RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

SYNOPSIS
OF
DISSERTATION

" SURGICAL TREATMENT MODALITIES IN THE

MANAGEMENT OF FRACTURES DISTAL END
RADIUS IN ADULTS IN ADICHUNCHANAGIRI
INSTITUTE OF MEDICAL SCIENCE, BELLUR "
Submitted by

Dr. JOBIN ALEX MOHAN

M.B.B.S.,

POST GRADUATE STUDENT IN

ORTHOPAEDICS (M.S.)

DEPARTMENT OF ORTHOPAEDICS
ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,
B.G.NAGARA-571448
0

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Dr. JOBIN ALEX MOHAN
P.G. IN ORTHOPAEDICS
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G. NAGARA,
MANDYA DISTRICT -571448

NAME OF THE CANDIDATE

AND ADDRESS
(in block letters)

2.

NAME OF THE INSTITUTION

3.

COURSE OF STUDY AND SUBJECT

M.S.IN ORTHOPAEDICS

4.

DATE OF ADMISSION TO COURSE

31ST MAY 2011

ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G.NAGARA.

5.

TITLE OF THE TOPIC

6.

BRIEF RESUME OF INTENDED WORK

SURGICAL TREATMENT MODALITIES

IN THE MANAGEMENT OF
FRACTURES DISTAL END RADIUS IN
ADULTS IN ADICHUNCHANAGIRI
INSTITUTE OF MEDICAL SCIENCE,
BELLUR
APPENDIX-I

6.1 NEED FOR THE STUDY

APPENDIX-IA

6.2 REVIEW OF LITERATURE

APPENDIX-IB

6.3 OBJECTIVES OF THE STUDY

MATERIALS AND METHODS

APPENDIX-IC
APPENDIX-II

7.1 SOURCE OF DATA

APPENDIX-IIA

7.2 METHOD OF COLLECTION OF

DATA : (INCLUDING SAMPLING
PROCEDURE IF ANY)

APPENDIX-IIB

7.3 DOES THE STUDY REQUIRE ANY

INVESTIGATION OR INTERVENTIONS
TO BE CONDUCTED ON PATIENTS OR
OTHER ANIMALS, IF SO PLEASE
DESCRIBE BRIEFLY.

YES
APPENDIX-IIC

7.4 HAS ETHICAL CLEARENCE BEEN

OBTAINED FROM YOUR INSTITUTION
IN CASE OF 7.3

APPENDIX-IID

8.

LIST OF REFERENCES

APPENDIX III

9.

SIGNATURE OF THE CANDIDATE

10.

REMARKS OF THE GUIDE

11

NAME AND DESIGNATION

(in Block Letters)

Since distal radius fractures are common in adults,

there is contraversies regarding various modalities
of treatments and their results. Hence we are
studying various methods used in treatment and
their results.

11.1 GUIDE

Dr. GOPALAKRISHNA. G
MBBS, D-ORTHO, MS ORTHO

Professor,
Department of Orthopaedics,
AIMS, B.G. Nagara-571448
11.2 SIGNATURE OF THE GUIDE

Dr. GUNNAIAH. K.G. MBBS, D-ORTHO, MS ORTHO

Professor and Head of Department,
Department of Orthopaedics,
AIMS, B.G. Nagara-571448

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF DEPARTMENT

Dr. GUNNAIAH. K.G. MBBS, D-ORTHO, MS ORTHO

Professor and Head of Department,
Department of Orthopaedics,
AIMS, B.G. Nagara-571448

11.6 SIGNATURE

12

12.1 REMARKS OF THE CHAIRMAN

AND PRINCIPAL

The facilities required for the investigation will be

made available by the college
Dr. M.G SHIVARAMU M.B.B.S., MD
PRINCIPAL,
AIMS, B.G. NAGARA.

