Functional Outcomes of Close Reduction With K-wires Vs Open Reduction and Internal Fixation in Distal Radius Fractures

Background: Radius and/or ulna fractures are frequent which encounter higher emergency room visits. Despite high incidence, proper management between closed reduction and internal fixation (CRIF) with K-wires and open reduction and internal fixation (ORIF) with anatomical Volar locking plate, remains debatable. This study aimed to compare the functional outcomes between the two management protocols. Methods: A total of 118 patients with distal radius fractures were treated operatively, at Dr. Ziauddin University Hospital Karachi, from January 2017 to October 2020. Out of these, 29 patients (24.6%) were treated with CRIF and 89 patients (75.4%) with ORIF. The functional outcomes of both groups were assessed through disabilities of arm, shoulder and hand (DASH) scores at 3 and 6 months. functional outcomes were assessed through a t -test, p -value <0.05 was considered significant. Results: The male to female ratio was 2.5:1, with an average age of 40.9 years. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) 23-B type injury was observed in 29 (24.6%) patients. The mean DASH score among the ORIF group and CRIF group at 3 months was 43.03 and 46.19 ( p <0.007) respectively. Whereas the DASH score of the ORIF and CRIF group at 6 months was 41.35 and 44.70 ( p <0.007) respectively. Both groups at 6 months of management reported 33 (28%) patients with complete satisfaction, however, the return to work in the ORIF group was found highly significant ( p =0.00). Conclusion: Open reduction and internal fixation with the distal radius locking compression plate produce functionally improved outcomes compared to K-wires for displaced distal radius fractures.


INTRODUCTION
The 640,000 radius and/or ulna fractures were reported in the United States alone, in 2001, accounting for nearly 1.5 percent of all emergency room visits. In the paediatrics and elderly populations, distal radius fractures account for 25% and 18% of all fractures, respectively 1,2 . As a result of increasing average life expectancy, distal radius articular fractures are reliably increasing 3 . Because of increased functional demand by elderly patients and short duration of functional rehabilitation as compared to non-operative cast immobilization leading to stiffness of wrist and fingers, a rising increase in surgical versus non-operative treatment of displaced articular fractures has recently been described 3 .
Non-displaced simple fractures are usually treated without surgery with a plaster cast. Because they heal in an unfavorable anatomical position, unstable fractures are commonly treated surgically 4 . Closed reduction and percutaneous K-wire fixation, fixation with volar or dorsal plates (locking or nonlocking), bridge plating, use of an external fixator, or a combination of these treatments are surgical and nonsurgical management options for patients with distal radius fractures 1,2 . Although the optimum treatment decision is dependent on the fracture characteristics (open/closed, un-displaced/displaced, extra-/intra-articular), there is just a small body of high-quality evidence to support it. The American Academy of Orthopedic Surgeons (AAOS) provided 29 recommendations in their clinical practice guidelines for distal radius fracture; none of these recommendations obtained a satisfactory grade due to the poor quality of the evidence 1 .
External fixation and Kirschner-wire stabilization have been linked to an increased risk of infection in several studies 2 . Patients with high demands may benefit from open reduction with locking volar plates, even if functional outcomes in older individuals with low needs are satisfactory despite the presence of a deformity 2 .
The introduction of locking plates with locking screws opened new surgical possibilities for fracture fixation and stability, even with comminuted fractures and osteoporosis 4 . On the volar side of the wrist, the radial artery is radially retracted, and the fracture is exposed, reduced, and set with a locking plate and screws utilizing the FCR technique. Early wrist range of motion is crucial for a successful postoperative recovery with volar plating. In any scenario, if standard locking plate application principles are not followed, there is a considerable risk of consequences such as median nerve palsy, tendon irritation, and tendon rupture 4 . There have been favorable outcomes of distal radius volar locking plate as compared to CRIF with K-wires group because of earlier mobilization 3 .
In a study published in 2018, it was found that Closed reduction and percutaneous pinning (CRPP) was an effective tool for recovering radiographic parameters following carefully selected types A and C distal radius fractures and that most patients had a good or exceptional range of wrist mobility after treatment with CRPP 5 . The objective was to determine the functional outcomes in patients with displaced distal radius fractures treated with CRIF with K-wires with ORIF with distal radius Volar locking plate in this study.

