Unstable articular fractures of the distal radius. Comparative techniques of ligamentotaxis. Dynamic external fixation of unstable fractures of the distal part of the radius. A prospective, randomized comparison with static external fixation. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. Improvement of the bone-pin interface strength in osteoporotic bone with use of hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized clinical study of wrist fractures. Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. External fixation of distal radial fractures: four compared with five pins: a randomized prospective study. Pins and plaster vs external fixation in the treatment of unstable distal radial fractures. A randomized prospective study. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus non-bridging external fixation.
Ligamentotaxis employing either pins and plaster or external fixators, frequently in conjunction with supplemental Kirschner wire internal fixation, has proved to be a reliable means of maintaining an accurate reduction of unstable articular fractures of the distal radius. Critical preoperative evaluation and surgical restoration of articular congruity along with attention to key technical details have resulted in a reproducible successful recovery. In our experience, the advantages of the pins and plaster technique are its relatively simple methodology, its comparatively low cost, and its high level of patient acceptance. The distinctive advantages of the external fixator are its superior mechanical efficiency, its capacity for fracture adjustment during the healing period, and the fact that it ensures unimpeded access to wounds. Nonetheless, regardless of the specific method chosen, this study clearly supports the contention that precision in patient selection and pin placement are the prerequisites for successful ligamentotaxis in the management of distal radius fractures. A prospective, randomized study was done to compare the results of dynamic external fixation (the Clyburn device) with those of static external fixation (the AO/ASIF device) in the treatment of fifty unstable fractures of the distal part of the radius. Mobilization of the wrist from neutral to 30 degrees of flexion was begun in the dynamic-fixator group at approximately two weeks, and full motion, allowing 30 degrees of extension, was started at approximately four weeks. The external fixation frames in both groups were kept in place for approximately ten weeks. Mobilization of the wrist in the dynamic-fixator group provided little gain in the mean motion of the wrist at the time of the removal of the fixator or at the one, six, or twelve-month evaluation. The static-fixator group had greater flexion of the wrist and radial deviation at the early and late follow-up examinations, while the dynamic-fixator group demonstrated only greater ulnar deviation one month after the fixator had been removed. Motion of the wrist in the dynamic-fixator group resulted in a statistically significant loss of radial length compared with that in the static-fixator group (four millimeters compared with one millimeter, p < 0.001). Complications were more frequent in the dynamic-fixator group. As evaluated with a modification of the scoring system of Gartland and Werley, 92 percent of the results at one year were excellent or good in the static-fixator group and 76 percent, in the dynamic-fixator group. The results of this study cannot support the concept of early mobilization with a dynamic external fixator for the treatment of unstable fractures of the distal part of the radius. We performed a prospective, randomised trial on 120 patients with redisplaced fractures of the distal radius comparing four methods of treatment. The four treatment groups, each containing 30 patients, were remanipulation and plaster, open reduction and bone grafting, and closed external fixation with and without mobilisation of the wrist at three weeks. The radiological results showed improvement in angulation of the distal radius for the open reduction and bone grafting group. Functional results at six weeks, three and six months and at one year, however, showed no difference between any of the four groups. The main influence on final outcome was carpal malalignment which had a statistically significant negative effect on function. Achieving adequate fixation strength in osteoporotic bone is a challenge. In this study, we examined the use of hydroxyapatite-coated tapered external-fixation pins for the fixation of wrist fractures in patients with osteoporosis.
                Twenty female patients with osteoporosis and a fracture of the wrist were divided into two paired groups and randomized to receive either standard tapered pins or hydroxyapatite-coated tapered pins. Two pins were inserted in the distal part of the radius, two pins were inserted in the second metacarpal, and an external fixation device was mounted. All fixation devices were removed six weeks after surgery.
                The mean pin-insertion torque (and standard deviation) was 461 +/- 254 Nmm in the group managed with standard pins and 332 +/- 176 Nmm in the group managed with hydroxyapatite-coated pins (p = 0.01). The mean pin-extraction torque was 191 +/- 155 Nmm in the group managed with standard pins and 600 +/- 214 Nmm in the group managed with hydroxyapatite-coated pins (p < 0.0001, power 95%). The mean extraction torque was lower than the corresponding insertion torque at each pin position in the group managed with standard pins (p < 0.05), whereas the mean extraction torque was higher than the corresponding insertion torque at each pin position in the group managed with hydroxyapatite-coated pins (p = 0.001). Two patients managed with standard pins and no patient managed with hydroxyapatite-coated pins had a pin-track infection. Pain during pin removal did not differ between the two groups.
