Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side Only for Fracture Distal Radius with Ulnar Styloid Fracture

doi:10.4236/ojo.2013.35043

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Open Journal of Orthopedics, 2013, 3, 227-233

http://dx.doi.org/10.4236/ojo.2013.35043 Published Online September 2013 (http://www.scirp.org/journal/ojo) 227

Comparison between Distractor Application on Both

Radial & Ulnar Side and Radial Side Only for Fracture

Distal Radius with Ulnar Styloid Fracture

Ujjal Bhakat1, Arindam Mukherjee2, Ranadeb Bandyopadhyay3

1B. S. Medical College, Bankura, India; 2The Mission Hospital, Durgapur, India; 3Department of Orthopaedics, B. S. Medical Col-

lege, Bankura, India.

Email: [email protected]

Received June 28th, 2013; revised July 29th, 2013; accepted August 14th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Fracture of distal radius with involvement of the ulnar styloid process is a common clinical problem. It

can be treated conservatively, u sually involving wrist immob ilization in plaster cast or surgically. A key method of sur-

gical fixation is external fixation by distractor. Distractor can be applied either only on the radial side or on both ulnar

and radial sides. Materials and Methods: A prospective randomized and comparative study of 1 year duration was

conducted on 32 patients admitted in the Department of Orthopaedics of BSMC & H in the age group of 20 to 75 years

old with AO types B and C distal radius fracture along with involvement of the ulnar styloid process. The parameters

studied were resto ration of radial len gth, restoration of rad ial angle, intracarpal step-off an d palmar tilt which were sta-

tistically evaluated and Fisher’s exact test was performed. The two tailed P-value was calculated and both the groups

were statistically compared. Results: In our study, 37.5% patients in Group A and 81.25% in Group B had a radial dif-

ference <3 mm which was statistically sig nificant ( Tab le 1 , Chart 1). 43.75% patients in Group A and 87 .5% in Group

B had radial angle <5’ which was significant (Table 2, Chart 2). 31.25% in Group A and 75% had intra carpal step off

<2 mm which was again statistically significant (Table 3, Chart 3). 62.5% had an abnormal palmar tilt in Group A

while only 6.25% had an abnormal palmar tilt in Group B which is extremely statistically sign ificant. On an average, 2

mm of distraction was required in 75% patients of Group A while only 30% patients in Group B required distraction

(Table 4, Chart 4). Conclusion: In our study, the radial difference, radial angle, intra carpal step off and palmar tilt

returned significantly to normal in the patients treated with distractor on radial side only when compared with distractor

application on both radial and ulnar sides for distal radius fracture with ulnar styloid process involvement. Also

post-operative distraction required under image intensifier was higher in the group treated with distractor on either side

than those with distractor only on rad ial side.

Keywords: Fracture Distal Radius; Plaster Cast; Distractor; Radial Length; Radial Angle; Intra Carpal Step Off; Palmar

Tilt; Fischer’s Test; P-Value

1. Introduction

The incidence of distal radius fracture with ulnar styloid

fracture is increasing together with average age of popu-

lation. Intra-articular incongruity is the most probable

cause of unsatisfactory outcome of these fractures in

younger and most active adults. Thus the main goal in

the treatment should be restoration of articular congru-

ence. Persistent intra-articular incongruity has been

shown to cause a 9.9 fold increased risk of radiological

osteoarthritis and restriction of range of motion [1,2].

New implants have been designed to provide stable

and enough fixations for early mobilization after surgery

and to lower complication rates, such as ex ternal fixation

by distractor and internal fixation by Allie’s plate. Distal

radius fracture along with involvement of the ulnar sty-

loid, closed or open, can be treated by distractor applica-

tion on the radial side only. It can also be treated by ap-

plication of distractor on both the radial and ulnar sides

of the affected forearm [3].

Hence we conducted a study in our rural set up to

compare the results of treatment of these fractures by

external fixation with a distractor by either of the two

methods.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side

Only for Fracture Distal Radius with Ulnar Styloid Fracture

228

2. Materials and Methods

A prospective randomized and comparative study was

conducted on the patients admitted in the Department of

Orthopaedics of BSMC & H. Our study population

mainly consisted 32 patients (16 in each group) aged be-

tween 20 to 75 years old, of either sex with distal radius

intra-articular fracture (AO types B and C), along with

involvement of the ulnar styloid process. The study pe-

riod was about 1 year from October 2010 to September

2011. Eligibility criteria for the patients included in the

study were as follows: 1) Patients who were in the age

group of 20 to 75 years of either sex, 2) distal radius in-

tra-articular fracture along with involvement of the ulnar

styloid process without any systemic or psychiatric ill-

ness, 3) patients fit for anaesthesia.

