Percutaneous Pins Versus Volar Plates for Unstable Distal Radius Fractures: A Biomechanic Study Using a Cadaver Model

doi:10.1016/j.jhsa.2007.03.015

The Journal of Hand Surgery

Volume 32, Issue 6, July–August 2007, Pages 813-817

https://doi.org/10.1016/j.jhsa.2007.03.015 Get rights and content

Purpose

A biomechanic study using a cadaver model of a dorsally unstable distal radius fracture was used to compare the stability of percutaneous pinning and volar fixed-angle plating. Among the many surgical options for treating distal radius fractures are percutaneous pinning and internal plate fixation. Although percutaneous pin fixation requires less soft-tissue trauma and has low complication rates, plate fixation allows for early active movement with good clinical results. The biomechanic stability of these 2 methods was studied by using a cadaver model of a dorsally unstable intra-articular distal radius fracture.

Methods

This study was performed on 7 fresh-frozen cadaver arms, in each of which an unstable intra-articular fracture with dorsal comminution was created. The fracture was first fixed with 0.062-mm K-wires inserted in standard crossed fashion and was tested in a pneumatic loading device that indirectly loaded the wrists through the 5 motor tendons 3 times at each level of force in flexion and extension. Testing was then repeated after removal of the pins and fixation with a fixed-angle DVR distal volar radius plate system (Hand Innovations, Inc., Miami, FL). Testing was performed in flexion up to 68 N and in extension up to 100 N, and the distance across the fracture site was measured.

Results

Volar plating was significantly more stable than pinning, with an average movement across the fracture site of 2.51 mm for pin fixation and 1.07 mm for plate fixation. The pins also showed a substantial degree of slipping after repeated stressing, but the plates remained stable.

Conclusions

These results show the superior biomechanic stability of internal fixation using plates for dorsally comminuted intra-articular distal radius fractures in this cadaver model. Further clinical correlations are needed.

Section snippets

Materials and Methods

Institutional review board approval was obtained before commencement of this cadaver study. This study was performed on 7 fresh-frozen cadaver arms from cadavers in which an AO type C1 fracture with dorsal comminution was created as follows. The soft tissue was removed from the specimens, leaving the 5 primary motor tendons of the wrist (extensor carpi radialis brevis, extensor carpi radialis longus, extensor carpi ulnaris, flexor carpi ulnaris, flexor carpi radialis), pronator teres, pronator

Results

Volar plating was significantly more stable than pinning, with an average movement across the fracture site of 2.5 mm ± 1.3 mm with pin fixation compared with 1.1 mm ± 0.5 mm with plate fixation (p = .024) (Table 1,Fig. 4). None of the fixators failed during testing. The volar cortex was not compromised in any specimen related to testing alone. The pins showed a notable degree of slipping within the bone after repeated stressing. With successive stressing, the fracture site experienced

Discussion

These results show that volar plate fixation results in less displacement of intra-articular distal radius fractures with dorsal comminution compared with K-wire fixation. When loaded in both extension and flexion, K-wire fixation allowed more motion across the fracture site at all levels of force. We also found that the K-wires experienced considerable slipping with higher levels of force. This was not seen after the K-wires were replaced with plates. The increased stability was statistically

References (17)

G.K. Kambouroglou et al.
Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: a brief report
J Hand Surg
(1998)
J.L. Orbay et al.
Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report
J Hand Surg
(2002)
S.H. Naidu et al.
Percutaneous pinning of distal radius fractures: a biomechanical study
J Hand Surg
(1997)
M.D. Putnam et al.
Distal radial metaphyseal forces in an extrinsic grip model: implications for postfracture rehabilitation
J Hand Surg
(2000)
T.E. Trumble et al.
Factors affecting functional outcome of displaced intra-articular distal radius fractures
J Hand Surg
(1994)
M.L. Missakian et al.
Open reduction and internal fixation for distal radius fractures
J Hand Surg
(1992)
J.L. Orbay et al.
Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient
J Hand Surg
(2004)
T. Trumble
Principles of hand surgery and therapy
(2000)

There are more references available in the full text version of this article.

