|Year : 2013 | Volume
| Issue : 1 | Page : 23-29
Percutaneous K-wire fixation of distal radius fractures: Our results of leaving the wire outside
KT Madhukar, G Gopalkrishna, Jobin Alex Mohan
Department of Orthopaedics, Adichunchanagiri Institute of Medical Sciences, Bellur, Karnataka, India
|Date of Web Publication||17-Apr-2013|
K T Madhukar
Department of Orthopaedics, Adichunchanagiri Institute of Medical Sciences, B. G. Nagar, Bellur, Mandya - 571 448, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Distal radius fracture is one of the common injuries seen in casualty often managed by closed reduction and percutaneous pinning. Aim: The purpose of this prospective study is to determine the incidence of infection following percutaneous wire fixation of distal radius fractures and it's bearing on the outcome in the management of distal radius fractures. Materials and Methods: We studied eighty-eight cases of closed distal end radius fractures managed with closed reduction and percutaneous Kirschner wires (K-wires) fixation with splinting for pintract infection. Results: Out of the 88 cases included in the study, 14 cases had pintract infections that were mild to moderate in nature. In 6 cases of early K-wire removal due to pintract infection, shortening of radius, malunion, reduced finger grip and poor functional outcome was noticed. Pintract infections resulted in extended hospital stay, early pin removal, decreased functional outcome, malunion of distal radius and requirement of second surgery to correct the deformity and to improve functional outcome. However, percutaneous K-wire fixation with keeping the wire outside has been advocated and routinely performed, though incidence of pintract infection and complications arising from early removal of K-wires cannot be ignored. Conclusion: Therefore, our study proposes to bury the pin ends under the skin to reduce complications and to achieve better functional outcomes.
Keywords: Colles′ fracture, percutaneous K-wire fixation, infection
|How to cite this article:|
Madhukar K T, Gopalkrishna G, Mohan JA. Percutaneous K-wire fixation of distal radius fractures: Our results of leaving the wire outside. Int J Health Allied Sci 2013;2:23-9
|How to cite this URL:|
Madhukar K T, Gopalkrishna G, Mohan JA. Percutaneous K-wire fixation of distal radius fractures: Our results of leaving the wire outside. Int J Health Allied Sci [serial online] 2013 [cited 2020 Feb 21];2:23-9. Available from: http://www.ijhas.in/text.asp?2013/2/1/23/110571
| Introduction|| |
A distal radius fracture is one of the most common fractures representing 16% of all fractures seen in casualty.  The treatment of distal radius fractures is an important topic in light of the aging population in whom it is frequently seen and that these patients may have significant associated co-morbidities to consider before a treatment plan is formulated. The management of the distal radius fractures has undergone tremendous changes in the recent past due to better understanding of pathological anatomy, mechanism of injury and development of newer implants. The objective of treatment of distal radius fracture is to restore the anatomy of the wrist in order to obtain early painless function. Closed reduction and cast immobilization, percutaneous pin fixation, external fixator, volar locking plate, intramedullary nail fixation were been used as single or combined procedures in the management of distal radius fractures. , Closed reduction and percutaneous K-wire fixation with plaster immobilsation is one of the commonest modes of treatment employed in the management of distal radius fracture.  Infection of the pin tract is one of the commonest complications seen with percutaneous K-wire fixation of the distal radius fracture. Infections are usually mild in nature and responds well to regular dressings, antibiotics, and early removal in some cases of resistant infections. ,, The purpose of this prospective study is to determine the incidence of infection following percutaneous K-wire fixation of distal radius fractures and it's bearing on the outcome in the management of distal radius fractures.
| Materials and Methods|| |
In this prospective study carried out at a tertiary care center, eighty-eight patients with simple extraarticular metaphysical fractures of the distal radius who underwent closed reduction and percutaneous K-wire fixation were included. Mean age of the patient was 56 years, with an age range of 26 to 84 years. Patients with open fractures, associated head injury, polytrauma, and late presentation requiring open reductions or a delay in surgery beyond 1 week were excluded from the study. Clearance from the medical ethical committee and formal informed consent was obtained from all the patients before the operative procedure.
