal cancellous bone defect may contribute to inherent instability of the distal radius fractures. Several classifications have been published, the commonest is Frykman cla~sification(~~), A.O. classification (22) older classification(23) intra or extra articular(@.These classifications have been frequently used to assist decisions regarding treatment to determine the prognosis, and for patients' grouping. A classification with many subgroups is cumbersome and difficult to remember. Studies on their reproducibility and validity in predicting prognosis in daily use were very weak(24.25). It may be impossible to classify the severity of a fracture based only on bone lesions since associated soft tissue injury and .lot damage to the articular cartilage: revealedby radiographs may lead .~,~ A~ , ~ purely to poor res~lts(~ ~) descriptive classification may be useful in daily practice(26).Indeed this was the finding in our series as patients with severe comrninution failed to get excellent or good functional outcome.

15 patients were pain free at final follow up, occasional pain in 7, pain on effort 2, with no cases of pain at rest. Regarding wrist movement, it was observed that most patients could not appreciate loss of minor degrees at extremes of motion. The final clinical outcome was excellent in 15, good in 7, fair in 2, with no bad cases. There was a strong statistical significant relation between adequacy of reduction and final outcome as none of the fair reductions got excellent clinical assessment. Strong association was observed between the amount of radial shortening and final clinical outcome. The more radial shortening the less is the clinical grading. Wrist grip was imnpaired in 12 patients compared to the other side. This was observed more in left wrist injury
in right handed patients.

Three patients got a pain tract infection that responded to local dressing. Superficial radial nerve praxia occurred in one patient that healed spontaneously. No cases of sympathetic dystrophy, wire breakage was encountered.

Evaluation of Percutaneous Kirschner wire fixation

197

Percutaneous Pinning with K. wires was first recommended by Green (1975)(5).In our study, the final end results are comparable to ~,~~ poor ). other reports on the s ~ b j e c t ( ' . ~ The results achieved in our series were due to comminution. It is agreed with other authors that comminutions more than 2 fragments could be better treated by external f i ~ a t o r ( ' . ~Percutaneous ~). pinning offers the advantage of early pain-free mobilization of the fingers and wrist joints and low risk of pin- track infection and absence of bulky apparatus, which is cumbersome in elder$ patients ("3). External fixators used were either bridging or non-bridging. Non-bridging i.e. the pins in the distal fragment is claimed to have the advantage of permitting the surgeon to have direct control, which allows exact reductio("). Non- bridging has limited use because it requires sufficient space in the distal fragment. However, several authors have reported complications such as stiffness, pintract infection, loosening and reflex sympathetic dystrophy(35,36). Dynamic external fixator was proposed to reduce disability by facilitating return of movement of the wrist (35). Its validity and superiority to other methods was questioned by Sommerkamp et a1(377'. Remanipulation and cast application does not regain or maintain position and is abandoned(38). Open reduction and internal fixation supplemented by bone graft has limited indications when the radius is markedly crushed and radial shorting is extreme in young patients. It is a difficult technique and requires extensive approach with stripping of soft tissues with high rate of malunion (7,34). Arthroscopic reduction is a demanding procedure and needs experience. It dose not aid in realignment of the distal fragment in relation to the long axis of the radius. Acute compartment syndrome has been reported due to leakage of fluid").

In the current series radial shortening and dorsal angulation were incompatible with good results. The accuracy of these angles is somewhat variable depending on the angle of the X-ray beam and the subjective interpretation of the measurer. Therefore changes of less than 5 degrees were considered insignificant. We observed progressive increase of radial shortening during the first six weeks, coinciding with other reports(') (8) but with no further significant increase after six weeks. This progressive shortening was more with external fixator, which may be attributed to case selection with more comminution in cases treated by external fixator. Also radial shortening was found to affect the grip strength which is also influenced by involvement of the distal radio - ulnar joint(39). The use of K. wire to maintain reduction allowed application of below- the-elbow cast in neutral position avoiding extreme flexion and ulnar deviation, which increases the tendency for redisplacernent after initial reduction (40). Pin track infection was very low in our series most likely due to excellent blood supply to the metaphysis. No cases of reflex sympathetic dystrophy were encountered. This may be due to insistence on immediate pbst - operative exercises for the elbow and shoulder and patient education regarding the value of exercised6). No cases of tendon ruptures were encountered in the current series. This complication occurred more with bridging external fixators due to forced distraction (41). Although the period of follow up is short to address the problem of osteoarthrosis, it is thought that the joint incongruity is the main cause of osteoarthrosis. It is sometimes difficult to quantify articular congruity and arthritis from plain radiographs especially when the changes are minimal.

