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A prospective study in surgical management of distal end radius fracture with variable angle locking compression plate

Background and Objective: The distal end of the radius is subject to many different types of fracture, depending on factor such as age, transfer of energy, mechanism of injury and bone quality i.e. Colle’s, Smith’s volar and dorsal Barton’s fracture . Fractures of distal end radius are the most common fractures of the upper extremity, encountered in all of the skeletal fractures and constitute 17% and 75% of forearm fractures and having incidence from 5.7 to 124.6 per 10,000 persons per year . In Intra articular distal radius fracture’s degree of anatomical reduction is directly related to the posttraumatic arthritis. Conservative treatment is usually unsuccessful, and it is fraught with complications, such as early osteoarthrosis, deformity, subluxation, and instability [3-5] The aim of treatment here is good reduction and immediate stability to achieve anatomic fracture union, which will allow the early mobilization of wrist and also to avoid the complications of fracture [6-8] Fracture healing decided by factors such as gap, stability and blood supply . With locking compression plate the locking screw supports subchondral bone and resists axial forces. Compression of locking compression plate to bone is unnecessary and preserves periosteal blood supply . The locking plate minimizes the compression exerted on the bone to achieve stability, impairment of blood supply, periosteal compression and along with that it allows screws to be angled around central axis of plate hole to match with the anatomy . The motive of this study is variable angle locking compression plates in the treatment of distal end radius fractures and it’s beneficial effects. Materials and Methods: 20 patients with Distal End Radius fracture were selected admitted at Chigateri general hospital and Bapuji hospital attached to J.J.M. Medical College, Davangere during October 2018 to October 2020.The study will include patients with distal end radius fractures seen as both out-patient and in-patient fulfilling the inclusion criteria. The patients are assessed both clinically and radiologically. Other associated injuries are noted. The patients undergoing open reduction and internal fixation and application of variable angle locking compression plates for distal end radius fracture are reviewed post operatively, one month, three month, six month and after one year clinically and with x-rays. Result: The study comprised of 15 male and 5 female patients aged from 18 to 72 years with the mean age of 42.2 years with most patient had injury to right side i.e. 11 out of 20 (55%) patients. The average duration from the date of injury to date of surgery was 3 days. The follow up ranged from 6 to 14 months. Using the Modified Cooney, Green and O’Brien functional score for wrist we had 50% excellent, 30% good, 15% fair and 5% poor results with only 3 out of 20 (15%) patients having complications like (arthritis, extensor pollicis longus tendon irritation, superficial skin infection) Interpretation and Conclusion: Fixation of Distal End Radius Fracture with a Variable angle locking compression plate has acceptable outcome for both the patients and surgeon. Variable angle locking plates give acceptable results in the treatment of this type of fracture with better and faster recovery of functions and range of movements.


Introduction
There are different types of distal end fractures of the radius , depending on factor such as age, transfer of energy, mechanism of injury and bone quality like Colles', Smith's, volar and dorsal Barton's fracture [1] . Fractures of lower end radius are the most common fractures of the upper extremity, encountered in practice and make up 17% of all fractures and 75% of all forearm fractures. Incidence rates vary from 5.7 to 124.6 per 10,000 persons per year [2] This fracture shows bimodal distribution of age with the fracture more commonly seen in children and elderly. The objectives of management for a distal end radius fracture should be restoration of range of motion and grip strength while facilitating the patient's early reinstallation to normal daily activities and minimizing the chances of post traumatic arthritis. In an intra articular distal radius fracture the degree of the anatomical reduction is directly related to the post traumatic arthritis. Conservative management for the same is usually unsuccessful, and it is also fraught with complications, such as early osteoarthrosis, deformity, subluxation, and instability [3][4][5] . The goal of treatment here is good reduction and immediate stability to achieve anatomic fracture union, which will help to get the early mobilization of the wrist and also to avoid the complications of fracture [6][7][8] . Fracture healing depends on the following factors: gap, stability, and blood supply 9 . The locking plate decreases the compressive forces exerted on the bone to achieve stability, which prevents associated impairment of blood supply [11] and periosteal compression and which is favored for fracture healing. Various surgical techniques have been reported in the literature [11][12][13][14][15][16] like percutaneous pinning, external fixators and internal fixation with a locking compression plate among which open reduction and internal fixation using a locking plate system is currently advocated for the treatment of distal end fractures, resulting in good reduction and providing immediate stability [3,4,17,18] . When adequate fracture reduction cannot be achieved with closed techniques, internal fixation can restore anatomy and improve functional outcomes. With locking compression plate the locking screw supports subchondral bone and resists axial forces. Compression of locking compression plate to the bone is unnecessary and preserves periosteal blood supply [10] Primary stability achieved with locking screw in a plate prevents secondary displacement irrespective of the bone enabling good result in osteoporotic bones and young patients [19] . The variable angle locking plate decreases the compressive forces exerted on the bone to achieve stability, which prevent associated impairment of blood supply and periosteal compression and which is favored for fracture healing and another advantage of variable angle is that it allows screws to be angles around the central axis of plate hole to match anatomy [11] . The purpose of this study is to evaluate the functional outcomes and assess the complications of patients with distal end radius fractures treated with a variable angle locking compression plate.