All the eighty-eight patients included in the study were admitted as inpatients. Preoperative anaesthetic evaluation was carried out. Ten patients were found to have uncontrolled diabetes mellitus and were medically managed before the operative procedure. Procedure was carried out under general anaesthesia, regional block. Parts were prepared and painted with 10% Betadine scrub solution. Intravenous 1.5 gm of cefixime sulbactum combination antibiotic was administered. Tourniquet applied as standby. Draping with full aseptic precaution was carried out. Closed reduction of the fracture was performed. Extreme flexion extension manipulation of the wrist was avoided for achieving reduction. Once an acceptable reduction was achieved and confirmed with C-arm, 1.5 mm to 2 mm thick K-wire (2 or 3 in numbers) were passed across the fracture site from the radial styloid process and dorsomedial aspect of radius after making a stab incision at the entry point. Kwire were engaged in the opposite cortex of the proximal fragment to achieve maximum stability of fixation.  The K-wire were bended and cut off outside the skin [Figure 1]. K-wire ends were cleaned and covered with antiseptic soaked sponge pieces. Dorsolateral slab/cast was applied keeping wrist in neutral position. Post-operative check X-rays were taken [Figure 2]. One more dose of intravenous antibiotic was administered. Post-operatively the limb was kept elevated and discharge was planned on the next day after initiating shoulder, elbow, and finger mobilizations. Check X- rays were repeated at 3 rd and 6 th week to rule out displacement of fragments. Slab and K-wires were removed on outpatient basis at 6 weeks and physiotherapy was initiated. Check X-rays were done at 3, 6, and 12 months follow up evaluation. Longest follow up was 12 months. No patients were lost during the follow up.
|Figure 1: Closed reduction and percutaneous Kwire fixation of the distal radius fracture with K wire being left outside the skin|
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|Figure 2: X ray showing percutaneous K wire fixation of the distal radius fracture with acceptable reduction|
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Pin tract infection severities were graded according to the modified Oppenheim's classification. 
Grade 1: Redness surrounding the pin tract with slight discharge
Grade 2: Soft tissue tenderness and redness with or without pus discharge
Grade 3: Grade 2 lesions not responding to antibiotics
Grade 4: Indicates involvement of surrounding soft tissue
Grade 5: Indicates radiological evidence of bone involvement
Grade 6: Indicates persistent sinus with sequestrum formation
The final assessments of results were based on Castings' modification of the method devised by Gartland and Werley.  Based on point score system, analysis of the residual pain in the radiocarpal and radioulnar joints, arc of flexion extension, rotation of the forearm, grip strength, and radiographic evaluation were performed. Severe pain was assigned 0 points; moderate pain 1 point; mild pain 2 points and no pain 4 points. Four points was assigned to an arc of flexion-extension of 130 to 140 degree; 3 points to arc of motion of 100 to 130 degree; 2 points to arc of motion of 80 to 100 degree and 1 point to arc of motion less than 80 degree. Rotation of the forearm of 180 to 160 degree scored 4 points; of 160 to 140 degree scored 3 points; 140 to 120 degree scored 2 points and less than 120 degree scored 1 point. Grip strength evaluated using steel spring dynamometer. 80 percent or more of that of uninvolved hand received 4 points; 65 to 70 percent received 3 points; 40 to 65 percent received 2 points and less than 40 percent received 1 point. The point scores for each of the criteria were added. In radiographic evaluation radial length, volar tilt and radial inclinations were measured.
A rating of very good was assigned to a wrist that had a score of 18 to 20 points; good 15 to 17 points; fair 12 to 14 points and poor less than 11 points.
| Results|| |
We had 14 cases (case no 5, 10, 15, 19, 26, 32, 37, 43. 46, 50, 52, 58, 72, 84) of pin tract infection following closed percutaneous K-wire fixation of 88 extraarticular fractures of the distal radius. Based on modified Oppenheim's classification,  6 cases of grade 2 infection, 5 cases of grade 3 infection, and grade 4 infections in 3 cases were noted [Table 1]. Once evidence of infection was noticed, pin tract sites were regularly cleaned with antibiotic solution, covered with gauze socked in Betadine solution and slab reapplied. Secretions were sent for culture and sensitivity examination. Out of 14 infected cases, Staphylococcus aureus was isolated in 7 cases, Pseudomonas in 3, Escherichia More Details coli in 2 and culture yielded no growth after 3 days in 2 cases. Appropriate antibiotics were stated intravenously as soon as evidence of infection was noted, which were continued for 10 days followed by conversion to oral antibiotics till K-wire removal.
In eighty-two cases of percutaneous K-wire fixation that underwent K-wire removal at normal average of six to eight weeks, average range of motion was 58 degree in flexion, 65 degree in extension, 23 in ulnar deviation, 10 degree in radial deviation, 75 degree of pronation and 70 of supination. The grip strength compared to normal side was 85 percent. The mean radial length, volar tilt, and radial inclination were 9.7 mm, –2.3 degree, and 18.4 degree respectively.