Cited by (36)

Is percutaneous pinning an outdated technique for distal radius fractures?
2019, Injury
Distal radius fracture is a very common injury representing 17.5% of all fractures seen in the emergency room. However, the most effective treatment is still unclear and controversially debated. For ten years, we have been facing a true revolution by the increasing use of open reduction and fixation by volar locking plates as an alternative to previous less invasive treatment such as closed reduction and percutaneous k-wire pinning. Several meta-analyses have compared the clinical results after closed reduction and percutaneous pinning and volar locking plate fixation. Volar locking plate fixation achieves better early functional recovery, better radiological outcomes and less minor complications. However, long-term results were similar for both fixation methods. In addition, worse radiological outcomes and more minor complications after closed reduction and percutaneous pinning seem not to be clinically relevant. Interestingly, volar locking plate fixation continues to be a more dominant treatment method compared to percutaneous pinning in operative care of distal radius fractures. Surgeon characteristics such as age, profession as well as location and type of the clinic seem to play a role in the decision for the surgical treatment method. It appears that implant cost plays a minor role in treatment choice between closed reduction and percutaneous pinning and volar locking plate fixation.
Contribution of arthroscopy to the treatment of intraarticular fracture of the distal radius: Retrospective study of 40 cases
2017, Hand Surgery and Rehabilitation
Citation Excerpt :
Intraarticular fractures of the distal radius are increasingly being treated by open reduction and internal fixation (ORIF) using volar locking plates. In comparison to fracture pinning, plate fixation reduces secondary displacement and post-traumatic stiffness by shortening the immobilization period [10]. It was shown that fluoroscopy was not sufficient to determine whether the articular surface had been correctly reduced.
Our study aimed to compare the anatomical result after treatment of intraarticular distal radius fracture with locking volar plates with and without arthroscopy. This was a retrospective, single-center study of intraarticular fractures. A volar locked plate was used for fracture fixation in all patients. Twenty patients were operated on with fluoroscopy only (“plate” group) and 20 operated using arthroscopy assistance (“arthroscopy” group). All patients underwent a CT scan before surgery and at 3 months postoperative. The main outcome measure was the residual intraarticular step-off (measured in millimeters). Other studied outcomes were the residual gap between fragments and extra-articular reduction. The two groups were similar preoperatively in all aspects except the size of the gap between fragments. The residual step-off was significantly less in the arthroscopy group: 1.9 mm (Q₁ 1.7; Q₃ 2.25) for plate versus 0.8 mm (Q₁ 0.7; Q₃ 1.5) for arthroscopy (P = 0.001). The change from the preoperative to the postoperative measurement was significantly greater in the arthroscopy group: 0.1 mm (Q₁ −0.5; Q₃ 0.8) for plate and −1 mm (Q₁ −1.9; Q₃ −0.6) for arthroscopy (P = 0.0002). The residual gap was similar between both groups: 2.4 mm (Q₁ 1.9; Q₃ 3.5) for plate vs. 2.3 mm (Q₁ 1.1; Q₃ 2.8) for arthroscopy (P = 0.37). The change in gap was not significantly different between the two groups: −0.9 mm (Q₁ −1.8; Q₃ −0.1) for plate vs. −2.9 mm (Q₁ −4.4; Q₃ −1.7) for arthroscopy (P = 0.32). There was no difference in the extra-articular reduction. Damage was found to the scapholunate ligament in 30% and the TFCC in 30% of arthroscopy cases. Arthroscopy improves intraarticular reduction without altering extra-articular reduction in patients with intraarticular fractures of the distal radius, and it allows for assessment and treatment of any injuries discovered. We must now follow these patients over the long-term to assess the clinical benefit.
3.
Cette étude visait à comparer le résultat anatomique obtenu après ostéosynthèse par plaque antérieure verrouillée des fractures articulaires de l’extrémité distale du radius, avec ou sans aide arthroscopique. Il s’agissait d’une étude monocentrique, rétrospective comparant 20 patients ayant une fracture articulaire de l’extrémité distale du radius, opérés sous fluoroscopie seule, à 20 patients opérés avec assistance arthroscopique. L’ostéosynthèse utilisait une plaque antérieure verrouillée. Tous les patients ont bénéficié d’un scanner pré- et postopératoire à 3 mois. Le critère principal était la mesure de la marche d’escalier intra-articulaire résiduelle (en mm). Étaient également mesurés l’écart interfragmentaire résiduel et la réduction extra-articulaire. Les groupes étaient comparables en préopératoire pour toutes les caractéristiques sauf pour l’écart interfragmentaire. La marche intra-articulaire résiduelle était significativement inférieure dans le groupe arthroscopie, de 1,9 mm (1,7/2,25) pour les plaques contre 0,8 mm (0,65/1,5) pour l’arthroscopie. La différence entre les états pré- et postopératoire était significativement supérieure dans