It is agreed that what is more important is the relation between the arthritic changes and symptoms (42). In the current study, early mobilization of the wrist joint was begun as early as the third week with only few patients starting at the fourth week with no marked deleterious effect on the fracture pattern. At that time, the cancelleous lower end of the radius is sticky enough to allow early supervised mobilization to regain wrist movements. Only few studies dealt with the length of time the wrist has to be immobilized where it was found that early mobilization led to significantly less pain and better early functional recovery (43,44,45) Traditional means of external fixators have immobilized the wrist for six to ten weeks producing traction forces, due to ligarnentotaxis across the joint, leading to stretching and tightening of the joint capsule with subsequent scaring. Dynamic fixators had better functional recovery compared to static f i ~ a t o r ( ~ ~ , ~ O ) . The evaluation system used in this series was modified to simplify the point system of Cartland and Werley('"I4). Our modification is simple and takes into consideration comparison with the uninjured wrist. Criteria are more rigid regarding loss of movement compared to the other system. Our modification is quick to use and interpret. In conclusion, Percutaneous Pinning offers the advantage of being simple, economic procedurc allowing early mobilization of the wrist with good functional results.

4. Riis J, Freuensgaard S. Treatment of unstable Collse fractures by external fixation. J Bone Joint Surg (Br) 1989; 66-B: (5) 749 - 753. 5. Green DP. Pins and plaster treatment of comminuted fractures of the distal end of the radius. J Bone Joint Surg (Am) 1975; 57- A:304 6. Pennig D, Gausephol T. External Fixation of the wrist. Injury 1996; 27 (1) 1:15. 7. McBirnie J, Court CM, McQueen MM. Early open reduction and bone grafting for unstable fractures of the distal radius. J Bone Joint Surg (Br) 1995; 77B: 571. 8. Adolfsson L, Sholm J. Arthroscopically assisted reduction of fntra -articular Fractures of the distal radius. J Hand Surg (B) 1998; 23-B (3) :391-395. 9. Abbaszadegan H, Jonsson U, Von Sivers K. Prediction of instability of Colles' Fractures. Acta Orthop Scand 1989; 60: 646 - 50. 10.Rayhak JM. The history and evolution of percutaneous pining of displaced distal radius fractures. Onhop Clin North Am 1993; 24 (2): 287-300. 11. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles' fractures: functional bracing in supination. J Bone Joint Surg (Am) 1975; 57-A: 31 1 -7. 12.Warvrich D, Prothero D, Field J, Bannister G. Radiological measurement of radial shortening in Colles' fracture. 3 Hand Surg (Br) 1993; 18-B:50-52.
13. Sarmiento A, Latta LL. Closed functional treatment of fractures. Berlin, etc.: Springer - Verlag, 1981.

References
1. Lenoble E, Dumontier C, Goutallier D, Apoil A.

14.Cartland JJ Jr, Werely CW. Evaluation of healed Colles' fractures. J Bone Joint Surg (Am) 1951; 33-A: 895 -907. 15. Smaill, GB. Long - Term Follow-up of Colles's Fracture. J Bone Joint Surg (Br) 1965; 47-B(1): 80-85. 16.Jakim I, Pieterse HS, Sweet MB. External fixation for intra - articular fractures of the distal radius. J Bone and Joint Surg (Br) 1991; 73-B: (2): 302-306. 17.McQueen M,Caspers J. Colles' fracture: Does the anatomical result affect the final function. J Bone Joint Surg (Br) 1988 ;70-B: (4) : 649 -651.

Fracture of the distal radius. A prospective Comparison between transstyloid and Kapandji Fixations. J Bone Joint Surg (Br) 1995; 77 - B(4) 562-7.
2. Krishman LS, Chipchase J, Slavotinen. J Hand surg (B) 1998 ;23 B: (3) :396-399.
3. McQueen M, MacLaren A, Chalmers J. The value of remanipulating Colles' fractures. J Bone Joint Surg (Br) 1986; 68-B: (2): 232 -233.