                The present study showed that hydroxyapatite-coated tapered external-fixation pins provided improved fixation in the treatment of wrist fractures in patients with osteoporosis. Non-bridging external fixation has been introduced to achieve better fracture fixation and functional outcomes in distal radius fractures, but has not been specifically evaluated in a randomized study in the elderly. The purpose of this trial was to compare wrist-bridging and non-bridging external fixation for displaced distal radius fractures.
                The inclusion criteria were women >/= 50 or men >/= 60 years, acute extraarticular or intraarticular fracture, and dorsal angulation of >/=20 degrees or ulnar variance >/= 5 mm. The patients completed the disabilities of the arm, shoulder and hand (DASH) questionnaire before and at 10, 26 and 52 weeks after surgery. Pain (visual analog scale), range of motion and grip strength were measured by a blinded assessor.
                38 patients (mean age 71 years, 31 women) were randomized at surgery (19 to each group). Mean operating time was shorter for wrist-bridging fixation by 10 (95% CI 3-17) min. There was no significant difference in DASH scores between the groups. No statistically significant differences in pain score, range of motion, grip strength, or patient satisfaction were found. The non-bridging group had a significantly better radial length at 52 weeks; mean difference in change in ulnar variance from baseline was 1.4 (95% CI 0.1-2.7) mm (p = 0.04). Volar tilt and radial inclination were similar in both groups.
                For moderately or severely displaced distal radius fractures in the elderly, non-bridging external fixation had no clinically relevant advantage over wrist-bridging fixation but was more effective in maintaining radial length. The purpose of this study of distal radial fractures was to compare the radiographic and clinical results after use of a standard four-pin external fixator with those after use of a five-pin fixator with the fifth pin stabilizing the distal radial articular fragment.
                In an open prospective trial, fifty patients with an unstable distal radial fracture were randomized for treatment with closed reduction and either a standard small Association for the Study of Internal Fixation (ASIF) four-pin fixator (twenty-five patients) or a five-pin external fixator (twenty-five patients). The fixators were removed at nine weeks, and all patients were assessed radiographically and clinically at six months.
                Follow-up radiographs demonstrated significantly less loss of alignment and length with the five-pin external fixator. Pin site infections were more prevalent with the four-pin fixator. The range of motion of the wrist and forearm, the grip strength, and the Lidstrom functional ratings at six months were all significantly better after use of the five-pin fixator.
                The use of a five-pin external fixator, with the fifth pin stabilizing the distal radial articular fragment, yields better radiographic and functional results than does a four-pin fixator. 90 unstable fractures of the distal radius were studied in a randomized, prospective manner. Follow-up consisted of patient questionnaire, medical record review, therapist evaluation and radiography at 4 months, 1 year and 2 years post-operatively. Overall results were good or excellent in 94%. No significant differences were found between treatment groups (external fixation and pins and plaster) in final results, range of motion, intrinsic tightness, grip strength, or the presence of arthritis. The complication rate was high for both groups (45%), and half of the complications were major. External fixation maintained radial length more effectively (significantly in those patients followed for 2 years) but was associated with higher initial costs (20 times) and a greater number of minor complications. A randomised, prospective study was carried out on 60 patients with unstable fractures of the distal radius to compare bridging with non-bridging external fixation using pins placed in the distal fragment of the radius. The radiological results showed significant improvement in the non-bridging group at all stages of review. In particular, normal volar tilt and carpal alignment were regained and maintained. The functional results at six weeks, three months, six months and one year showed statistically better grip strength and flexion in the non-bridging group at all stages of review. Other ranges of movement showed an early advantage in the non-bridging group. Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius which have sufficient space for the placement of pins in the distal fragment.
There is insufficient robust evidence to determine the relative effects of different methods of external fixation. Adequately powered studies could provide better evidence.