A STUDY OF KAPANDJI INTRAFOCAL PINNING FOR THE TREATMENT OF UNSTABLE EXTRA- ARTICULAR DISTAL RADIUS FRACTURES

Intrafocal pinning of distal radius fracture is indicated in unstable distal radius fractures without significant intra-articular displacement. It is a simple and effective, minimally invasive method of fixation for achievement of alignment and stability of unstable fractures. The study was conducted between November 2013 and October 2016. Patients attending the emergency and outpatient departments with history of trauma followed by pain and swelling of wrist, were evaluated clinically & radiologically. Patients with distal radius fracture who met the criteria were enrolled in the study. The operation was performed either under regional anaesthesia or intra venous anaesthesia. Reduction was carried out under image intensifier guidance and intrafocal pinning was undertaken with 2 Kirschner wires as described by Kapandji. Above elbow slab was applied for 3 weeks. Kirschner wires were removed at 6th week. Follow ups were done with radiological and functional evaluation on 1st week, 3rd week, 6th week, 12th week and 6 month. Of the 30 cases enrolled in our study, the age ranged from 40 to 72 years and the mean age of the patients was 54.77 years. The female/male ratio was 5:1 and the majority (83%) of patient sustained injury due to trivial trauma. All fractures united by 6 weeks. In the final follow up at 6th month, assessment of range of motion showed almost full range of motion. Functional evaluation was carried out with Gartland & Werleys Demerit point system (modified by Sarmiento et al). According to the score, 9 patients had excellent, 19 had well and 2 had fair results. None of the patient had poor results. Kapandji intrafocal pinning provides a stable fixation and good functional outcome in extraarticular distal radius fractures with few complications only.


INTRODUCTION
The distal radius fractures are the most common of the upper extremity fractures representing 17% of all fractures treated each year. 1,2 Although distal radius fractures are most common among the females over 40 years of age, young adults make up a significant portion of the cases. Treatment of displaced distal radius fractures has changed over the period of time. In the past, closed reduction with cast immobilization was considered the treatment of choice. However, these methods often results in unsatisfactory anatomical and functional outcomes with varying degree of deformity and disability. To address these problems, Kapandji 3 mentioned a method of Kirschner wire (K-wire) osteosynthesis in which the wires were inserted from the dorsal aspect "intrafocally" i.e. into the fracture gap with good results. The purpose of this study was to assess the outcome of distal radius fractures among adults treated with Kapandji technique. Surgical procedure (Kapandji technique) Patient was positioned supine in operation table and preoperative prophylactic intravenous antibiotic (Cefazolin 1 gm) was given. All the patients were operated either under brachial block or general anaesthesia. Reduction was performed with traction and counter-traction under image intensifier guidance. After maintaining aseptic precautions, a stab incision was made and a K-wire mounted in a drill sleeve was inserted directly into the fracture gap, initially directed at 90 degrees. The wire was inserted directly at the proximal, dorsal margin of the fracture to support area of comminution. The fracture was aligned, drill sleeve was connected to the drill and the K-wire was anchored at an angle of 45 degrees in the opposite cortex. The manoeuvre was repeated for the lateral part of the fracture gap with second K-wire. The bending and cutting of the K-wires were just above the skin. Above elbow cast was applied. The patients who received brachial block were observed for 4 hours, postoperative check X-ray was taken. Possible complications and precautions were explained. The patient was evaluated next day in OPD for possible complications and was call for first follow up after 1 week. The patients who underwent procedure under general anaesthesia were admitted in postoperative ward for a day. They were discharged on first post-operative day following the check X-rays. They were also called after 1 week & precautions were explained. All patient received analgesics for 3 days and no patients received postoperative antibiotics.

MATERIAL AND METHODES
All the patients were followed up at 1 st , 3 rd , 6 th , 12 th and 24 th weeks. On every follow up, all the patients were evaluated clinically for the features of clinical union and appearance of any complications of the procedure. Radiological evaluations were done at the immediate post-operative period and at 6th week follow up. At the third week follow up, above elbow cast was shortened to below elbow with initiation of elbow range of motion exercise to prevent elbow stiffness. K-wires were removed at 6 th week. Physiotherapy & mobilization was started after removal of cast. For radiological evaluation, we assessed the radial inclination; radial height, ulnar variance and volar tilt at the final follow up and compared with the average measurements provided in the standard orthopaedic textbook. The functional evaluation was done at the final follow up by using Demerit point system of Gartland and Werley's with Sarmiento et al. modification

Data analysis:
The selected data was analysed with the help of SPSS (Statistical package for social science) windows program 16.5 version. The student t-test quantitative variables were used and values of P= <0.05 were considered significant with confidence level of 95% throughout the study.

RESULTS
The mean age was 54.77 years. There were 24 female patients (80%) and 6 male patients (20%). Nineteen patients (63.33%) had fractures involving left wrist and remaining 11 patients (36.66%) had fractures on the right wrist. Seventy (21 cases) fractures were classified as Frykman's type I and 30% (9 cases) as Frykman's type II. The mode of injury in 25 patients (83%) was trivial fall, in 4 patients (13%) was road traffic accident and 1(4%) patient suffered injury due to domestic violence. Clinical and radiological signs of union were noted in 2 nd follow up onwards.
In 7 fractures (23%), sign of union was observed at 3 rd week and all 30 fractures (100%) united by 6 th week.

Range of motion
The range of motion (dorsiflexion, palmarflexion, supination , pronation, radial deviation and ulnar deviation) was assessed at 6 th week, 12 th week and 24 th week. So, various studies [4][5][6][7][8][9][10][11][12][13][14][15][16] showed superior functional outcome with Kapandji intrafocal pinning for unstable extra-articular distal radius fractures among adults. Although we had found good to excellent functional outcome with this technique, there are some limitations of this study. First, we included few numbers of patients in this case series, so large number of patients must be included to further validate the results. Second, we compared the radiological parameters with the standard average measurements provided in the standard textbooks, which might not be the same for our population. Third, we did not do comparison this technique with other available procedures, so that we could claim this procedure as a superior one.

CONCLUSION
Kapandji intrafocal pinning is safe, simple and easy procedure for unstable distal radius extraarticular fractures that provide good to excellent radiological and functional outcomes with very few complications.