METHODS
In this study, 118 patients, who sustained Distal Radius Fractures, were included and retrospectively analyzed, with 89 of them receiving Open Reduction and Internal Fixation (ORIF) and 29 receiving CRIF (with K-wires), and were managed at Dr. Ziauddin University Hospital Karachi from January 2017 to October 2020. The study included patients of all ages, genders, and races who matched the inclusion criteria.
The inclusion criteria included all patients with >18 years of age, sustaining isolated distal radius fracture with >15° lateral displacement and>5mm radial shortening on the frontal plane, and fractures classified as B, C1-C2 type (Simple articular fractures) in AO classification. While exclusion criteria consisted of all open fractures and compromised neurovascular state, polytrauma, A and C3 type fractures types in AO, ipsilateral upper extremity fracture (Floating elbow) and bilateral wrist fractures.
In the ORIF group, the treatment protocol followed with FCR approach, reduction and internal fixation with angular stable plate and functional rehabilitation 15 days following surgery; while CRIF with K-wires followed Closed reduction and percutaneous K-wire fixation, 2-3 K-wires implanted from distal to the proximal region of fracture engaging opposing cortex and one K-wire for distal stability of radio-ulnar joint, if necessary, further stabilized in a brachio-metacarpal plaster cast. The wires and cast were removed after 6 weeks, followed by functional rehabilitation.
For patients that were surgically managed with Open Reduction and Internal Fixation (ORIF), the flexor carpi radialis (FCR) approach for Distal Radius Fracture was utilized, and the surgeons were familiar with the implants used. The patient selection for ORIF and K-Wire was decided considering the fracture pattern, patient's medical and clinical history and presenting status, adequacy of closed reduction and surgeon choice. All the patients' clinical and radiological findings were documented both before and after surgery. The study used anteroposterior and lateral X-ray scans of the wrist as radiographic examinations.
In a few patients undergoing ORIF, a wrist splint was applied post-operatively, which was removed two weeks later during the follow-up visit. Concomitantly, the splint applied with K-wires was removed at the period of 6 weeks along with the K-wires. Metal staple sutures were used in cases with ORIF and were removed after 2 weeks. Antibiotics were used for three doses perioperatively and analgesics were advised considering each patient. The DASH score was used to calculate the Functional Outcomes (at 3 and 6 months of follow-up). A t-test was used to compare the functional outcomes of the two groups, and it was done on SPSS version 23.0.  Figure 1).

Figure 1 (A-D): Comparison of mean DASH scores between plate and K-wire group at 3 and 6 months (p =0.007).
A total of 29 patients (24.6%) were treated with CRIF while the remaining 89 patients (75.4%) had surgical interventions (ORIF) performed (p =0.000). Among the ORIF group, the mean value for the DASH Score was found to be 43.03 and 46.19 at 3 months and 6 months, respectively, with 26 out of 89 (29.2%) with a DASH Score of equal and more than 55, who reported a much better result, while the mean DASH Score among CRIF group was found to be 41.35 and 44.70 at 3 months and 6 months, respectively (p =0.007). Of the patients who returned to perform their work 109 (92.4%) while those who changed their occupation were 9 (7.6%). A significant association was found between occupation and type of fracture patterns (p =0.067). The patient reported satisfaction was found as 33 (28%) with complete satisfaction with the management, 54 (45.8%) were moderately satisfied while 14 (11.9%) were slightly satisfied, for both groups at 6 months of management (Table 2). Among patients treated with ORIF, 92.4% returned to work efficiently and 7.6 % of patients changed their occupations, while 83.1% returned to work efficiently and 16.9% changed their occupations in the K-Wire group.

