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. 2020 Oct 29;15:46–50. doi: 10.1016/j.jcot.2020.10.049

The “AIIMS hairpin loop” technique for ‘extreme’ volar rim fractures of distal radius

Bhavuk Garg 1, Tungish Bansal 1,∗, Nishank Mehta 1
PMCID: PMC7919956  PMID: 33680824

Abstract

Background: Treatment of distal radius fractures has seen a paradigm shift since the use of volar locking plates became popular. However, there is a subset of fractures, which includes extreme distal volar rim fractures, that is often not amenable to fixation by volar locking plates as there is insufficient bone mass to put screws. These fractures as such are quite rare but carry a huge morbidity due to frequent lack of anatomical reduction and fixation. A number of different techniques like hook plates, specially designed distal volar locking plates and loop wire techniques have been described for these fractures, but they have been found to be less helpful when the fracture fragments are very small.

Methods: Herein, we describe our experience on 6 patients, using a novel surgical technique for fixation of distal radius volar rim fractures which works equally well even when the fragments are quite small (2–3 mm). The technique uses low cost and readily available implants (K wire and conventional volar locking plate) without the need of any special implants.

Results: The total of 6 cases of distal radius volar rim fractures (AO/OTA Type B3 = 4, Type C1 = 2) were operated. The mean age was 50.83 years (range: 31–72). The mean follow-up duration was 43.3 months (range: 26–66). The mean size of the volar fragment was 3.66 mm (range: 2–5). The mean pronation and supination were 72.5° (60–80) and 74.2° (60–85). The main flexion and extension were 52.5° (40–75) and 58.3° (50–80) respectively. The mean grip strength was 19.8 kg (4–38) and it was mean 79.3% (40–130%) compared to uninjured side. The mean PRWE score was 12.3 (2–31). One patient developed symptoms of Complex Regional Pain syndrome 1 (CRPS 1) which resolved with conservative management and no other complications were noted.

Conclusion: Our technique offers an indigenous, cost-effective way for fixation of extreme volar rim fracture fragments which can be easily adopted and used by surgeons in developing countries.

Keywords: Volar rim, Distal radius, K-wire, Volar marginal fractures, Hairpin loop, Indigenous technique

1. Introduction

Intra-articular distal radius fractures are commonly encountered low/high energy fractures which more often than not, require operative intervention. Volar locking plates have revolutionized the management of distal radius fractures and have resulted in good outcomes.1,2,3 The lower morbidity and technical ease of the volar approach to distal radius as compared to the dorsal approach have only added to the popularity of this implant. Despite being the overwhelming choice for fixing most volar fractures of the distal radius, it is difficult to stabilize and hold small, marginal volar rim fragments with these plates. The primary issue in fixation of volar rim fractures with volar locking plates is that these fractures are often beyond the watershed line – the placement of volar locking plates beyond this watershed line leads to flexor tendinopathy.4 There is often insufficient bone to hold even the smallest screw available. Attempts to buttress these fragments with volar locking plates can result in further fragmentation and comminution.5 The fixation of these fragments is of utmost importance as unfixed fractures can lead to articular incongruity, loss of structural support and carpal instability.6

Amongst volar rim fractures, the volar marginal fragment (anteromedial fragment of the lunate fossa) has been of particular interest. The volar rim of the lunate fossa prevents volar translation of carpus and provides attachment to the short radiolunate ligament, thus enhancing the stability of the radiocarpal joint.6,7 The need to address these fractures has also been highlighted by various authors leading to popularization of fragment specific fixation techniques.8,9,10 Over the years, several implants and fixation strategies have been described with particular reference to distal radius volar rim fractures-these include hook plates, distal volar locking plates, wire loops, buttress pin clamps and headless screws.9, 10, 11, 12, 13, 14, 15, 16, 17, 18 However, these implants or fixation strategies have broadly been described for large, volar marginal fragments greater than 4–5 mm in size. There are only a few techniques addressing small, volar marginal fragments and such fractures continue to pose a challenge to orthopedic surgeons.5,19,20 Most existing classifications do not identify volar rim fractures of the distal radius as a separate category. Volar distal radius fractures may be included in Type B3, C1, C2 and C3 categories of the AO/OTA classification.21 while this may serve well for standardizing the terminology for communication between surgeons, it does not advocate a surgical strategy based on the fracture configuration. We aim to describe a new technique which addresses the fixation small volar rim fractures through our experience with the same in 6 cases.

