Treatment of Severely Comminuted Intra-Articular Fractures of the Distal End of the Radius by Open Reduction and Combined Internal and External Fixation

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Abstract
Background: Severely comminuted AO type-C3 intra-articular fractures of the distal end of the radius are difficult to treat. Failure to achieve and maintain nearly anatomic restoration can result in pain, instability, and poor function. We report the results of a retrospective study of the use of a standard protocol of open reduction and combined internal and external fixation of these fractures. Methods: Seventeen of twenty-five patients treated with the protocol were available for follow-up evaluation. Six had an AO type-C3.1 fracture; eight, type-C3.2; and three, type-C3.3. Eleven fractures required a dorsal buttress plate and/or a volar buttress plate, and eleven required bone-grafting. The mean time until the external fixator was removed was seven weeks. Results: At a mean of thirty months postoperatively, the mean arc of flexion-extension was 72% of that on the uninjured side and the mean grip strength was 73% of that on the uninjured side. The mean articular step-off was 1 mm, the total articular incongruity (the gap plus the step-off) averaged 2 mm, and the radial length was restored to a mean of 11 mm. Thirteen patients had less than 3 mm of total articular incongruity. Arthritis was graded as none in three patients, mild in ten, moderate in three, and severe in one. According to the Gartland and Werley demerit-point system, ten of the patients had a good or excellent result. According to the modified Green and O’Brien clinical rating system, five had a good or excellent result. One patient had a fracture collapse requiring wrist fusion, one had reflex sympathetic dystrophy, and three had minor Kirschner-wire-related problems. Total articular incongruity immediately postoperatively had a moderately strong correlation with the outcome as assessed with both clinical rating systems (r = 0.70 and 0.74 for the Gartland and Werley system and the Green and O’Brien system, respectively; p < 0.05). Conclusions: Open reduction and combined internal and external fixation of AO type-C3 fractures can restore radiographic parameters to nearly normal values, maintain reduction throughout the period of fracture-healing, and provide satisfactory functional results.