Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly chinese population: a prospective randomised controlled trial

Abstract

We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a ‘Cast’ group (n = 30) or a ‘K-wire’ group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.

Keywords

cast percutaneous pinning randomised controlled clinical trial distal radial fracture Chinese elderly

INTRODUCTION

There is debate whether fractures of the distal radius should be treated by conservative or operative methods. Many treatments have been described for these fractures (Chung et al., 2006; Clancey, 1984; Cooney et al., 1979; Mah and Atkinson, 1992; Ring and Jupiter, 2000; Shankar and Craxford, 1992; Stoffelen and Broos, 1999; Willis et al., 2006). These include: closed reduction and casting, closed reduction and percutaneous pinning by different methods such as Kapandji intra-focal pinning, transradial styloid pinning, pinning via Lister’s tubercle or trans-ulnar pinning; closed reduction and external fixation by means of ligamentotaxis to realign the fracture displacement; open reduction and internal fixation by different approaches such as dorsal, palmar or combined; and by different implants such as screws, non-locking plates and locking plates, which are currently favoured by many orthopaedic surgeons (Kamano et al., 2005; Musgrave and Idler, 2005; Wong et al., 2005).

The choice of treatment depends on many factors such as the patient’s age, life style, associated medical conditions, compliance, functional demands, limb dominance, type of fracture, severity and alignment of the fracture, condition of the soft tissue, including any open wound, and concomitant fractures. For patients of advanced age and low functional demand, we have usually treated extra-articular fractures without comminution of the metaphyseal region by closed reduction and casting. However, some unstable fractures treated with closed reduction and casting will have a poor functional outcome.

The aim of this study was to compare the functional and radiological outcomes and quality of life between patients treated by immobilisation in a cast alone or percutaneous pinning alone for unstable, extra-articular fractures of the distal radius after closed reduction in an elderly Chinese population.

PATIENTS AND METHODS

Between July 2006 and July 2007, all patients admitted to our department who presented with an unstable, dorsally angulated, extra-articular fracture of the distal radius were provisionally enrolled into this study (Fig 1). We defined fractures with dorsal angulation more than 20° and radial shortening more than 5 mm as unstable fractures (Azzopardi et al., 2005).

Fig 1

Radiographs of a 70-year-old woman with an unstable extra-articular distal radial fracture. (a) AP view showing severe radial shortening of the fracture. (b) Lateral view showing marked dorsal displacement of the distal fragment.

We classified the fractures by Frykman’s classification (Frykman, 1967). This classification considers involvement of radiocarpal and radioulnar joints in addition to presence or absence of a fracture of the ulnar styloid process. The classification does not include the extent or direction of initial displacement, dorsal comminution, or shortening of the distal fragment.

The study was conducted in accordance with the Helsinki Declaration (Helsinki Declaration, 2006) and the hospital’s institutional review board approved the protocol. We obtained informed consent from all patients enrolled into this study. Patients were then randomly allocated by opening sequentially numbered opaque sealed envelopes to either the ‘Cast’ group who would be treated with closed reduction and casting by standard plaster of Paris, or the ‘K-wire’ group who would be treated with closed reduction and percutaneous pinning. We excluded patients younger than 65 years old, patients with intra-articular involvement, compound fractures, concomitant fractures elsewhere, palmar angulated fractures, minimally displaced fractures or fractures with dorsal tilting less than 20° and fractures more than 2 weeks old. Patients who had dementia or psychiatric illness were also excluded from the study. All patients in each group were treated by an orthopaedic specialist who had more than 10 years experience to standardise the method. For the ‘Cast’ group, one surgeon, who used the same method of moulding the plaster of Paris, applied all plasters. In the ‘K-wire’ group, another surgeon with a similar length of experience as the surgeon in the ‘Cast’ group did all the operations.

Sixty-five patients who met the inclusion criteria were identified, and 62 of them agreed to participate. The preoperative demographics of each patient were recorded in detail. All patients included in the outcome analysis remained in their primary randomisation group regardless of secondary procedures, according to the intention-to-treat principle, and CONSORT guidelines were followed (Moher et al., 2001).