12.2 SIGNATURE

APPENDIX-I
2

6.BRIEF RESUME OF THE INTENDED WORK:

APPENDIX I A
6.1 NEED FOR THE STUDY:
Distal end radius fractures are the most common fractures of the upper extremity. There
is an increase in the incidence of fracture distal end radius and its complications in the rural
population as compared to urban population.
The purpose of this study is to help improve the functional aspect of wrist, based on the
current surgical modalities available.
In this study we are comparing the functional outcome of treatment fracture distal end
radius with various surgical modalities ie: closed reduction and percutaneous K-wire fixation
under C-arm guidance with post op cast immobilization, Ligamentotaxis and stabilization with
external fixator, Open reduction and internal fixation with Dynamic Compression Plates,
Locking Compression Plates and Buttress Locking Compression Plate.
Three column theory- The distal radius has been conceptualized as a three column
model. The wrist is divided into medial, intermediate and lateral columns. This theory
emphasizes that the lateral or radial column is an osseous buttress for the carpus and is an
attachment point for the intra capsular ligaments. The primary function of the intermediate
column is load transmission and the medial or the ulnar column serves as an axis for forearm
and wrist rotation as well as a post for secondary load transmission.

APPENDIX I B
6.2 REVIEW OF LITERATURE

Ever since Abraham colles published on the fracture

of the carpal extremity of the radius in Edinburgh
medical journal (1814), no other fracture has been
discussed about as much. Even after 197 years the best
treatment for this fracture remains enigmatic and a
topic of perennial debate, which speaks of the
complexities involved in this study.

Until late 1920s principle treatment of colles fracture was forceful traction, manipulation
and immobilization in wrist in flexion and ulnar deviation. The result of this position
(cotton ladder) led to very high incidence of median nerve neuropraxia. The exact position
of immobilization and plaster cast extent varied, nevertheless treatment essentially
remained the same.

After 115 years, Bohler L was the first one to go off the
beaten track. In 1929, Bohler published his original
technique of transfixation with skeletal pins and
incorporated in plaster cast, to maintain the reduction of
fracture; the so called pin and plaster method showed
significant better results than the century old method.
This technique has been reviewed time and again by
workers such as Scheck M.

Scheck was the first one to describe the dorsomedial radial or diepunch fragment resulting
from impact of the lunate. He was also the first one to describe three objective parameters
for results evaluation viz-the radial angle, the volar angle and the radial length. He reported

79% satisfactory results and 21% poor results. One significant observation was poor
anatomical results led to greater disability.

De Palma (1952) described his original technique of ulnar pinning where as threaded kwire was obliquely introduced through ulna into reduced distal fragment of radius. He
reported 18% unsatisfactory results. Dowling and Sawyer (1961) showed 84% good to
excellent results with same method.

Ellis.J (1965) was one of the earliest to recommend open reduction and internal fixation of
unstable smiths type-2 or volar Barton fracture. He devised a T shaped plate which plated
as an excellent volar buttress preventing the deformity.

Green .D.P (1975) reported 86% good to excellent results with pin and plaster technique.
Cooney W.P (1979) reviewed interest in the Roger Anderson external fixator by showing
90% excellent and 8% fair results in comminuted intra articular surfaces gave better results.
He found that articular congruity and the residual dorsal tilt were the most significant
criteria affecting results.

Charles melone (1986) is one of the proponents of open reduction of displaced intra
articular fractures of distal radius. He has proved in his series that maximal functional
recovery following such fracture is dependent to a great extent on accurate and stable
restoration of articular surfaces. He has analysed these fractures to have essentially four
basic components namely; the radial styloid, radial shaft, dorsal and volar medial
fragments. The key medial fragments possess strong ligamentous attachments to carpus and
ulnar styloid, they together constitute the medial complex, on the basis of displacement of
this medial complex, he has classified into four types. The first two types being amenable
to closed manipulation or skeletal traction. Type 3 and 4 associated with grossly rotated
fragments which are absolute indication for open reduction and internal fixation. He

believes that buttress plates do not provide effective splintage to the key medial fragments,
hence prefers k-wire fixation. The advantages of open reduction and internal fixation are:

1) Early & better immobilization and function of hand. 2) Low incidence of posttraumatic
radiocarpal & radioulnar arthrosis, and hence less residual pain, stiffness and restriction. 3)
Concomitant repair of ruptured tendons if any. 4) Superlative results of nerve recovery in
cases complicated with nerve injury, especially if procedures like epineurolysis for
subepineural heamatoma are done. 5) Very low incidence of complications like post
traumatic dystrophy.

