Unstabil radius distal uç kırıklarının volar kilitli plak ile yönetimi: Retrospektif kohort çalışma

Öz

Amaç: Unstabil distal Radius kırığının tedavi yönetimi zordur. Voler kilitli plak uygulamaları diğer yöntemlere kıyasla (external fiksatör, k teli vb.) daha iyi bir yöntemdir. Bu nedenle, bunu göstermek için, merkezimizde Volar yerleşimli kilitli plak vida tespitleri ile tedavi edilen instabil radius alt uç kırıklarının radyografik ve fonksiyonel klinik sonuçları değerlendirildi.
Yöntemler: Radius dital uç instabil kırığı nedeniyle volar yerleşimli kilitli plak tespiti uygulanan 52 hasta (29 erkek, 23 kadın, ort. Yaş 42; dağılım 18-77) incelendi. AO sınıflamasına göre altı hastada B2 (%11,5), beş hastada B3 (%9,6), dört hastada C1 (%7,6), yirmi dokuz hastada C2 (%55,7) ve sekiz hastada C3 (%15,3) olarak sınıflandırıldı. Kırıkların 21’inde (%77,8) dorsal, altısında (%22,2) volar açılanma vardı. Dört hastada (%14,8) kırığa dirsek çıkığı ve/veya kırık eşlik etmekteydi. On bir hastada (%21,1) distal radioulnar eklem sorunları vardı. On beş hastada (%28,8) kırık tespitine ek olarak otolog krista iliaka grefti kullanıldı. Hastaların hareket açıklıkları, kavrama kuvvetleri ölçüldü, Stewart ölçütlerine göre radyografik değerlendirmeleri yapıldı. Fonksiyonel değerlendirmede Quick-DASH-T (Disabilities of the Arm, Shoulder and Hand-Türkçe) sorgulaması ve Gartland-Werley değerlendirme formu kullanıldı. Ortalama takip süresi 15 ay (dağılım 12-34 ay) idi.
Bulgular: Kırıkların tümü ortalama 7 haftada (dağılım 6-8 hafta) sorunsuz kaynadı. Stewart derecelendirme skalasındaki ortalama radyografik skor 0.5 (0-3) idi. Otuz hastada (%57,6) ulnar vayans değerleri ortalama olarak -0,4 (0 ila -2,5 mm arası) oluştu. On iki hastada (%23) 0.5 mm (0-2,5mm aralığı) ortalama pozitif ulnar varyansı değeri oluştu. On hastada (%19,2) nötral varyans değeri oluştu. Radial inklünasyon açıları eşitlenmemiş olan 32 hastada (%61,5); sağlam taraf 28,5° (Aralık 21 ° -30°) iken ameliyat edilen taraf için ortalama açı 22,3° (Aralık 18°-27°) idi. On beş hastada (%28,8) radyal inklünasyon açısı sağlam tarafla eşitlendi. Diğer hastalarda, sağlam tarafta ortalama radyal inklünasyon açısı volar yönüne (dorsal 2° - volar 13°) doğru 5,9° idi. Yirmi beş hastada (%48) radial yükseklikteki kayıp ameliyat edilen tarafta 1,3 mm (0-5 mm) idi. Tedavi edilen tarafta kavrama gücü, sağlam tarafın ortalama %69’ü (18 kg) idi. Quick-DASH-T skoru ortalaması 8,3 (dağılım 0-70,5), Gartland-Werley puanı ortalaması 4,7 (dağılım 0-16) bulundu. Gartland-Werley değerlendirmesine göre, 25 hastada (%48) mükemmel, 25 (%48) hastada iyi, üç has tada (%4) ise orta sonuç alındı.
Sonuç: Volar yerleşimli kilitli plak uygulamaları radius distal uç anatomisinin düzeltilmesinde ve korunmasında etkilidir.

Anahtar Kelimeler

• Açık redüksiyon,Kilitli plak,Unstabil kırık,Distal radius kırığı

Management of distal unstable radius fractures with volar locking plates: A retrospective cohort study

