Distal radius fracture: Compound injury stabilised with Hoffman II External Fixator
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Distal radius fractures are a common injury and there is no agreed consensus on the best treatment method. The Cochrane review “Surgical interventions for treating distal radius fractures in adults” was withdrawn in 2009 due to its size and complexity. There is however another Cochrane review covering some of this ground titled “External fixation versus conservative treatment for distal radial fractures in adults”. The authors of this suggest that, allowing for the limitations of the available studies, external fixation augmented with percutaneous pin fixation has better radiographic outcomes and may have better functional outcomes when compared with cast immobilisation.
The majority of orthopaedic surgeons and hand surgeons would tend to use internal fixation in preference to external fixation although there is a paucity of evidence to support this. There would probably be little disagreement about using a wrist-spanning external fixator for open fracture-dislocations of the radio-carpal joint. Non-bridging external fixators are typically used for extra-articular fractures or for stabilising extra-articular corrective osteotomies.
In my practice for a displaced closed distal radius fracture where a closed reduction is possible, I would treat this with manipulation under anaesthetic and K-wire stabilisation (MUA + K-wires). When a closed reduction cannot be achieved, then I would use open reduction internal fixation (ORIF). For open fractures, my decision for the method of treatment is determined by the degree of wound contamination. In contaminated wounds from high energy injuries (i.e. there is a broken bone within a significant soft tissue injury) I would initially apply a spanning external fixator. This will often require conversion to a formal open reduction and internal fixation. Initially this allows the soft tissues to either improve or declare themselves as non-viable prior to open surgery. In low energy fractures that are only mild-moderately contaminated, I feel with a thorough debridement and irrigation open reduction internal fixation is a safe and definitive strategy.
Open fractures should be managed according to the British Orthopaedic Association Standard for Trauma which sits on the BOA site and the guidelines section of this technique.
The principles for the management of open fractures include:
- Combined Orthoplastic care
- Intravenous antibiotics within 1 hour
- Remove gross contamination (no mini-washout); photograph; saline soaked dressing
- Realign a deformed limb and splint (neurovascular assessment both pre- and post-reduction)
- Debridement immediately for highly contaminated wounds (agricultural, sewage, aquatic)
- Debridement within 12 hours for high energy open fractures
- Debridement within 24 hours for low energy open fractures.
The Hoffman II Compact External Fixator system is a modular system that is particularly suited for fracture management of the foot and hand & wrist. Its’ design allows many configurations and any deformity can be corrected in 3 planes. It can be used for both temporary and definitive fracture stabilisation.
Other techniques on OrthOracle that deal with the management of distal radial fractures are volar plating https://www.orthoracle.com/library/distal-radius-fracture-fixation-volar-approach-synthes-2-4-mm-variable-angle-locking-lcp/ ,K wiring https://www.orthoracle.com/library/distal-radius-fracture-manipulation-under-anaesthetic-mua-and-k-wire-fixation/ , and dorsal plating https://www.orthoracle.com/library/distal-radial-fracture-fixation-dorsal-approach-synthes-2-4mm-variable-angle-plating-system/
Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006194
Author:Mr Ross Fawdington FRCS Ed (Tr & Orth)
Institution: Queen Elizabeth Hospital, Birmingham, UK.