2. Material and methods

Between 2013 and 2017, the senior author (BG) operated upon 6 distal radius volar rim fractures with small-sized distal fragments. These patients were retrospectively reviewed with a minimum follow-up of 2 years. Patient demographic data, fracture type, mean volar fragment size and range of motion at final follow-up (flexion, extension, pronation, and supination) were recorded. Clinical assessment was made subjectively using patient rated wrist evaluation scores (PRWE) and objectively through grip strength evaluation compared to contralateral hand at final follow-up. A summary of the same is presented in Table 1. A description of the AIIMS hairpin technique employed in treating these fractures is described in the following subsection.

Table 1.

Summary of cases operated with AIIMS hairpin loop technique.

S.no. Age& Gender Mode of injury Follow up (Months) Size of volar fragment (mm) Injured hand (dominant vs non dominant) Classification (AO/OTA) Pronation/supination (at final follow-up) Flexion/Extension (at final follow-up) Grip strength in kg (% of uninjured side) (at final follow-up) PRWE score (at final follow-up) Postoperative complications
1 72/F FOOSH 66 3 Non dominant 2R3B3 70°/70° 45°/50° 6 (66) 16.5 None
2 38/M RTA 49 4 Dominant 2R3C1 80°/80° 80°/80° 38 (88) 4 None
3 41/M FOOSH 42 2 Dominant 2R3B3 75°/80° 55°/60° 28 (92) 2 None
4 67/M FOOSH 41 5 Dominant 2R3B3 70°/70° 40°/50° 9 (60) 13 None
5 31/M RTA 36 3 Dominant 2R3C1 80°/85° 75°/80° 34 (130) 7.5 None
6 56/F FOOSH 26 5 Non Dominant 2R3B3 60°/60° 40°/50° 4 (40) 31 CRPS 1, resolved in 3 months with conservative management
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M-Male, F-Female, RTA-road traffic accident, FOOSH- fall on outstretched hand, PRWE- Patient rated wrist evaluation, CRPS 1 – Complex Regional Pain syndrome 1.

2.1. Surgical technique

For the technique the patient is positioned supine with the limb which is to be operated extended on a side-table. General or regional anesthesia can be given. The surgery is usually performed with the tourniquet inflated. Longitudinal incision, 6–7 cm long, is given over the FCR tendon. After raising subcutaneous flaps, the fascia over the FCR tendon is then incised and a surgical plane developed between the FCR tendon (retracted ulnarly) and radial artery (retracted radially). This exposes the underlying FPL tendon which is also retracted ulnarly. The fascia overlying the pronator quadratus (PQ) muscle is then incised and the PQ muscle is detached from the anterolateral border of radius and the watershed line in an L-shaped fashion. The fracture fragments are delineated, and fragment edges are cleaned. The capsular and ligamentous attachments on the volar rim fractures are not disturbed. A hair pin loop is fashioned from a 0.8–1 mm thick Kirschner wire (K-wire) which is sharp at both ends. The two sharp distal ends of the K-wire are bent at an angle of 90–120° to create a ‘prong’ configuration – with each limb of the prong being 7–10 mm long. One or 2 such K-wires can be used for fixation of fractures. The prongs of the wire are manually inserted into the distal fragment and the fragments are levered out and manipulated using the loops to achieve reduction (Fig. 1). If the fragment is not wide enough to accommodate both the prongs, one prong is inserted in the fragment and the other in the intact bone nearby. PA tilt and lateral tilt views were used to ensure that the prongs are not intra articular.22 Once reduction is achieved, a volar locking plate is applied over the loops, with one of the distal locking screws going through each loop (Fig. 2). This step buttresses the reduction through the loop and prevents side to side movement of the loop. PQ is sutured back into place and wound closure is done in layers. A bulky dressing and short forearm Plaster of Paris (POP) splint is applied. For at least the initial 24 h after the surgery, the patient is advised to keep limb elevated and actively move fingers of the hand. The sutures are removed at 2 weeks postoperatively and the POP splint is kept in place for a total of 6 weeks. After removal of the splint, gentle range of motion (ROM) exercises are started. Three illustrative cases with preoperative and postoperative imaging and functional outcome are available for reference and better understanding of the technique (Fig. E- Content 1, Fig. E- Content 2, Fig. E- Content 3).

Fig. 1.

Fig. 1

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Intraoperative photograph demonstrating the insertion of the prongs of the hairpin loop, fashioned from a titanium K-wire, inserted into the distal fragment.

Fig. 2.

Fig. 2

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Fixation of the loop under the volar locking plate after reduction.

The technique described here is indicated in volar rim fractures of distal radius with or without volar marginal fragments which are not amenable to fixation by a conventional volar locking plate. Moreover, this technique can be used in cases where the volar fragment size is up to 2–3 mm. Our technique is mainly indicated in AO type 2R3B3 and selected cases of type 2R3C fractures. This technique addresses the volar rim shear and avulsion fractures associated in type C fractures and can be combined with dorsal plating, bone grafting etc. to address other components of type C injury as needed.