The parameters studied were radiographic parameters:

1) Restoration of radial length (within 3 mm of contra-

lateral side), 2) restoration of radial angle (<5 degrees), 3)

intracarpal step-off (<2 mm) and 4) palmar tilt (0 de-

grees).

After obtaining ethical clearance from the institutional

Ethics committee, study was conducted among the study

populations after obtaining written informed consent in

accordance with the Ethical standards of the 1964 Dec-

laration of Helsinki as revised in 2000. The relevant in-

formation collected by using a pre-designed proforma

including history, general and systemic examination find-

ings. Initial radiograph of the wrist joint was conducted

besides routine pre anesthetic investigations. The 32 pa-

tients were divided in to two groups, 16 in each. The pa-

tients under group A were treated by distractor applica-

tion on both the radial and ulnar sides, while group B

were treated with distractor application on the radial side

only. The patients were followed up with radiographs at

2 weeks apart. Distraction was done in only those with

persistent deformity under image intensifier. The dis-

tractor was maintained for 6 weeks on an average till

bony union was eviden t on skiagram. Following removal

of the distractor, the patients were advised active and

passive range of motion exercises of the wrist joint. Pa-

tients were followed up at every 2 weeks. Radiographs

were obtained again at the end of 12 weeks for compari-

son. The number of patients with restoration of radial

length (within 3 mm of the contralateral side), radial an-

gle (<5 degrees), intracarpal step-off (<2 mm) and pal-

mar tilt (0 degrees) in each group were evaluated and

Fisher’s exact test was performed. The two tailed P-value

was calculated and both the groups were statistically

compared.

3. Results

The 32 patients under the study were divided into 2

groups (16 in each).

Group A-distractor application on both the radial and

ulnar side of the forearm (Figures 1- 5).

Group B-distractor application on the radial side of the

forearm only (Figures 6-10).

In both Groups A and B, 10 were males and 6 were

females.

In either groups, 9 were AO type B and 7 were AO

type C.

Figure 1. Post operative clinical photograph of distractor

application on both radial & ulnar side.

Figure 2. Pre-operative skiagram of wrist showing forearm

A-P view.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side

Only for Fracture Distal Radius with Ulnar Styloid Fracture 229

Figure 3. Pre-operative skiagram of wrist showing forearm

lateral view.

The results were statistically analyzed using Fisher’s

exact test and the two tailed P valu e was evaluated.

In our study, 37 .5% (6 of 16) patien ts in Group A had

a radial difference <3 mm while 62.5% (10 of 16) had

radial difference >3 mm. In Group B, 81.25% (13 of 16)

had a radial difference <3 mm whereas 18.75% (3 of 16)

had a difference >3 mm which was significant (P-value

0.0290) (Table 1, Chart 1). 43.75% (7 of 16) patients

had radial angle <5’ while 56.25% (9 of 16) had radial

angle >5 ’ in Group A. I n Group B, 87.5 % (14 of 16) h ad

radial angle <5’ while 12.5% (2 of 16) had >5’ which

was significant (P-value 0.0233) (Table 2, Chart 2).

31.25% (5 of 16) had intra carpal step off <2 mm and

68.75% (11 of 16) had step off >2 mm in Group A. In

Group B, 75% (12 of 16) had intra carpal step off <2 mm

while 25% (4 of 16) had step off >2 mm which was

Figure 4. Post operative skiagram of wrist showing forearm

with distractor on both radial and ulnar side A-P view.

again significant statistically (P-value 0.0320) (Table 3,

Chart 3). 62.5% (10 of 16) had an abnormal palmar tilt

in Group A while only 6 .25% (1 of 16) had an abnormal

palmar tilt in Group B which is extremely statistically

significant (P-value 0.0021) (Table 4, Chart 4).

In our study, on an average 2 mm of distraction was

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side

Only for Fracture Distal Radius with Ulnar Styloid Fracture

230

Figure 5. Post operative skiagram of wrist showing forearm

with distractor on both radial and ulnar side lateral view.

Figure 6. Post operative clinical photograph of distractor

application on radial side.

Figure 7. Pre-operative skiagram of wrist showing forearm

A-P view.