Dennis Foster (1986) opined in a comparative study that both Hoffmann and Roger
Anderson device gave equally good results. All these good results were however marred by
the fact, 4% to 6% serious pin track infection, 10% cases had persistent pain and 8% had
wrist weakness, leading to somewhat prolonged recovery in significant number of patients.

Mauizio Altissimi (1986) recommends open reduction and internal fixation with, if need be
bone grafting if after manipulation an articular step more than 2mm is present.

Clyburn T.A (1987) described a new dynamic external fixation that allows controlled wrist
movement and full movements of fingers. This early wrist mobility facilitates very early
rehabilitation and has afforded excellent results. It is based on the biomechanical principle
of having a ball type joint on the fixator exactly in par with the physiological centre of
rotation (in proximal capitate), which allows motion but maintains the distraction force.
Clyburn agrees that the best results are obtained when combined with limited internal
fixation especially for a diepunch or radial styloid fragment.

Keating J.F., et al (1994) studied a series of 79 patients with volar displaced fractures of
the distal radius over 26 months, with a small AO T-plate and concluded that malunion,
defined as more than 2mm of radial shortening, more than 4mm of radial shift, more than
15 degree of volar tilt, or more than 10 degree of dorsal tilt was prevalent in their series, but

most patients nevertheless achieved acceptable function. Internal fixation using a buttress
plate is an adequate means of treating volarly displaced fractures of the distal radius.

Another milestone was laid in (1994) by Roger Anderson who described the prototype of
todays external fixator for the comminuted fracture of distal radius. He was one the earliest
to analyze the cause of poor results as shortened radius, maltilted irregular joint surface. He
emphasized that shortening was not only due to impaction and over-riding, but also due to
actual crushing of the juxta-articular cancellous bone and hence devised fixator that
maintained sustained traction to maintain reduction. He reported good functional results
particularly in elderly osteoporotic bones.

Fitoussi F., IP W.Y., chow S.P. (1997) in their study of 34 patients with intra articular
fractures of the distal end radius treated with open reduction and internal fixation with
buttress plate and screws, concluded that the potential for restoration normal alignment and
stability of fixation are the main advantages of internal fixation with plates.

Frederick A. kaempffe et al., (2000) retrospectively reviewed19 patients with distal radius
fractures treated wth external fixation and supplemental kirschner wire fixation over a
period of 6 years. They concluded that external fixation with supplemental pin fixation is a
satisfactory method of treating severe fractures of the distal radius. Outcome likely is
improved with shorter duration of external fixation.

Abbas Emami. , et al., (2000) treated 40 patients by insertion of the external fixator half
pins dorsally (rather than dorso-radially) in the diaphysis of radius and concluded that this
safer position of the pins avoided the symptoms related to the superficial radial nerve.

Richard A. Rogachejsky et al ., (2001) demonstrated that severe comminuted intraarticular fractures of the distal radius should be treated by open reduction and combined
internal and external fixation. The combined technique, supplemented by bone grafting and
plate fixation as needed, is a satisfactory treatment.

 Peter M.Murray. (2002) reviewedthier preferred technique of using the external fixator as
a neutralization device rather than as a traction device. The absence of sustained radiocarpal
traction during distal radius fracture healing may facilitate and help avoid the complications
associated with sustained longitudinal traction.

David Ring, et al., (2004) evaluate 25 patients with AO C3-2 fractures treated with
combined dorsal and volar plate fixation at an average of 25 months after injury and
concluded that combined dorsal and volar plate fixation can achieve a stable, mobile wrist
in patients with very complex fractures. The results were limited by the severity of injury
nad deteriorated with longer follow up. A second operation for implant removal was
common, and there was a small risk of tendon related complications.

APPENDIX IC
6.3 AIMS AND OBJECTIVES OF STUDY

To study fracture patterns of distal radius fractures.

To compare the results of different surgical methods of treatment of fracture distal end
radius. The various methods of treatment include percutaneous pinning, internal
fixation by plating, external fixation, pinning with cast immobilization.

To find out basis for selecting the best method of treatment for fracture distal end
radius.