Abstract

Aim: Unstable distal radius fractures are difficult to manage. Volar locking plate screw is a better option than the other treatment methods (external fixator, K pin, etc.). The aim of this study is to present the radiographic and functional clinical results of patients with lower end unstable radius fractures who were treated with volar locking plate screws in our clinic.
Methods: A total of 52 patients (29 males, 23 females, mean age 42; the distribution 18-77) who underwent volar locking plate fixation due to an unstable distal radial end fracture were examined. Based on the AO classification, six patients (11.5%) had B2, five patients (9.6%) had B3, four patients (7.6%) had C1, 29 patients (55.7%) had C2 and 8 patients had (15.3%) C3 fractures. Twenty-one (77.8%) of the fractures had dorsal angulation, while six (22.2%) had volar angulation. The fracture was accompanied by an elbow dislocation and/or fracture in four patients (14.8%). Eleven patients (21.1%) had distal radioulnar joint problems. In fifteen patients (28.8%), autogenous crista iliac graft was used in addition to fracture fixation. The patients’ range of motion and grip strength were measured. Evaluations were made according to the Stewart criteria. In the functional evaluation, the Quick-DASH-T (Disabilities of the Arm, Shoulder and Hand-Turkish) questionnaire and the Gartland-Werley evaluation form were used. The average duration of follow-up was 15 months (range: 12-34 months).
Results: All bones healed smoothly in approximately 7 weeks (range: 6-8 weeks). The average radiographic score was 0.5 (0-3) in the Stewart rating scale. The ulnar variance value was approximately -0.4 (between 0 and -2.5 mm) in 30 patients (57.6%). The average positive ulnar variance level was 0.5 mm (between 0-2.5 mm) in 12 patients (23%). A neutral variance level occurred in ten patients (19.2%). In 32 patients (61.5%) whose radial inclination angles were not equalized, the intact side was 28.5° (the interval 21°-30°) while the average angle for the side that underwent surgery was 22.3° (the interval 18°-27°). The radial inclination angle of fifteen patients (28.8%) gradually equaled the intact side. In other patients, the average radial inclination angle was 5.9° towards the volar direction (dorsal 2°- volar 13°) on the intact side. In twenty-five patients (48%), the loss of radial height was 1.3 mm (0-5 mm) on the side that underwent surgery. The grip strength of the side treated was approximately 69% (18 kg) of the intact side. The average Quick-DASH-T score was found as 8.3 (the distribution being 0-70.5), and the average Gartland-Werley score was found as 4.7 (the distribution 0-16). According to the Gartland-Werley evaluation, the results were excellent in 25 patients (48%), good in 25 (48%) and moderate in 3 (4%).
Conclusion: Volar locking plate applications are efficient in correcting and protecting the distal radius end anatomy. 

Keywords

• Open reduction,Locking plate,Unstable fracture,Distal radius fracture

References

1. 1. Arora R, Lutz M, Fritz D, Zimmermann R, Oberladstätter J, Gabl M. Palmar locking plate for treatment of unstable dorsal dislocated distal radius fractures. Arch Orthop Trauma Surg. 2005 Jul;125(6):399-404.
2. 2. Trumble TE, Culp RW, Hanel DP, Geissler WB, Berger RA. Intra-articular fractures of the distal aspect of the radius. Instr Course Lect. 1999;48:465-80.
3. 3. Khanduja V, Ng L, Dannawi Z, Heras L. Complications and functional outcome following fixation of complex, intra-articular fractures of the distal radius with the AO Pi-Plate. Acta Orthop Belg. 2005 Dec;71(6):672-7.
4. 4. Sobky K, Baldini T, Thomas K, Bach J, Williams A, Wolf JM. Biomechanical comparison of different volar fracture fixation plates for distal radius fractures. Hand (N Y). 2008 Jun;3(2):96-101.
5. 5. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. Instr Course Lect. 2003;52:185-95.
6. 6. Willis AA, Kutsumi K, Zobitz ME, Cooney WP 3rd. Internal fixation of dorsally displaced fractures of the distal part of the radius. A biomechanical analysis of volar plate fracture stability. J Bone Joint Surg Am. 2006 Nov;88(11):2411-7.
7. 7. Levin SM, Nelson CO, Botts JD, Teplitz GA, Kwon Y, Serra-Hsu F. Biomechanical evaluation of volar locking plates for distal radius fractures. Hand (N Y). 2008 Mar;3(1):55-60.
8. 8. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006 Apr;445:58-67.

9. 9. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg Am. 2005 Jul;30(4):743-9.
10. 10. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006 Mar;31(3):359-65.
11. 11. Haus BM, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults: reexamined as evidence-based and outcomes medicine. J Bone Joint Surg Am. 2009 Dec;91(12):2984-91.
12. 12. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG. Am J Ind Med. 1996 Jun;29(6):602-8.
13. 13. Turgay T, İkidağ M, Karadeniz P, Ulutaş M. Vertebral fractures and spinopelvic parameters in patients with osteoporosis. J Surg Med. 2020;4(1):53-7.
14. 14. Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg Am. 2006 Jan;31(1):9-16.
15. 15. Chung KC, Watt AJ, Kotsis SV, Margaliot Z, Haase SC, Kim HM. Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Joint Surg Am. 2006 Dec;88(12):2687-94.
16. 16. Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced fractures of the distal radius. Clin Orthop Relat Res. 2002 Apr;(397):403-8.
17. 17. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci. 2007 Mar;12(2):134-40.
18. 18. Jeudy J, Steiger V, Boyer P, Cronier P, Bizot P, Massin P. Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating. Injury. 2012 Feb;43(2):174-9.