Treatment technique

For the ‘Cast’ group, closed reduction was done under a haematoma block. After reviewing the radiographs of the injured wrist, 1% lidocaine was injected directly over the most tender site after aspirating some of the haematoma, which was confirmation that the lidocaine was injected into the fracture site.

For reduction, we used Jones’ method which involves increasing the deformity, applying traction, flexing the distal fragment over the proximal shaft fragment and immobilising the wrist in the reduced position. The closed reduction of distal radial fractures is facilitated by an assistant providing counter traction by grasping the arm above the elbow. The surgeon controls the distal fragment with both hands and both thumbs over the dorsal surface of the distal fragment.

A pre-measured plaster of Paris which was 6–8 layers in thickness was used after reduction. The plaster of Paris was moulded by the surgeon to apply three-point fixation before it set and became rigid. We did not immobilise the elbow joint. We avoid placing the hand and wrist in too much flexion to prevent median nerve compression and stiff fingers. Radiographs including an anteroposterior view and true lateral view of the injured wrist were obtained to confirm the reduction alignment (Fig 2).

Fig 2

Radiographs of the same patient after closed reduction and immobilisation with a plaster of Paris. (a) AP view showing correction of the radial shortening and inclination. (b) Lateral view showing the restored palmar tilt.

In the ‘K-wire’ group, the operation was done under Bier’s block. Before inflation of the tourniquet, 1 g of cefazolin was injected via the heparin block to act as a prophylactic antibiotic to prevent pin tract infections. With the distal radius in the reduced position, the surgeon then inserted three percutaneous K-wires under fluoroscopic guidance through three small stab incisions. To avoid injuries to tendons, nerves and vessels, after making a small stab incision over the skin artery forceps were used to dissect the soft tissue bluntly to the cortex of the bone. A drill guard was used to protect the surrounding soft tissue when inserting the K-wire. The K-wires were inserted under fluoroscopic guidance during the whole procedure to avoid blocking the path of the K-wires.

The directions of the percutaneous K-wires insertion were as follows: one 1.5 mm K-wire was inserted via the dorsoradial side of the distal radius through the radial styloid process, directed obliquely to fix the fracture and was anchored in the far cortex; the second 1.5 mm K-wire was inserted from the dorsoulnar side of the distal radius, directed obliquely to fix the fracture and was anchored in the palmar cortex of the proximal radial side; the third 1.5 mm K-wire was inserted from the palmar radial side of the distal radius and directed dorsally to anchor in the proximal dorsal cortex. During insertion, the surgeon ensured all K-wires had enough purchase to the osteoporotic fractured metaphysis. By using this ‘tripod technique’, there are three points of fixation on each side of the fracture, which, ideally, should be very rigid just like a tripod chair (Fig 3).

Fig 3

Radiographs of a 68-year-old woman after closed reduction and immobilisation with percutaneous K-wires. (a) AP view showing correction of the radial shortening and inclination. (b) Lateral view showing the restored palmar tilt.

The fracture stability was reassessed for each of the constructs after insertion of the K-wires. It was essential to hold the fracture as closely reduced as possible while the pins were inserted to minimise skin traction against the pins. Damage to the superficial branch of the radial nerve and the extensor tendons was minimised by blunt dissection of the skin and soft tissue down to the use of the bone and the protective drill guard.

We positioned the distal forearm on a stack of towels which allows the wrist to be maximally flexed to help with the reduction. This facilitates pin insertion as the hand and thumb are moved out of the way and aids fluoroscopy since the distal forearm rests parallel to the ground. After fixation of the fracture, we tested the stability of the fracture by passively extending and flexing the wrist under fluoroscopy. The K-wires were left protruding percutaneously and were removed once the fracture consolidated.

Radiographs including an anteroposterior view and a true lateral view were obtained to confirm the adequacy of the reduction. We allowed gentle mobilisation of the wrist immediately under the instruction of an orthopaedic physiotherapist.

We did not apply plaster of Paris to augment the fracture stability but the occupational therapist made a removable palmar splint for resting purpose.

Outcome assessment

All patients were discharged after assessment of the radiographs. They were assessed in a specialist outpatient clinic at 1, 2, 4 and 6 weeks, and after 3 months, 6 months and 1 year by the same hand specialist.

The plaster of Paris and K-wires were removed at 6 weeks after reviewing the radiographs to confirm that the fracture had united, as shown by obvious cross trabeculation between the fracture lines or gap.