APPENDIX-II
7.0 MATERIALS AND METHODS

APPENDIX-II A
7.1 SOURCE OF DATA
The material for the present study is proposed to be collected from minimum of 60
patients attended at Sri Adichunchanagiri Hospital & Research Centre, B.G.Nagara attached to
Adichunchanagiri Institute Of Medical sciences B.G.Nagara from July 2011 to October 2013.

APPENDIX-II B
7.2 METHOD OF COLLECTION OF DATA

Data will be collected from patients who are attended in orthopaedics opd and admitted
in orthopaedics wards of SAH & RC.

Clinical study will be through questionnaires and clinical examination.

All patients will undergo preoperative and post operative x-ray investigations.

Surgical management of the fracture.

Post-operative observation of patients for any complications.

Regular follow up and health education for the patients treated to study the functional
outcome.

INCLUSION CRITERIA

Fractures of distal end radius of either side or both with or without ulnar styloid.

Age between 20 70 years.

Both males and females.

Closed fractures.

Fractures up to 3 cm from distal articular surface of radius.

9

Fractures with history of trauma < 2 weeks.

EXCLUSION CRITERIA

Age group below 20 years.

Compound fractures.

Fracture beyond 3 cm from distal articular surfaces of radius (diaphyseal extension).

Fractures with history of trauma > 2 weeks.

Epiphyseal injuries of distal radius.

APPENDIX-II C
7.3 Does the study require any investigation or intervention to be conducted on the
patients or animals, if so please describe briefly
YES
INVESTIGATIONS: routine investigations like:
1. Plain radiographs of wrist: Anteroposterior view and Lateral view
2. Routine investigations to evaluate fitness for surgery.
Special investigations like

CT if indicated.

MRI if indicated.

No animal studies are conducted in this study.

10

APPENDIX-IID
PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL
SECTION A

Title of the study

SURGICAL TREATMENT MODALITIES IN

THE MANAGEMENT OF FRACTURES
DISTAL END RADIUS IN ADULTS IN
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCE, BELLUR

Principle investigator
(Name and Designation)

Dr. JOBIN ALEX MOHAN

P.G. IN ORTHOPAEDICS
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G. NAGARA,
MANDYA DISTRICT -571448

Co-investigator
(Name and Designation)

Name of the Collaborating

Department/Institutions

NO

Whether permission has been obtained from

the heads of the collaborating departments &
Institution

YES

Dr. GOPALAKRISHNA. G
MBBS, D-ORTHO, MS ORTHO

Professor,
Department of Orthopaedics,
AIMS, B.G. Nagara-571448

Section B
Summary of the Project
Section C
Objectives of the study
Section D
Methodology

APPENDIX I
APPENDIX IC
APPENDIX - IIB

A Where the proposed study will be undertaken

S.A.H. & R.C., B.G.NAGARA

B Duration of the Project

18 MONTHS

C Nature of the subjects:

Does the study involve adult patients?

YES

Does the study involve Children?

NO

Does the study involve normal volunteers?

NO

Does the study involve Psychiatric patients?

NO

Does the study involve pregnant women?

NO
11

D If the study involves health volunteers

I.

Will they be institute students?

NO

II.

Will they be institute employees?

NO

III.

Will they be Paid?

NO

IV.

If they are to be paid, how much per

NO

session?
E Is the study a part of multi central trial?

NO

F If yes, who is the coordinator?

(Name and Designation)

NA

Has the trail been approved by the ethics

Committee of the other centers?

NA

If the study involves the use of drugs please

indicate whether.

NA

I. The drug is marketed in India for the

indication in which it will be used in the study.

NA

II. The drug is marketed in India but not for

the indication in which it will be used in the
study

NA

III. The drug is only used for experimental use

in humans.

NA

IV. Clearance of the drugs controller of India

has been obtained for:

NA

Use of the drug in healthy volunteers

Use of the drug in-patients for a new
NA

indication.
Phase one and two clinical trials
Experimental use in-patients and healthy
volunteers.

12

G How do you propose to obtain the drug to be

used in the study?
-

Gift from a drug company

Hospital supplies

Patients will be asked to purchase

NA

- Other sources (Explain)

H Funding (If any) for the project please state

None

Amount

Source

To whom payable

NONE

Does any agency have a vested interest in the

NO

out come of the Project?

Will data relating to subjects /controls be stored
in a computer?