Figure 8. Pre-operative skiagram of wrist showing forearm

lateral view.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side

Only for Fracture Distal Radius with Ulnar Styloid Fracture 231

Figure 9. Post operative skiagram of wrist showing forearm

with distractor on radial side A-P view.

Figure 10. Post operative skiagram of wrist showing fore-

arm with distractor on radial side lateral view.

Table 1. Restoration of radial length.

Radial length

difference <3 mm Radial length

difference >3 mm P-value

Group A6 10

Group B13 3 0.0290

Chart 1. Restoration of radial length to within 3 mm of

contra-lateral normal side.

Table 2. Radial angle.

Radial angle <5’ Radial angle >5’ P-value

Group A 7 9

Group B 14 2 0.0233

Chart 2. Restoration of radial angle to <5 degrees.

required in 75% patients of Group A while only 30%

patients in Group B required distraction.

4. Discussion

Fracture of distal radius along with fracture ulnar styloid

process usually is classified as either extra-articular or

intra-articular. Numerous eponyms are applied to frac-

tures in this region [2]. The most used AO classification

divides distal radius fractures in three groups and three

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side

Only for Fracture Distal Radius with Ulnar Styloid Fracture

232

Table 3. Intra-carpal step off.

Intra-carpal

step off <2 mm Intra-carpal

step off >2 mm P-value

Group A 5 11

Group B 12 4 0.0320

Chart 3. Intra-carpal step off.

Table 4. Palmar tilt.

Normal palmar tilt

(0 degree ) Abnormal

palmar tilt P-value

Group A 6 10

Group B 15 1 0.0021

Chart 4. Palmar tilt.

subgroups. Groups A1-3 include extra-articular fractures,

Groups B1-3 include partly intra-articular fractures such

as volar and dorsal Barton fractures and Groups C1-3 in-

clude completely intra-articular fractures [4]. 76% to 91%

of fractures of young adults with residual intra-articular

incongruity showed arthritis 7 years after the injury com-

pared to 11% of fractures with congruous joint.

Dorsal angulation of radiocarpal joint surface worsens

functional outcome considerably when it exceeds 20 de-

grees [3]. 38 years after the injury, each ten degrees of

dorsal angulation diminishes volar flexion by three de-

grees [4]. Dorsal angulation exceeding 20 degrees caused

a 6 and 8 degrees loss of volar flexion 3 and 7 years after

the injury respectively [4-7]. Radial shortening of more

than 4 mm associates with decreased forearm rotation at

3 years follow-up [8,9].

So the main goal of treatment is to maintain the ar-

ticular congruity and anatomical restoration of fracture

site by different methods of treatment like external fixa-

tion by distractor or by conservative methods. This study

compares the result outcome of treatment of distal radius

fracture by distractor application on both radial and ulnar

sides of the forearm and distractor application on only

radial side of the forearm [10].

In our study, 37.5% patients in Group A had a radial

difference <3 mm wh ile in Group B 81.25% had a radial

difference <3 mm which was statistically significant (Ta-

ble 1, Chart 1). 43.75% patients had radial angle <5’ in

Group A while in Group B, 87.5% had radial angle <5’

which was significant (Table 2, Chart 2). 31.25% had

intra carpal step off <2 mm in Group A. In Group B,

75% had intra carpal step off <2 mm which was again

statistically significant (Tab le 3, Chart 3). 62.5% had an

abnormal palmar tilt in Group A while only 6.25% had

an abnormal palmar tilt in Group B which is extremely

statistically significant (Table 4, Chart 4). On an aver-

age, 2 mm of distraction was required in 75% patients of

Group A while only 30% patients in Group B required

distraction.

In conclusion, the results of distractor application for

intra articular distal radius fracture (AO types B and C)

with ulnar styloid involvement on radial side alone are

better than application on both radial & ulnar sides. Fur-

thermore, it is seen that on application of distractor on

either sides of a forearm, there is a chance of collapse of

the radial fracture fragment. This is probably due to ulnar

stretching that distorts the normal anatomical relation

between the two styloids (i.e., the radial styloid being at a

lower level compared to the ulnar styloid). Also, only

30% patients with distractor on radial side required re-

peat distraction at 2 weeks whereas 75% patients with

distractor on both sides necessitated distraction.

Hence distractor applied on radial side only is superior,

less costly as well as less cumbersome to distractor ap-

plied on both radial and ulnar sides.

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