This study compared outcomes of external fixation and volar plating for displaced intra-articular distal radius fractures. 110 patients were randomized to external fixation or volar plating. At 6 months, volar plating showed lower pain and higher range of motion, but by 1 year, external fixation led to greater improvements in range of motion, grip strength, and outcomes, especially in patients under 50. The study concluded external fixation may be superior for treating these fractures.

1. : a
prospective randomized comparative study of the functional
outcomes
AHMED AZMY
JOURNAL CLUB
TEAM D

4. to compare the efficacy of
external fixation and volar plating
on the functional parameter of displaced intra-
articular (Cooney’s type IV) distal end radius
fractures using the Green and O’Brien scoring
system.

5. Complex anatomy
Can not use same approach and materials for different
types of fractures
Strategic placement of the selected materials more
important than the characteristics of these materials
particularly in intra-articular fractures

6. External fixation
Advantages:
Maintain the continuity of reduction under c-arm
Improved reduction by ligamentotaxis
protect the reduction until healing occurs.
The relative ease of application,
Minimal surgical exposure
Reduced surgical trauma
Kapoor H, Agarwal A, Dhaon BK (2000) Displaced intra-articular fractures
of distal radius: a comparative evaluation of results following closed reduction,
external fixation and open reductionwith internal fixation. Injury 31:75–79
Disadvantages
Neuropathy of median and superficial radial nerve
Pin tract infection
Pin loosening
Non union and malunion
Loss of radial height and radial tilt
Collapse of ulnar border
Complications of Treating Distal Radius Fractures with External Fixation: A Community Experience John T Anderson, MD, Resident in
Orthopaedic Surgery,* George L Lucas, MD, Professor & Chairman, Section of Orthopaedic Surgery,** and Bruce R Buhr, MD, Clinical
Assistant Professor. Iowa Orthop J. 2004; 24: 53–59.

7. Volar Locking Plate
Advantages:-
Direct visualization and manipulation of the fracture fragments
Stable rigid fixation
Possibility of immediate postoperative motion.
Minimize screw loosening in the distal fragments
Useful to buttress small articular fragments
Successfully control shortening and angular displacement,especially in
osteoporotic bone
Disadvantages:
Longer surgical time
Iatrogenic injuries
symptomatic tenosynovites (protruding of screws) (sugun et al., 2011)

8. Green and O’Brien scoring system

9. Universal (Cooney’s) Classification
Of Distal End Radius
Cooney WP. Fracture of the distal radius. A modern treatment-based classification.
Orthop Clin North Am. 1993; 24(2):211-216

10.  Prospective randomized study but not blinded.
 The patients were randomized into two groups using random number tables
generated online (http://www.graphpad.com/quickcalcs/)
 The external fixation technique was chosen for group 1 and volar locking
plates were chosen for group 2. All surgical procedures were performed by a
single author (RS) at a single institute using standard protocols
 The mean follow up period for patients was up to 6 months and 1 year after
surgery
 The assessment of pain, range of motion, grip strength and activity were
assessed at each follow-up visit and scored according to the Green and O’Brien
scoring system

11. Inclusion Criteria
 between June 2010 and May 2012
 mean age 39.12 +/- 13 years
 Cooney’s type IV fracture
 110 patients:
-61 female
-49 males

12. Exclusion Criteria
Patients with any other associated injury/fracture
Bilateral distal radius fractures
Open fractures of distal radius
Associated head injury

14. Group 1: The external fixation
Two 2.5-mm schanz pins in the second metacarpal and two 3.5-mm
pins in the radius proximal to the fracture.
After application of a frame, reduction was checked in the c-arm
Reduction was achieved via manual traction and closed reduction
method in all cases
A below elbow plaster of paris slab was applied in all patients for
1 week.
The external fixator was removed in all patients after 8 weeks.
No extra wire was used in any patient.

15. Group 2: volar locked plating
The FCR approach for distal radius
Under control of c-arm
Cast applied to prevent free mobilization

16. The patients of both groups were discharged after 2 days
proper antibiotic coverage (3rd generation cephalosporin for 3
days)
The patients were recalled for suture removal and to see the
reduction in fracture radiologically after 10 days. Acceptable criteria
for fracture reduction were:
1- radial inclination of >15
2- radial shortening <5mm compared to the contralateral side
3- sagittal tilt between 15 dorsal and 20 volar tilt
4- intra-articular step off <2 mm.
All the patients

17. Followed for 6 months and 1 year after surgery.
Assessed for pain, grip strength, wrist range of motion
(rom) and activity.
Scored according to the Green And O’brien scoring system.
All the patients

18. All data were entered in SPSS 20.0 (IBM SPSS Inc. USA).
The mean values of scores between the two techniques
were compared by Student’s t-test
scores at different intervals within the same group were
compared by paired Sample t-test.

20. Follow-up data could be obtained for :-
109 patients after 6 months.
100 patients (91.7 %) after 1 year.

21. Patients Demography
There was no significant difference between groups regarding age
or sex

22. Mean surgery time was 35.1±2.5 in the external fixation
group and 56.5±2.7 min in the volar plate fixation group
Reduction in fracture was achieved in all patients in both
groups and no patient required revision surgery
One patient in the volar locking plate group developed
Complex regional pain syndrome that improved Within 2
months by physical therapy and pain medication.
Swelling, inflammation and occasional pain were observed
In two patients in the external fixation group and one
Patient in the volar locking plate group.

23. External fixator group:-
A significant reduction in pain, increased ROM, grip
strength, activity and final score after 1 year follow-up
compared to that at 6 month follow-up

24. Volar locking plate group:-
No change in pain, ROM and grip strength; however,
there was a significant change in activity and final score at
1 year compared to 6 month follow-up

25. At 6 month follow up:
low pain and high ROM in patients treated with volar locking plates
compared to those treated by external fixation
At 1 year follow up:
a significant increase in only ROM, grip strength and final outcome in
patients treated with external fixation compared to patients treated
with volar locking plates.
No difference was found in pain and activity between patients
in either group.

26. Comparison of Green and O’Brien score in two techniques
at 1 year follow-up in two age group:
External fixator group:
Patients aged <50 years had a better outcome than patients aged
>50
years in all parameters studied at the end of 1 year.
volar plating group:
there was no change in pain, ROM grip strength and activity in these
two age groups

28. • Prospective randomized study
• Follow up period is sufficient for the outcome.
• No conflict of interest
• The study was authorized by the local ethical
committee
• Fair sample of patients
Good points:

29. Negative points:
Authors involved in evaluating patients, not
blinded to the study
Didn’t mention about confounding factors like
smoking or diabetes.
No mention of co-morbidities of patient

30. Is it valid ?

31. Is it reliable

32. Is it reproducible ?

33. After acceptable radiological reduction Was achieved in all
patients, external fixation has superiority over volar
locked plating techniques at final outcome.
At 1 year follow-up. Patients aged <50 years had better
Results when treated with external Fixation.
Study recommend external fixation technique in treating
displaced intra-articular distal end radius Fractures
(cooney’s type IV).