The functional outcome was assessed by an orthopaedic specialist physiotherapist, who was considered as blinded to the procedure since the cast, splint and K-wires were removed before the functional assessment and the pin track scars were covered by a bandage to control the swelling and could not be easily observed.

The active ranges of motion of the wrist including extension, flexion, supination, pronation, ulnar deviation and radial deviation were measured using a standardised goniometer. Grip strength was assessed by a standardised dynamometer and the mean of three readings was obtained.

The pain level and assessment of activity of daily living were assessed by using the Mayo wrist score (Cooney et al., 1987). The pain level was graded as no pain, mild, moderate and severe. The grading of the activities of daily living was classified into: normal, meaning that the patient was able to resume their original work or job using the injured limb; mildly restricted, meaning that the patient could resume their original work or job but not using the injured limb as normally as previously; moderately restricted, meaning that the patient could not resume their original work and were very limited in using injured limb; and severely impaired, meaning that the injured limb was totally non-functioning. The Mayo wrist scores were then calculated from the above categories.

The subjective satisfaction score was also assessed by using the following grading: grade 1 for very satisfied; grade 2 for moderately satisfied; grade 3 for not satisfied but able to work; and grade 4 for not satisfied and unable to work.

We used the World Health Organization Quality of Life (WHOQoL) questionnaire (Leung et al., 2005) to assess the quality of life of the patients. It was divided into five categories. They were: overall score, physiological, psychological, social and environmental. They were assessed during admission to assess the quality of life before the injury retrospectively and at 2 weeks, 3 months and 1 year after treatment.

For the radiological assessment, standardised anteroposterior and true lateral views of the wrist were taken with the forearm in neutral rotation. The radial inclination angle, radial length and ulnar variance were measured and the measurements were compared with the radiographs of the uninjured wrist. The dorsal angulation of the distal radius was measured in degrees from the neutral position. The assessor of the radiological outcomes was blinded to the method of the treatment and the functional outcomes after removal of the plaster of Paris, the K-wires and the splint.

Statistical analysis

The statistical difference was calculated by using Fisher’s exact test for dichotomous variables with a frequency < 5 and the Chi-squared test for variables with a frequency > 5; ANOVA and Wilcoxon tests were used for the analysis of continuous variables of parametric data and of nonparametric data. All tests of significance were two-tailed. Statistical significance was defined as P < 0.05.

RESULTS

The study included 62 patients, but two patients were excluded from all analyses due to their deaths caused by heart disease which was not related to postoperative complications. Of the 60 patients who remained in the study, 30 were randomised to the ‘Cast’ group and 30 to the ‘K-wire’ group. Both groups had comparable preoperative demographics. The patients were predominantly female and the mean age was around 70 years. Both groups had comparable injured sides and classifications of the fracture. The details are summarised in Table 1.

Table 1–

Demographic data for both groups, mean (range)

	Cast group	K-wire group	P-value
No. of patients	30	30	—
M : F	5 : 25	6 : 24	—
Age	71 (65–76)	70 (66–76)	0.852
Dominant side injury	20	21	—
Involved side R : L	19 : 11	20 : 10	—
Frykman’s classification I : II	18 : 12	17 : 13	—
Time between injury and treatment (days)	1 (0–3)	1 (0–3)	0.912
T score (L1–L4)	−2.6 (−2.9 to −1.1)	−2.6 (−3.1 to −1.1)	0.522
T score (left femoral neck)	−2.5 (−3.1 to −1.3)	−2.6 (−3.0 to −1.2)	0.622
Follow up (months)	19 (13–24)	20 (13–24)	0.762

Functional outcome measurement

The comparison between the ranges of motion and grip strength at final follow-up of the two groups is summarised in Table 2. There was no statistically significant difference between the two groups.

Table 2–

Comparison between ROM (degrees) and grip strengths of both groups at final follow-up, mean (standard deviation)

	Cast group	K-wire group	P-value
Extension	71 (8)	72 (7)	0.453
Flexion	72 (10)	73 (8.2)	0.343
Pronation	75 (7)	77 (4)	0.444
Supination	75 (7)	76 (4)	0.243
Radial deviation	24 (7)	21 (6)	0.262
Ulnar deviation	21 (7)	20 (6)	0.513
Grip strength (kg)	9.0 (7.2)	8.5 (6.2)	0.453

There was no statistically significant difference between the two groups for the mean Mayo wrist score or its individual components (Table 3).