le groupe arthroscopie : 0,05 mm (−0,45/0,75) pour les plaques et de −1 mm (−1,9/−0,55) pour l’arthroscopie. L’écart interfragmentaire résiduel n’était pas différent : 2,4 mm (1,9/3,5) pour les plaques contre 2,25 mm (1,1/2,8) pour l’arthroscopie. La différence était significativement supérieure dans le groupe arthroscopie : −0.9 mm (Q₁ −1,8 ; Q₃ −0,1) pour le groupe plaque contre −2,9 mm (Q₁ −4,4 ; Q₃ −1,7) pour le groupe arthroscopie (p = 0,32). Il n’y avait pas de différence pour la réduction extra-articulaire. Il était retrouvé 30 % de lésions du ligament scapho-lunaire et 30 % de lésions du TFCC diagnostiquées lors de l’arthroscopie. L’arthroscopie permet d’améliorer la réduction intra-articulaire sans modifier la réduction extra-articulaire des fractures articulaires de l’extrémité distale du radius. Elle permet de faire le bilan et le traitement des lésions associées. Il faut maintenant suivre ces patients à long terme pour juger du bénéfice clinique.
3.
Volar plate versus k-wire fixation of distal radius fractures
2016, Injury
Citation Excerpt :
The use of volar locking plates for distal radial fractures (DRF) has become increasingly popular. One of the advantages of volar locking plates is increased pullout strength in osteoporotic bone [2,3]. In addition to this, the volar plate construct allows for earlier active range of motion.
The optimal management of distal radius fractures remains controversial. The aim of this study was to compare the radiographic and functional outcomes of 318 patients who underwent k-wire fixation or volar plating for fractures of the distal radius. Patients were aged between 20 and 65 years and followed for a mean of 32 months. The mean values for volar tilt, radial inclination, radial length and ulnar variance were all significantly better in the volar plate group. Malunion occurred in 13.2% of patients undergoing k-wiring and 4% of patients treated with a volar plate (p < 0.007). Higher values for radial inclination, radial length and volar tilt correlated with better functional outcome as measured by disabilities of the arm shoulder and hand (DASH) and patient rated wrist evaluation (PRWE) scores. Lower values for ulnar variance correlated with better functional outcome. Although volar plate treatment resulted in a superior radiological outcome, there was no evidence that this translated into a superior functional outcome (DASH 13.12 vs. 11.25, p = 0.28) (PRWE 17.56 vs. 16.31, p = 0.69). The k-wiring procedure remains a suitable inexpensive option for simple fractures. Volar plating should be reserved for complex fractures that cannot be reduced by closed means.
Biomechanical studies: Science (f)or common sense?
2014, Injury
Citation Excerpt :
From the remaining 99 studies, 12 had a good illustration of the constructs. Among those 12 studies, we selected 11 for which we thought the answer was obvious prior to performing the study [2,7–9,11,12,14,15,19,21,23]. Orthopaedic and trauma surgeons affiliated with the Science of Variation Group (SOVG) and medical students from the University of Amsterdam were invited to predict the outcome of biomechanical studies comparing different fixation constructs.
It is our impression that many biomechanical studies invest substantial resources studying the obvious: that more and larger metal is stronger. The purpose of this study is to evaluate if a subset of biomechanical studies comparing fixation constructs just document common sense.
Using a web-based survey, 274 orthopaedic surgeons and 81 medical students predicted the results of 11 biomechanical studies comparing fracture fixation constructs (selected based on the authors’ sense that the answer was obvious prior to performing the study). Sensitivity, specificity, and accuracy were calculated according to standard formulas. The agreement among the observers was calculated by using a multirater kappa, described by Siegel and Castellan.
The accuracy of predicting outcomes was 80% or greater for 10 of 11 studies. Accuracy was not influenced by level of experience (i.e., time in practice and medical students vs. surgeons). There were substantial differences in accuracy between observers from different regions. The overall categorical rating of inter-observer reliability according to Landis and Koch was moderate (κ = 0.55; standard error (SE) = 0.01).
The results of a subset of biomechanical studies comparing fracture fixation constructs can be predicted prior to doing the study. As these studies are time and resource intensive, one criterion for proceeding with a biomechanical study should be that the answer is not simply a matter of common sense.
More is not necessarily better. A biomechanical study on distal screw numbers in volar locking distal radius plates
2013, Injury
Currently available volar locking plates for the treatment of distal radius fractures incorporate at least two distal screw rows for fixation of the metaphyseal fragment and have a variable-angle locking mechanism which allows placement of the screws in various directions There is, however no evidence that these plates translate into better outcomes or have superior biomechanical properties to first generation plates, which had a single distal screw row and fixed-angle locking. The aim of our biomechanical study was to compare fixed-angle single-row plates with variable-angle multi-row plates to clarify the optimal number of locking screws.