Objectives
To study advantages of variable ANGLE locking compression plate over other methods of treatment of Distal end radius fractures. To assess the complications associated with the variable angle locking compression plate in distal end radius fractures. To study the functional outcome of distal end radius fracture treated by variable angle locking compression plate.

Immediate Management
Following admission to the hospital, a careful history was elicited from the patients and / or attendants to reveal the mechanism of injury and the severity of trauma. All patients were thoroughly examined. Their general condition associated systemic diseases and associated injuries were noted. All the findings were duly recorded in the patient proforma.
All patients presented with the involved elbow flexed and the wrist supported by the other hand. Careful inspection of the deformity, swelling and echymosis were done. Clinically tenderness, bony irregularity, crepitus and the relative position of radial and ulnar styloid process were elicited. Movements of the wrist and forearm were checked and found to be painful and limited. Distal vascularity was assessed by radial artery pulsations, capillary filling, pallor and paraesthesia over finger tips. The involved forearm was immobilized in a below elbow POP slab and kept elevated. Pain and inflammation were managed using analgesics like diclofenac sodium 50mg twice daily.

Pre-operative planning
Routine examination of blood was done for hemoglobin percentage, total and differential WBC counts, fasting blood sugar, blood urea, serum creatinine, bleeding and clotting time, HIV and HbsAg. Examination of urine was done for presence of albumin and sugar. Blood pressure and ECG were recorded in all patients. Preparation of the part was done on the day of surgery. Tetanus toxoid injection and intravenous antibiotic were given to all patients pre-operatively. Physician fitness was obtained for all patients. Consent for surgery was taken and patients were operated after a preanesthetic checkup.

Radiographic Examination
Standard radiographs in PA and lateral views were taken for confirmation of the diagnosis and also to know the type of fracture. Oblique views were also taken in a few patients who had complex comminuted fractures. The fracture fragments were analyzed and involvement of radiocarpal and distal radioulnar joints were assessed and classified according to the Frykman's and AO classification.

Surgical Procedures
The duration from the date of injury to date of operation ranged from 1-7 days (average 3.5 days).

Anesthesia
The operations were performed under general anesthesia in all cases and brachial block in 3 cases. Position and tourniquet: The patient was placed supine on the operating table. The affected limb was elevated for 2-3 minutes and exsanguinated. Then a mid-arm pneumatic tourniquet was applied.
The limb was placed on a side arm board by abducting the shoulder so that operating surgeon and assistant can sit either side of the hand table and can operate comfortably. The position of limb should allow complete imaging in the frontal and sagittal plane of the distal radius. Forearm and hand were thoroughly scrubbed, painted with betadine and spirit and draped.

Procedure
All cases are treated with a variable angle locking compression plate using a modified volar Henry approach.

ORIF with plating
Approach: With the forearm in supination, make a longitudinal incision over the interval between the brachioradialis and the flexor carpi radialis muscles. Identify and protect the sensory branch of radial nerve, which lies beneath brachioradialis muscle. Carefully mobilize and retract medially the flexor carpi radialis and the radial artery and vein. The flexor digitorum sublimis, FPL, and pronator quadratus muscles are exposed. Beginning at the anterolateral edge of radius, elevate subperiosteally the flexor pollicis longus and the pronator quadratus and strip them medially.

Fig 1: Volar henry approach for distal radius
The fracture line is now clearly visualised and reduced by manipulation and ligamentotaxis. Provisional k-wires may be used to maintain reduction. The appropriate plate with 3.5mm cortical and 4mm cancellous screws is applied. It is safer to check the screw size in fluoroscope to prevent later complications. Pronator quadratus sutured covering the distal end of plate to prevent tendon irritation. The plate functions in two waysbuttress the distal fragment and maintains metaphyseal reduction.