Table 3–

Details of Mayo wrist score of both groups at final follow-up, mean (standard deviation)

	Cast group	K-wire group	P-value
Pain (25 points)	21.8 (3.4)	20.5 (3.2)	0.873
Functional status (25 points)	23.5 (6.1)	23.1 (7.1)	0.914
Range of motion (25 points)	18.2 (4.2)	20.1 (6.3)	0.455
Grip strength (25 points)	15.3 (6.2)	14.2 (4.5)	0.765
Total score (100 points)	80.5 (7.5)	82.2 (6.2)	0.563

One patient in the ‘K-wire’ group had a pin track infection at around 4 weeks after treatment and one K-wire was removed. The wound swab cultured Staphylococcus aureus, which was sensitive to penicillin. One course of oral penicillin was given to the patient. The pin track subsequently healed with daily dressing. There were no tendon nerve or vessel injuries. There were no complications associated with the palmar K-wire.

One patients in the ‘Cast’ group had complex regional pain syndrome and presented with pain and very stiff joint 3 months after treatment. She was treated with intense physiotherapy but she still complained of pain and limited range of motion 6 months after treatment.

For the quality of life, there was no statistically significant difference between the two groups before the injury but there was a statistically significant difference between the two groups 2 weeks after receiving the treatment. However, there was no statistically significant difference 3 months postoperatively and at final follow-up assessment (Table 4).

Table 4–

Details of WHOQoL and satisfaction score of both groups at final follow-up, mean (standard deviation)

	Cast group	K-wire group	P-value
Overall	3.5 (0.5)	3.7 (0.7)	0.855
Physiological	14.1 (2.1)	15.5 (1.9)	0.663
Psychological	14.5 (3.2)	15.5 (3.4)	0.679
Social	16.2 (6.7)	15.2 (5.4)	0.327
Environment	14.3 (1.8)	14.5 (2.3)	0.546
Satisfaction score	2.3 (0.4)	2.4 (0.3)	0.895

Radiological outcome assessment

The mean dorsal angulation angle, radial inclination angle, radial length and ulnar variance before the reduction were similar in both groups and there was no statistically significant difference between the two groups.

The mean dorsal angulation angle, radial inclination angle, radial length and ulnar variance immediate after the treatment were the same in both groups without statistically significant difference but the dorsal angulation, radial inclination and radial length had statistically significant differences between the two groups, with better alignment maintained in the K-wire group at 1, 2, 4, 6 weeks, 3 months, 6 months and 1 year after treatment. The ulnar variance at different periods of follow-up assessment and the healing time did not show any statistically significant difference between the two groups. The details of the radiological outcome comparison are summarised in Tables 5 to 8.

Table 5–

Comparison of the dorsal angulation of both groups, mean degrees (standard deviation)

	Cast group	K-wire group	P-value
Normal wrist	−12 (3)	−11 (3)	0.672
Preop	31 (6)	33 (6)	0.764
Postop D1	−7.5 (1)	−8 (1)	0.545
1/52	−4 (1)	−5 (1)	0.043*
2/52	2 (1)	−5 (1)	0.033*
4/52	2 (1)	−4 (1)	0.033*
6/52	3 (1)	−4 (1)	0.033*
3/12	3 (1)	−4 (1)	0.032*
6/12	3 (1)	−4 (1)	0.032*
1 Year	3 (1)	−4 (1)	0.032*

Statistically significant difference.

Table 6–

Comparison of the radial length of both groups, mean degrees (standard deviation)

	Cast group	K-wire group	P-value
Normal wrist	11.3 (2.4)	11.4 (3.1)	0.873
Preop	5.2 (1.8)	6.1 (2.2)	0.555
Postop D1	10.7 (2.1)	11.4 (1.8)	0.678
1/52	7.4 (1.5)	9.2 (2.1)	0.044*
2/52	6.5 (1.7)	8.8 (1.9)	0.032*
4/52	5.5 (1.2)	8.4 (1.7)	0.033*
6/52	4.8 (1.3)	7.7 (2.5)	0.032*
3/12	4.2 (1.1)	7.5 (2.2)	0.025*
6/12	4.2 (1.1)	7.5 (2.2)	0.025*
1 Year	4.2 (1.1)	7.5 (2.2)	0.025*

Statistically significant difference.

