Role of Percutaneous Pinning with K. Wires fixed by Joshi’s

Clamp in Distal Radius Fractures

A. Mantovani, M. Trevisan, M. Cassini

U.O.S. di Chirurgia della Mano e Arto Superiore Ospedale di Legnago (VR)

A.U.L.S.S. n° 21 Regione Veneto Italy

•  In 70s, Dr. B.B. Joshi, an eminent Orthopaedic Surgeon from Mumbai established a 30 bedded Hand Surgery Unit at ESIS Hospital in Parel and subsequently made significant contributions in the field of Hand Trauma.

•  In 1988 he developed a system of external fixation for the hand using simply Kirschner wires connected and blocked by a steel clamp, cheap and still now largely employed in India

•  Dr. A.G. Bhatia eminent Hand and Reconstructive Surgeon from Mumbai, is well known for the brachial plexus surgery. He was the first person to demonstrate the utility of the Joshi system of external fixation in Italy in 1992 during his fellowship at Gaetano Pini Institute in Milano and at Modena University Hospital

After having employed the Joshi clamp in a number of different fractures, we were looking for its standard use with percutaneous pinning in distal radius fractures

HISTORY AND EVOLUTION OF PERCUTANEOUS PINNING OF THE DISTAL RADIUS

(WITH CAST) •  Lambotte (1908) Pure radial styloid pinning (bicortical)

•  DePalma (1952) Ulnar-radial pinning •  Stein and katz (1975) Radial styloid pinning and dorsal radial pinning

HISTORY AND EVOLUTION OF PERCUTANEOUS PINNING OF THE DISTAL RADIUS

(WITH CAST)

•  Uhl (1976) Radial styloid and ulnar radial pinning

•  Kapandji (1976) Triple intrafocal pinning (dorsal buttress pinning)

•  Rahyack (1989) Ulnar radial pinning with fixation of the distal radial ulnar joint

HISTORY AND EVOLUTION OF PERCUTANEOUS PINNING OF THE DISTAL RADIUS

(WITHOUT CAST) •  Ulson (1983 and 1988) Intramedullary pinning

•  Poggi (1994) (EPIBLOC) Intramedullary pinning with external plate clamp (spring device under costant tension) “Active and immediate mobilization permits a quik consolidation” “Elastic” or “dynamic” fixation.

JOSHI CLAMP ALLOWS EVERY KIND OF DISTAL RADIUS PERCUTANEOUS PINNING, AVOIDING CAST

PERCUTANEOUS PINNING

INTRAMEDULLARY BICORTICAL INTRAFOCAL COMBINED

+

JOSHI’S CLAMP

=

STRONGER STABILITY, WITHOUT CAST

INDICATIONS • The percutaneus pinning with K. Wires fixed by Joshi Clamp is indicated in Colles and Goyrand-Smith fractures, that is the A2 and A3 (but A3.3) of AO Classification. Particularly if there is instability with loss of cast reduction after one or two weeks

• Bilateral Colles fractures

•  Hemodialysis patients

RADIUS/ULNA, AO CLASSIFICATION

SURGICAL TECHNIQUE •  Manual reduction of

the fracture under local anaesthesia (haematoma block + pin track block) or brachial plexus block after some days from trauma

•  Under X-ray control the hand placed directly upon the C-arm

•  Intravenous administration of one dose of cephazoline before surgery and in the next five days orally

SURGICAL TECHNIQUE •  The K. wires are inserited either by a Jakobs chuck or by a drill •  If a drill is used, the tip of K. Wire should not be bent •  In intramedullary techniques it is better to insert K. wires by

hand with a chuck bending the tip •  The caliber of K. wires is generally 1.8 or 2.0 mm

SURGICAL TECHNIQUE •  The first intramedullary pin is insert on the top of the radial styloid between first and

second compartment of extensor tendons: 2 mm dorsal to “volar line of Lewis” •  The second intramedullary pin is inserted at the ulnar corner of the radius •  The third pin is intrafocal (dorsal buttress) or bicortical to allow greater stability •  The choice of perforating the opposite cortex (bicortical) depends on the bone quality and the pattern of the fracture

SURGICAL TECHNIQUE •  K. wires are bent 90° out, without skin stretching •  Supplementary bending of wires is done in direction of

Joshi clamp, that is finally blocked on the wires

POST-OPERATIVE CARE •  No cast (antalgic volar splint for 3 days if needed) •  Immediate active mobilization •  Weekly dressing program (pins cleaning with hydrogen peroxide +

dry dressing around the pins)

•  Removing K. wires and Joshi’s clamp in the OPD, usually 5-7 weeks after surgery, if Rx show fracture consolidation

CASE intramedullary pinning

CASE combined pinning: bicortical + intrafocal

CASE combined pinning: intramedullary + intrafocal

CASE combined pinning: intramedullary+intrafocal

+bicortical

CASE bicortical pinning

PATIENTS

•  37 cases, from 2000 to 2007 (about 5-6 cases every year: rare indication!) •  31 women (aged 52-88 years)

•  6 men (aged 61-78 years) •  22 cases after primary treatment with cast and

subsequent loss of reduction after one week (16 cases) and after two weeks (6 cases)

RESULTS (changes in X-ray parameters) 37 CASES (follow-up on 36)

a= Radial shortening : 8 cases, 1-3 mm only with intramedullary pinning b= Radial displacement: 3 cases, 2-3 mm only with intramedullary pinning c= Radial inclination : 0 cases d= Dorsal angle : 4 cases, 0°-15° only with intramedullary pinning e= Dorsal displacement: 0 cases

RESULTS •  Neither vascular nervous nor

tendineous lesions have been observed

•  Only with intramedullary

pinning there was modification of X-ray parameters with no need of further treatment

•  With combined pinning X-ray

parameters never changed (the system is more stable)

•  In a case it was necessary

changing the treatment because of a deep infection

•  Resumption of the daily activities on average after 1 weeks from the surgery and of jobs and hobbies after 6 weeks

•  Deep infection: 1 case necessitating removal of hardware, débridement, intravenous antibiotics and cast treatment definitive (residual malunion)

•  Superficial pin track infection or infammation (eritema and minor pin track drainage): 6 cases responsive to oral antibiotics

•  Distal pin migration: (with intramedullary pinning) 1 case at the end of the

treatment without influence on consolidation

COMPLICATIONS (pin-related complications)

DISCUSSION •  The value of percutaneous pinning in distal

radius fractures has been reported recently.

•  However, percutaneous pinning only offers incomplete biomechanical stability and so a cast or an external fixator should be added

DISCUSSION •  In distal radius fractures the K. wires only do not

provide full stability, but if K. wires are joined by Joshi’s clamp, they create a structure strong enaugh to block the fractured bone, without the need for other devices.

CONCLUSIONS •  The percutaneous pinning with K.wires fixed by

Joshi’s clamp can be an alternative treatment along with casting and the open internal fixation of the unstable Colles fractures

(AO classification, A2-A3) •  Combined percutaneous pinning provides more

stability (at least one K. wire intrafocal or bicortical)

3 K. Wires !

Grazie per l’attenzione