YES

Will the data analysis be done by

K

The researcher

YES

- The funding agent

L Will technical / nursing help be required form

NO
YES but it will not interfere with their duties

the staff of hospital.

If yes, will it interfere with their duties?

NO

Will you recruit other staff for the duration of

NO

the study?
If Yes give details of
I.

Designation

II.

Qualification

III.

Number

IV.

Duration of Employment

NA

13

M Will informed consent be taken? If yes

YES

Will it be written informed consent:

YES

Will it be oral consent?

NO

Will it be taken from the subject themselves?

NO

Will it be from the legal guardian? If no, give

NO

reason:
N Describe design, Methodology and techniques

APPENDIX II

Ethical clearance has been accorded.

Chairman,
P.G Training Cum-Research Institute,
A.I.M.S., B.G.Nagara.
Date :
PS : NA Not Applicable

14

APPENDIX-III
8. LIST OF REFERENCES
1. Colles A On the fracture of the carpal extremity of the radius. Edinburgh Med. Srug J
1814 ; 10 : 182-86.
2. Bohler L. The treatment of fracture. New York, Grune and Stratton 1932 ; 90-96.
3. Scheck M. Long-term follow-up of treatment of comminuted fractures of distal end of
the radius by trans-fixation with kirschner wires and cast. J Bone Joint Surg 1962; 44
(A) : 337-51.
4. De Palma AF, Comminuted fractures of the distal end of the radius treated by ulnar
pinning. J Bone Joint Surg 1952 ; 34 (A) : 651.
5. Ellis J. Smiths and Barons fractures. A method of treatment.J Bone Joint Surg 1965 ;
47 (B) : 724.
6. Green DP. Pins and plaster treatment of comminuted fracture of the distal end of radius.
J Bone Joint Surg 1975; 57 (A) : 304.
7. Cooney WP. Linscheid RL, Dobyns JH et al. External pin fixation for unstable colles
fractures. J Bone Joint Surg 1979; 6 (A) : 840-45.
8. Melone CP, jr. Open treatment for displaced articular fractures of the distal radius. Clin
Orthop 1986 ; 202 : 103-11.
9. Melone CP. Jr. Open treatment for displaced articular fractures of the distal radius.
Orthop Clin North Am 1984 ; 15 : 217-36.
10. Dennis F. Updated on external fixators in wrist fractures. C.O.R.R. 1986 ; 204.
11. Antenucci R, Altissimi M, Fiacco C et al. Long term results of conservative treatment
of fractures of distal radius. Clin Orthop 1986 ; 20006: 202.
12. Clyburn TA. Dynamic external fixators for comminuted intra articular fractures of the
distal end of radius. J Bone Joint Surg 1987; 2 : 248.

15

13. Keating JF, Court-Brown CM, McQueen MM. Internal fixation of volar- displaced
distal radial fractures. J Bone Joint Surg (Br) 1994 ; 76-B : 401- 405.
14. Anderson R., O Neil G. Comminuted fractures of the distal end of the radius. S.G.D.
1994 ; 78 : 434.
15. Fitoussi F, IP WY, Chow SP. Treatment of displaced intra articular fracture of the distal
end of radius with plate. J Bone Joint Surg 1997 ; 79-A (9) : 1303-12.
16. Kaempffe FA, Walker KM. External fixation of distal radius fracture : effect of
distraction on outcome. Clin Orthop 2000 ; 1(380) : 220-225.
17. Emami A, Mjoberg B. A safer pin position for external fixation of radial fractures.
Orthop Clin N-Am 2000 ; 31 (9) : 749-750.
18. Rogachefsky RA, Scott RL, applegateB, Ouellette EA, Savenor AM, McAuliffe JA.
Treatment of severly comminuted intra articular fractures of the distal end of the radius
by open reduction and combined internal and external fixation. J Bone Joint Surg 2001 ;
83-A (4) : 509-519.
19. Murray PM, Trigg SP. Treatment of distal radius fractures with external fixation :
Technical considerations for rehabilitation. Tech in Hand and Upper Extrem Surg 2002;
6 (4) : 213-218.
20. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of
complex fractures of distal part of the radius, J Bone and Joint Surg 2004; 86-A (9) :
1646-1652.

16