DISCUSSION
In comparison to Kirschner-wire (K-wire) closed fixation, open reduction and internal fixation (ORIF) with volar locking plate yielded much better outcomes. The DASH score was used to quantitatively examine the data in this study, which aimed to compare the functional outcomes of the two procedures. In the current study, the male to female ratio was 2.47:1, indicating that males were found to be more prevalent in the current study data. This differs from a previous study that found the M: F ratio to be 1:3 in the past 10 . In the United States, a woman's lifetime chance of suffering a distal radius fracture is estimated to be 15%, whereas men's risk is only 2% 11 . Because this study was conducted in a low-resource situation, the authors speculate that environmental factors may have influenced the male-to-female ratio of fracture survivors.
The volar locking plate (VLP) and Kirschner wire/pin fixations are the most popular surgical fixation techniques for distal radius fractures, notably in the United Kingdom 10,12 . Both are effective treatments for dorsally displaced, unstable, extra-articular, or simple intra-articular distal radius fractures 13 . To keep the fracture in the proper anatomical position, K-wires are introduced through the skin over the dorsal face of the distal radius and into the bone. Through an incision made across the volar (palm) area of the wrist, the locking plate is secured to the bone with fixed angle locking screws. To stabilize the most complex fractures, a volar fixed-angle plate must support the dorsal, central, and volar aspects of the subchondral bone 14,15 . Even though external K-wire fixation is a common technique for treating unstable distal radius fractures, a study published in 2019 found that VLP fixation outperformed external K-wire fixation in terms of wrist mobility, ulnar variance correction, and articular congruence improvement 16,17 . Wire fixation is insufficient in complex intraarticular type fractures of the distal radius when compared to VLP because it causes more volar tilt loss and arthritic changes in the postoperative period 18 . Other significant differences in functional outcomes have been discovered in previous studies, such as the volar locking plate group having better alignment restoration in terms of volar tilt and radial length 19 . Furthermore, the anatomical reduction was significantly more likely to be preserved in the plating group 20 .
The main theoretical benefits of plating internal fixation for distal radius fractures could be the early functional recovery seen in this study, as well as a previous comparative study that found that using ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing for early postsurgical wrist motion 21 .
Another comprehensive study published in 2015 found that volar locking plates for displaced distal radius fractures in adults have better DASH scores at 3-and 12-month follow-up when compared to K-wires and external fixation, as well as a lower overall incidence of problems, lower infection rates, and much better flexion-extension motion 22,23 . Furthermore, ORIF is associated with superior functional outcomes, which is advantageous for patients who require a faster return to function following surgery, particularly in present study case where we had 88 (74.6%) patients with a desk job and 30 (25.4%) patients who were field workers 13 .
The average age in this study conducted at Ziauddin hospital was 40.9, but findings suggest that ORIF with plates is also an effective treatment alternative in patients above 60 years of age which adds to its advantages 24 .
There are some limitations to the current study. Firstly, the small sample size increases the chances of unreliability in the results, like the research conducted in the past with a small sample 13,25,26 . Second, due to the small number of trials, we did not conduct any follow-up outcomes to examine long-term effects, as no significant differences between the two types of treatment have been detected in long-term follow-up studies completed to date 10,27 . Lastly, the cost-effectiveness of both the procedures was not taken into consideration. K wire fixation, comparatively, is an inexpensive procedure [28][29][30] .
To the authors' knowledge, very few studies have been conducted locally comparing the two procedures and thus, the research can serve as a preliminary study. To further look at the effectiveness of this intervention, more thorough research should be done for patient satisfaction with larger sample size and more randomized control trials are needed to obtain better results.
In conclusion, the main aim of the intervention is to secure and maintain anatomic reduction of joint surface to achieve better levels of patient satisfaction and better functional outcomes, along with ensuring minimal complications. In the current study, open reduction with internal fixation yielded better results.

CONCLUSION
Regardless of the age or gender of the patients, the candidates who were successfully surgically managed with Volar plating for fractures of the distal radius reported a much better functional outcome, in comparison to those patients who were treated with K-wires.

ETHICS APPROVAL
The study was approved by the ethics review committee of the Ziauddin University with the reference code: 4351021SMORT.

PATIENT CONSENT
Informed consent was taken from patients. Patient identity was not disclosed at any point during the research.

FUNDING
No financial aids, funds, grants, or sponsors were involved in the submitted study.

AUTHORS' CONTRIBUTION
Idea conceptualization, writing, data collection and data analysis were done by SM. MIS also assisted in the idea conceptualization and reviewed the manuscript. SKP had written the manuscript and performed the data analysis. SAR did the data collection and SLA assisted in paper writing and data collection.