Implant Features
The two column volar distal radius variable angle locking compression plates combines the advantages of locked plating with Variable angle locking Holes which allow up to 15° offaxis screw angulation in all directions in order to address the individual fracture patterns providing fracture fragment specific fixation [8] .
Strictly subchondral screw placement avoiding intra-articular misplacement of the screw remains sometimes challenging, due to the fixed angle of the locking screw. Which has been overcome by variable angle locking screws technique.
The plate system allows for the creation of construct that resists angular collapse and also functions as an effective fracture reduction aid. The precise screws trajectories, anatomic contour and variable angle locking capabilities of the volar distal radius variable locking compression plates provide a stable construct for predictable reconstruction of complex fractures of distal radius. VA-LACP Two column volar distal radius plate 2.7mm provide various locking screw options in the head of the plate to optimally support the articular surface [21] . Radial screws for the radial column Ulnar screws for the intermediate column

Plate:
The VALCP distal radius plate is a 2.7 mm low profile stainless steel and titanium plate with a 26° distal volar tilt that allows for optimal anatomic fracture reduction and restoration of radial inclination [10,19,20] .
The distal articular end of the plate consists of 4 locking holes for 2.7mm locking screws angled at 15°. The shaft of the plate consists of combiholes for insertion of 3.5mm locking or cortical screws [20,21] .  The plates are available in 2, 3, 4, 5, 6, hole shaft length.
~ 706 ~   The conical shape of the threaded head of fixed angle locking screws allows screw fixation only orthogonal to the plate hole ,where as the cup shaped threaded head of variable locking screws allows screw insertion in a variable angle up to 15° inclination [8] .  Locked screws allow unicortical screw fixation and load transfer to near cortex [22] .  Available in 6mm to 30mm lengths (2mm increments)

Variable angle technique
To drill variable angle holes up to 15° deviation from the nominal trajectory of the locking hole, the tip of the VA-LCP drill sleeve and key inserted into the cloverleaf design of the VA locking hole. Using funnel-shaped end of the VA-LCP drill sleeve variable angle holes are drilled at the desired angle Alternatively, we use the freehand VA-LCP drill sleeve and insert it fully into the VA locking hole and Drill variable angle holes at the desired angle [23] .

Drill Bit
 A 2mm regular drill bit is used for all the cancellous locking screws [21] .  2.8mm regular drill bit for all the cortical locking and non locking screws

Variable Locking Compression Plate
The conventional fixed angle locking screws will provide stable Locking in the plate hole if inserted with in less than 5°of the precise perpendicular direction to the hole [8,24] . Fixed angle locking screw applications are limited to the use of a drill sleeve correctly fixed in the threads of the plate hole. without the use of the drill sleeve the correct screw insertion angle could not be maintained. This lead to the development of variable angle locking plate designs which enables to strategically place the locking screws at various desired angles. Strictly subchondral screw placement avoiding intraarticular misplacement of the screw remains challenging due to fixed angle of the locking screw.these difficulties have led to the development of variable angle locking screws which permit an inclination of the screw insertion angle up to 15°. The variable angle locking screws have Cup shaped Threaded head which locks securely into the threaded holes in the plate to allow screw insertion into plate upto 15° inclination. Within this range of inclination a locking strength comparable to fixed angle locking screws inserted in 0° inclination is provided.
The conical shape of the threaded head of fixed angle locking screws allows screw fixation only orthogonal to the plate hole, where as the cup shaped threaded head of variable locking screws allows screw insertion in a variable angle up to 15° inclination.

Advantages of Variable Angle Locking Compression Plating
VA-LCP volar column plates have the following attributes:  It enables the surgeon to address individual fragments separately  Anatomical reduction depending on the pattern of fracture may be done and stabilization may be provided by using k-wires temporarily as the plate is applied.  Plates are provided with elongated holes that make it convenient to make adjustments in the position of the plates. 1. Universal anatomical shape eliminates need for anatomical contouring of plate based on variations in bone anatomy. 2. Stable Fixation: As the system is versatile, it allows stabilization of even complex fractures. In complex fractures treated based on the three column theory, radius and ulnar fragments may be separately dealt with. Also there are a variety of locking options which is beneficial in fractures near distal radio-ulnar joint where additional screws may be used to support the styloid process [25,26]

Result
The present study consists of 20 cases of distal radius fractures treated at Bapuji Hospital and Chigateri General Hospital, Davangere, treated between, october 2018 to october 2020. All 20 were closed fractures. All cases were followed up periodically during the period 2018 to 2020. The following are the observations made to the available data analyzed as follows. In this series 2 (10%) patients were between 18-20 years, 2 (10%) patients were between 21-30 years, 4 (20%) between 31-40 years, 6 (30%) between 41-50 years, 2 (10%) between 51-60 years and 3 (15%) patients between 61-70 years and 1 (5%) patient was >70 years of age. The age of the patients ranged from 18-72 years with an average of 42.2 years.  Right side (dominant wrist) was involved in 11 (55%) patients and the left side was involved in 9 (45%) patients.  5 25 In our study there were 15 (75%) patients with road traffic accidents and 5 (25%) patients fell on their outstretched hand Out of 20 cases, 6 (30%) patients had associated injuries. Surgery was done between 1-5 days in 18 (90%) patients as an elective procedure. Surgery was delayed up-to the 7 th day in 2 (10%).  3 15 In the present study 17 (85%) patients had union in < 2-3 months and 03 (15%) patients had union in > 3 months. In our study 20 (100%) patients had dorsiflexion within the normal functional range (minimum 45°), 20 (100%) had palmar flexion within the normal functional range (minimum 30°), 20 (100%) had pronation within the normal functional range (minimum 50°), 20 (100%) had supination within the normal functional range (minimum 50°), 18 (90%) had radial deviation within the normal functional range (minimum 15°) and 19 (95%) patients had ulnar deviation within the normal functional range (minimum 15°). 19(95%) patients had grip strength more than 60% compared to the opposite side. 1(5%) had significant loss of grip strength (< 60% compared to the opposite side). 1 (5%) patient had pain in the distal radioulnar joint. None of the patients had stiffness of the wrist. 1 (5%) patient had extensor pollicis longus tendon irritation because of long volar to dorsal screw. 1 (5%) patient had developed arthritis of the wrist joint due to improper reduction and articular step and 1 (5%) patient had developed superficial skin infection which was treated with antibiotics and got recovered. None of the patient had median nerve complication. There were no intra operative complications. Using score system of Modified Cooney, Green and O'Brien functional score for wrist we had 10 (50%) Excellent result, 6 (30%) Good result, 3 (15%) Fair result and 1 (5%) had poor result.