In six cases of percutaneous K-wire fixation that underwent early K-wire removal due to pintract infection, the average range of motion was 45 degree in flexion, 20 degree in extension, 10 degree in ulnar deviation, 15 degree in radial deviation, 45 degree of pronation and 40 of supination. The grip strength compared to normal side was 40 percent. The mean radial length, volar tilt, and radial inclination were 3.9 mm, -15 degree, and 21 degree respectively [Figure 3].
|Figure 3: X ray showing malunion after early removal of K wires for pintract infection|
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Combined using the Gartland and Werley  method of assessment the overall clinical and functional result was, twelve cases had very good results (13.6%) [Figure 4]; good in 56 cases (63.6%); fair in 12 (13.6%) cases and poor in eight cases (9%) [Table 2], [Figure 3].
|Figure 4: Percutaneous K wire fixation of distal radius fracture with excellent outcome at 12 months follow up on the right side|
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Of the eight cases with poor results, six cases had early removal of K-wire due to pintract infections. Thus, all cases (100%) of percutaneous K-wire fixation of distal radius fractures that had early removal of K-wire due to pintract infections had poor end results when compared with only two cases (2.5%) without early removal.
| Discussion|| |
Fracture of the distal end of radius is an injury that Orthopaedic surgeons deal with frequently, accounting for 1/6 of all the injuries seen in emergency department.  Early scholars managed these cases with conservative non-operative methods and achieved reasonable results.  With better understanding of the disrupted anatomy, biomechanics of injury pattern and improved imaging techniques, surgeons today have opportunity to improve maximal functional outcome and reduce the possibility of posttraumatic arthritis. Percutaneous K-wire fixation of the reduced distal end of radius fracture is one of the commonest treatment modality followed [Figure 1]. ,, It is one of the simplest procedures in the management of the distal radius fractures which commonly happens in elderly patients who may not be fit candidates to tolerate other long surgical procedures and the anaesthetic effects due to other associated medical co-morbidities. Also in these cases keeping K-wire outside avoids necessary of one more anaesthetic and surgical procedure for implant removal. Burying the K-wires under the skin is not routinely followed because of the necessity of one more surgical procedure for removal and difficulty in management if wires get infected when they are buried under the skin. Pin tract infection is the commonest complications with percutaneous K-wire fixation of distal radius fractures keeping the cut ends of the K-wires outside bearing an impact on the final outcome. ,,,, Most of the pin site infections in the present series were mild (8 out of 14 cases) and could be managed by local and systemic use of antibiotics. Infection usually subsided with regular dressings and antibiotics, but the presence of infection forced us for early removal of K-wires at the end of 3 or 4 weeks as against 6 weeks in six cases. In all, 6 (100%) cases of pin tract infection with early K-wire removal shortening of radius, redisplacement of fracture fragments, malunion [Figure 3], reduced finger grip, with poor functional outcome was noted (poor rating with Gartland and Werley criteria) [Figure 3]. Whereas, only two cases of poor results were noted when K-wires were removed at usual time (2.5%). All six cases with poor results required secondary surgery in the form of corrective osteotomy of radius or Darraks salvage surgery to improve the functional outcome and to reduce the pain.  Burying the K-wires under the skin should greatly reduce the possibility of pin track infection occurring due to external exposure of the pins and there by poor results associated with pin tract infection, early pin removal and loss of fixation.
| Limitations of the Study|| |
A comparative study of K-wires kept outside and those buried under the skin would have clearly indicated possible advantages and disadvantages between these two methods of fixation.
| Conclusion|| |
Percutaneous K-wire fixation of the distal radius fractures is one of the simplest and most commonly performed procedures. Pin tract infections following percutaneous K-wire fixation of distal radius fractures forces extended hospital stay of patient, early pin removal and poor functional outcome secondary to redisplacement and malunion of distal radius fracture [Figure 5]. The rate of infection and associated complications with percutaneous K-wire fixation are unacceptably high. It is advisable to bury the pin ends under the skin to minimize pin tract infections secondary to external exposure though it necessitates one more surgical procedure for removal of K-wires.
|Figure 5: Early removal of percutaneous pinning of distal radius fracture due to infection resulting in malunion and restricted forearm and wrist movements on the left side with fair result|
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]