Evaluation of Percutaneous Kirschner wire fixation 18.Simpson NS, Wilkinson R, Barbenel JC, Kinninmont AWGK. External fixation of the distal radius. J Hand Surg (Br) 1994; 19-B: 188-192. 19. Boyd LG, Home JG. The outcome of the fractures of the distal radius in young adults. Injury 1988; 19: 97. 20.Roumen RTVllI, Wlem H, Bruggink EDM. Unstable colles' fractures in elderly patients. J Bone Joint Surg (Br) 1991 ; 73-B : 307. 21. Frykman, G. Fracture of the distal radius including sequelae -shoulder - hand - finger syndrome. Acta orthop Scand 1967; Supplementum 108. 22.Conney WP. Fractures of the distal radius: Classification and indications for external fixation. In: Cziffer E(ed). Minifixation. External fixation of small bones. Literatura Medica 1994; P. 135. 23.01der TM, Stabler EY, Cassebaum WH. Colles' fracture: Evaluation and selection of therapy. J Trauma 1965; 5 (4) : 469 - 76. 24. Illarramendi A, Gonzalez Della Valle, Segal E, Decarli P. Maignon G. Evaluation of simplified Frykman and A 0 classifications of fractures of distal radius. Assessment of interobserver and intraobserver agreement. International Orthopaedics (SICOT) 1998 ; 22: 11 1 - 115. 25. Flinkkila T, Raatikainen T, Hamalainen M. A0 and Frykman's classifications of Colles' fracture. No prognostic value in 652 patients evaluated after 5 years. Acta Orthop Scand 1998; 69 (1) : 77-81. 26. Cotton JL. Fracture classification. J Bone Joint Surg (Br) 1997; 79 - B 7098 -9. 27. Bernstein J, Monaghan BA, Silber JS, DeLong WG. Taxonomy and treatment: a classification of fracture classifications. J Bone Joint Surg (Br) 1997; 79-B :706-7. 28. Geissler WB, Freeeland AE, Savoie FH, Mclntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fractures of the distal end of the radius. J Bone Joint Surg (Am) 1996: 78-A: 357-65.

199 29. Ludvigsen T, Johansen 5, Svenningsem 5, Saetermo R. External fixation versus percutaneous pinning for unstable colles' fracture. Equal outcome in a randomized study of 60 patients. Act Orthop Scand 1997 ; 68 (3) : 255-258. 30.Habernek H, Weinstable R, Fialka C, Schmid L. Unstable distal radius fractures treated by modified Kirschner wire pinning: Anatomic considerations, technique, and results. J Trauma 1994; 36: 83-8. 3 1. Pritchett JW. External fixation or closed medullary pinning for unstable Colles' fractures?. J. Bone Joint Surg (Br) 1995; 77-B: 267-9. 32. Leung KS, Shen WY, Tsang HK, et al. An effective treatment of comminuted fractures of the distal radius. J Hand Surg (Am) 1990; 15-A: 11-7. 33. Clancey GJ. Percutaneous Kirschner-wire fixation of Colles' fractures a prospective study of thiry cases. J Bone Joint Surg (AM) 1984; 66 -A: 1008-14. 34. McQueen IVIM. Redisplaced unstable fractures of the distal radius A randomized prospective study of bridging versus non - bridging external fixation. J Bone Joint Surg (Br)1998; 80 - B: 665 - 669. 35.Clyburn TA. Dynamic external fixation for comminuted intra - articular fractures of the distal end of the radius. J Bone Joint Surg (Am) 1978; 69-A: (14) 248.

36. Schuind F, Donkerwolcke M, Rasquin C, Burny F.

External fixation of fractures of the distal radius a study of 225 cases. J Hand Surg (Am) 1989; 14-A: 404-7. 37. Sommerkamp TG, Sceman M, Silliman J, Jones A, Patterson S. Walker J, Semmler M, Browne R, Exaki M. Dynamic external fixation of unstable fractures of the distal part of the radius. J Bone Joint Surg (Am) 1994; 76- A (8) :1149-61. 38.McQueen MM, Hajducka C, Court - Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomized comparison of four methods treatment. J Bone Joint Surg (Br) 1996; 78 - B: 404-9.

Hamam Adel. 200 39. Koplov P. Johell 0, Redlund I, Bengner U.Fractures of the distal end of the radius in young adults: A 30 - year follow- up. J Hand Surg (B) 1993; 18-B:45 -49.
40. Oskam J, Degraaf JS, Klasen HJ. Fractures of the

44.Millet PJ, Rushton N. Early Mobilization in the treatment of Colles fracture: 3 years prospective study. Injury 1995; 26: 67 1-675. 45.Vanghamsen F, Staumstrup H, Mihelcen S. A comparison of 3 and 5 weeks Immbolization for older type I and 2 Colles' fractures. J hand surg (Br) 23-B (3) ~400-401.

distal radius and scaphoid. J Hand Surg (Br) 1996; 21-B: (6): 772 - 774.
41. Knirk JJ, Jupiter JB. Intra -articular fractures of the

distal end of the radius in young adults. J Bone Joint Surg (Am) 1986; 68-A: 647.
42. Van Dijk JP, Laudy FGJ. Dynamic external fixation

versus non-operative treatment of severe distal radial fractures. Injury 1996; 27: 57-6 1.
43. McAuliffe TB, Hilliar KIvI, Coates CJ et al. Early
Correspondence to:
Hamam Adel. Department of Orthopedics and Tramatology
Suez Cannel University

mobilization of Colles' fractures A Prospective trial.

J Bone Joint Surg (Br) 1987; 69-B : 727.

Evaluation of Percutaneous Kirschner wire fixation

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