Conclusion
The present study was undertaken to assess the functional outcome of operative management of Distal End Radius fractures in adults by a Variable Angle Locking Compression Plate and the following conclusions were drawn. Distal End Radius fractures are more common in the 3rd to 5th decades. Male preponderance is due to their involvement in heavy manual labour, outdoor activities and riding vehicles.
Most of the fractures in the younger individuals are due to motor vehicle accidents or high energy trauma. The fractures occurring in the older individuals will be due to trivial fall on outstretched hand causing fracture in the osteoporotic bone. The mode of injury is either a road traffic accident or fall on the outstretched hand. Road traffic accidents were more common for young patients while self fall was common for older individuals. According to many studies, locked plates provide successful results for the treatment of intra-articular unstable fractures of distal radius. variable angle Locking compression plate used in Distal End Radius fractures fracture for its effective anatomic reduction, allowing early joint motion because of its rigid fixation. Close placement to joint interface and screwing capability in different orders are its biomechanical superiorities. Modified Volar Henry approach provides both access with minimal surgical trauma on distal radius and fixation with a better adaptation to surrounding tissues.
In the subjects of our study, a successful anatomic alignment was acquired with modified volar Henry approach. The patients, who were young adults in majority, went back to their daily activities with 90% recovery. We encountered some complications (15%) in our study. One is extensor tendon irritation, which was because of long screws projecting dorsally. Other one complication was arthritis in one patient which was because of improper reduction and articular step. One patient developed superficial skin infection of operative wound which was treated with antibiotics and recovered in 2 weeks. These complications can be prevented once the surgeon gets adapted to the procedure. Use of variable angle locking compression plates in Distal End Radius fractures provide good to excellent results and are effective in the correction and maintenance of distal radius anatomy. By using these plates, joint motions and daily functioning is recovered in a shorter time and patient is able to go for his routine work and job in much shorter period of time comparative to other methods of fixation with almost complete normal functions of wrist. The study comprised of twenty cases of Distal End Radius fractures in adults. All patients treated with open reduction and internal fixation with a variable angle locking compression plate. The followup ranged from 9-18 months. The average age was 42.2 years with the fracture being more common in the 3 rd to 5 th decades. Males were predominant with right wrist affection more than left. All fractures were either due to road traffic accidents or fall on the outstretched hand, with road traffic accidents being more common of the two. The average duration from the date of injury to the date of surgery was 3.5 days. All (100%) the patients had their range of motion within the normal functional range. None of the patients had wrist stiffness. Complications were minimal. There was 1(5%) case of extensor pollicis longus tendon irritation. There was 1 (5%) case with an intra articular fracture developed grade I radiocarpal arthritis doing well with physiotherapy. And there was 1(5%) case with superficial infection of operative wound treated with antibiotics.

Summary
The study comprised of twenty cases of DISTAL END RADIUS fractures in adults. All patients treated with open reduction and internal fixation with a variable angle locking compression plate. The followup ranged from 9-18 months. The average age was 42.2 years with the fracture being more common in the 3 rd to 5 th decades. Males were predominant with right wrist affection more than left. All fractures were either due to road traffic accidents or fall on the outstretched hand, with road traffic accidents being more common of the two. The average duration from the date of injury to the date of surgery was 3.5 days. All (100%) the patients had their range of motion within the normal functional range. None of the patients had wrist stiffness. Complications were minimal. There was 1(5%) case of extensor pollicis longus tendon irritation. There was 1 (5%) case with an intra articular fracture developed grade I radiocarpal arthritis doing well with physiotherapy. And there was 1(5%) case with superficial infection of operative wound treated with antibiotics.