Table 7–

Comparison of the radial inclination of both groups, mean degrees (standard deviation)

	Cast group	K-wire group	P-value
Normal wrist	23 (4)	23 (3)	0.894
Preop	13 (3)	13 (4)	0.764
Postop D1	23 (4)	23 (2)	0.775
1/52	19 (3)	22 (4)	0.044*
2/52	18 (3)	21 (3)	0.043*
4/52	17 (2)	20 (2)	0.032*
6/52	17 (2)	20 (2)	0.032*
3/12	16 (2)	20 (2)	0.021*
6/12	16 (2)	20 (2)	0.021*
1 Year	16 (2)	20 (2)	0.021*

Statistically significant difference.

Table 8–

Comparison of the ulnar variance (mm) and healing time of both groups, mean (standard deviation)

	Cast group	K-wire group	P-value
Normal wrist	0.9 (0.1)	1.1 (0.2)	0.534
Preop	4.3 (1.2)	5.2 (1.8)	0.087
Postop D1	0.5 (0.2)	0.3 (0.1)	0.086
1/52	1.7 (0.7)	1.2 (0.6)	0.086
2/52	1.9 (0.9)	1.3 (0.7)	0.084
4/52	2.4 (1.2)	1.3 (0.8)	0.084
6/52	3.1 (1.4)	1.9 (0.7)	0.083
3/12	3.2 (1.4)	2.1 (1.1)	0.074
6/12	3.2 (1.4)	2.1 (1.1)	0.074
1 Year	3.2 (1.4)	2.1 (1.1)	0.074
Healing rate	30	30	—
Healing time (weeks)	6.5 (3.2)	6.8 (2.4)	0.782

DISCUSSION

The general belief is that older patients with lower functional demands do relatively well in spite of obvious deformity resulting from a fracture of the distal radius. However, many orthopaedic surgeons now think that there is a direct relationship between anatomical alignment and functional outcomes.

Anatomical reduction can usually be achieved by closed methods. However the methods of immobilisation are controversial, particularly in osteoporotic bone. An external support such as a cast is a generally acceptable treatment for extra-articular fracture but the alignment may not be maintained (Fernandez, 2005). Percutaneous pinning to treat extra-articular fractures of the distal radius is a simple procedure that can be done under local anaesthesia (Gofton and Liew, 2007). We compared these two methods in patients in our Chinese population.

Several publications have addressed this topic but the percutaneous pinning methods were different from ours and percutaneous pinning was used in conjunction with a cast (Green, 1975; Rodriguez-Merchan, 1997; Shankar and Craxford, 1992). In our study we used percutaneous pinning alone to fix the fracture and allow the patients to do gentle mobilisation exercise without casting because we believe that early mobilisation is good for the patients and may avoid later complications.

Stoffelen and Broos (1999) used a splint for 1 week only after K-wiring and they were unable to demonstrate any significant difference between closed reduction and pinning. Our study has only 10 patients more than theirs (60 vs 50) and demonstrates that, although wiring may produce superior radiological results, the functional outcome is the same. As our study population was of relatively old people, we cannot predict the functional results in younger patients.

To the authors’ knowledge, the ‘tripod technique’ has not been described elsewhere. The study provides a comprehensive assessment of functional and radiological outcomes in a Chinese population which has not been reported previously.

There are several limitations to the current study because it did not have either a predefined primary outcome measure or a formal calculation of sample size. Therefore, it is possible that the study was too small in size to detect clinically relevant differences in functional outcomes and complication rates.

Although our study showed that the ‘tripod technique’ is safe without significant complications, there is a Cochrane review of wiring for distal radial fractures (Handoll et al., 2007) which concluded that, although there might be some advantage to wiring, there was no consensus about the best construct and the complication rate was higher. These were all extra-articular fractures. We do not provide a biomechanical rationale to explain our ‘tripod technique’ but we feel that it is a better construct to prevent collapse of the fracture.

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