Five different plate-screw combinations of three different manufacturers were tested, each group consisting of five synthetic fourth generation distal radius bones. An AO type C2 fracture was created and the fractures were plated according to each manufacturer's recommendations. The specimens then underwent cyclic and load-to-failure testing. An optical motion analysis system was used to detect displacement of fragments.
No significant differences were detected after cyclic loading as well as after load-to-failure testing, neither in regard to axial deformation, implant rigidity or maximum displacement. The fixed-angle single-row plate showed the highest pre-test rigidity, least increase in post-testing rigidity and highest load-to-failure rigidity and least radial shortening. The radial shortening of plates with two distal screw rows was 3.1 and 4.3 times higher, respectively, than that of the fixed-angle single-row plate.
The results of our study indicate that two distal screw rows do not add to construct rigidity and resistance against loss of reduction. Well conducted clinical studies based on the findings of biomechanical studies are necessary to determine the optimal number of screws necessary to achieve reproducibly good results in the treatment of distal radius fractures.
Prospective continuous study comparing intrafocal cross-pinning HK2<sup>®</sup> with a locking plate in distal radius fracture fixation
2013, Chirurgie de la Main
The fixation of distal radius fractures by pinning or locking plates remains controversial. The aim of this prospective continuous study was to compare the results of 28 anterior locking plates with 23 intrafocal cross-pinning HK2^® systems. The mean age of group I (SVP^®, SBI™ plate) was 61 years. There were 15 extra-articular and 13 articular fractures. The mean age of group II (HK2^®, Arex™) was 63 years, with 13 extra-articular and 10 articular fractures. Twelve clinical variables were measured: pain, wrist strength, supination strength, pronation strength, quick DASH score, range of wrist motion in flexion, extension, pronation, and supination, ulnar variance, radial slope, and radial volar tilt. At 40 weeks follow-up, there was no difference between the two groups for 10 variables; two variables showed differences between the two groups: mean quick DASH score was 10.7 for group I, 19.7 for group II, and mean ulnar variance was −0.95 mm for group I, and 1.16 mm for group II. Six transient complications were noted for group I: five tenosynovitis, and one carpal tunnel syndrome. We noted 12 complications in group II: four superficial infections, two secondary displacements, one pin migration, two CRPS type II, two tendon ruptures and one nerve irritation. Generally, plates provided a more stable fixation associated with less complications while the HK2^® system was quicker and less costly. The indications for its use need to be refined with a larger series and longer follow-up.
L’ostéosynthèse des fractures du radius distal reste controversée, soit par broches soit par plaque. Le but de cette étude prospective continue était de comparer les résultats de 28 plaques antérieures à vis bloquées à 23 systèmes de brochage intrafocal bloqué HK2^®. L’âge moyen du groupe I (plaque SVP^®, SBI™) était de 61 ans. On notait 15 fractures extra-articulaires et 13 fractures articulaires. L’âge moyen du groupe II (HK2^®, Arex™) était de 63 ans. On notait 13 fractures extra-articulaires et dix fractures articulaires. Douze variables cliniques et radiologiques ont été mesurées : douleur, force de la poigne, force en supination, force en pronation, DASH, mobilité du poignet en flexion, extension, pronation, supination, variance ulnaire, pente radiale, antéversion radiale. Au recul de 40 semaines, il n’y avait aucune différence entre les deux groupes pour dix variables sauf deux : score DASH moyen (10,7 pour le groupe I, 19,7 pour le groupe II), variance moyenne (−0,95 mm pour le groupe I, 1,16 mm pour le groupe II). On notait six complications résolutives dans le groupe I : cinq ténosynovites, un syndrome du canal carpien. On notait 12 complications dans le groupe II : quatre infections superficielles, deux déplacements secondaires, une migration de broche, deux syndromes douloureux régionaux complexes de type I, deux ruptures tendineuses, une irritation nerveuse. Au total, si les plaques sont plus stables et entraînent moins de complications, le système HK2^® est plus rapide et moins onéreux. Ses indications seront affinées après étude d’une série plus importante avec un plus long recul.

View all citing articles on Scopus

: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

View full text

Distal radial fracturePercutaneous Pins Versus Volar Plates for Unstable Distal Radius Fractures: A Biomechanic Study Using a Cadaver Model

Purpose

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Principles of hand surgery and therapy

Distal radial fracture
Percutaneous Pins Versus Volar Plates for Unstable Distal Radius Fractures: A Biomechanic Study Using a Cadaver Model