A few technical pearls which can help the surgeons adopt this technique better are:

  • 1)

    Preoperative CT scans with 3D reconstruction should be obtained and studied in all cases to understand and anticipate the size of the volar fragments, displacement and comminution.

  • 2)

    The attachment of capsule, volar radioscaphoid and radiolunate ligaments should be preserved as these are essential to maintain stability of the joint.

  • 3)

    As the volar rim fragments are small, repeated insertion of K-wire should be avoided to prevent further comminution and fragmentation.

  • 4)

    Titanium K-wire should be used as they can be bent and molded easily.

  • 5)

    The same K wire can be used first to drill a hole in the fragment to ease the insertion of wire prong.

  • 6)

    The prongs of the K-wire can be bent to varying lengths and varying degrees, depending on the thickness and size of the fragment.

3. Results

These patients included 2 females and 4 males with a mean age of 50.83 years (range: 31–72). The distribution of the fractures according to the AO/OTA classification21 was as follows: Type B3 = 4, Type C1 = 2. The mean follow-up duration was 43.3 months (range: 26–66). The mean size of the volar fragment was 3.66 mm (range: 2–5). The mean pronation and supination were 72.5 (60–80) and 74.2 (60–85). The main flexion and extension were 52.5 (40–75) and 58.3 (50–80) respectively. The mean grip strength was 19.8 kg (4–38) and it was mean 79.3% (40–130%) compared to uninjured side. The mean PRWE score was 12.3 (2–31). The clinical findings relevant to the injury as well as the performance with respect to various outcome measures are depicted in Table 1.

We did not face any intraoperative complications while executing this technique in any of the 6 cases, nor did we have to abandon this technique and resort to other maneuvers for fixation. One patient developed symptoms of Complex Regional Pain syndrome 1 (CRPS 1) in the postoperative period which resolved with conservative management at 3 months. None of the patients had any complications like flexor tendinopathy, neural injuries, carpal instability or radiocarpal arthritis until their final follow up. We did not perform implant removal in any of the patients.

4. Discussion

Due to the important attachments of joint capsule, radioscaphoid ligament and the long and short radiolunate ligaments, surgical stabilization of the volar rim fragments is important to maintain congruity and stability of the wrist joint.4,5Volar locking plates have been largely unsuccessful in addressing volar rim fracture fragments as these are located distal to or near the watershed line, whereas the recommendation is to not place the volar locking plates beyond 2 mm proximal to the watershed line.2,7Multiple fixation methods have evolved over the past two decades to address these volar rim fractures-especially, the lunate volar marginal fractures. Gorrens et al. noted their experience with 2.4 mm variable angle LCP volar rim plates in 10 patients. The implant used was a low-profile volar rim contouring plate. At a mean follow-up of 11 months they noted high satisfaction rates with good ROM and grip strength. The mean pre-injury and post-operative Quick DASH scores were similar. Although no complications pertaining to flexor tendinopathy were noted, the authors removed the implants at 4 months in all their cases. The authors, however, noted that this method of fixation was not suitable for small and comminuted fracture fragments.12Natio et al.utilized a distal volar locking plate or a volar rim plate in their study of 32 patients with volar distal marginal radius fractures. They noted good functional and pain scores and did not report any nerve or flexor tendon related complications. The mean size of the volar fragments in this study was 13.2 ± 3.9 mm.13

Fragment specific fixation was popularized by Medoff, in the form of radial styloid plates for radial styloid, volar plates for volar lip fragments, ulnar dorsal pin plates for dorsal ulnar fragments and wire forms (dorsal and buttress clips) for dorsal shear and die punch fractures. This has gained tremendous popularity in the past two decades – particularly for complex, intra-articular fractures.8,9,10The volar plate in this system is a distally curved plate which intends to support the volar lip.8 Though this is a definite improvement over the conventional volar plate, it may not be able to support small and multiple rim fragments. In such a scenario, the use of volar buttress pins is recommended. These involve drilling of a pilot hole with 1.75 mm drill bit and inserting the 2 legs of the pin in the fragment.11 These implants give good results but difficulty in their insertion has been described.16

The inability of conventional volar locking plates and volar rim plates to address the small volar rim fracture fragments led to the evolution of volar hook plates. Bakker et al. utilized the volar hook plate in 8 volar marginal rim fracture patients. They noted good functional outcomes and no surgical complications till the last follow-up. They also highlighted that the fracture must be at least 3–4 mm in size for use of their technique.14 The Trimed implant system (Trimed Orthopedics, Santa Clarita, CA) was used in a study on 26 patients with volar rim fractures - but according to the study, the fragment needed to be at least 4 mm in volar-to-dorsal dimension, 5 mm long and 7 mm wide to be amenable to this method of fixation. Over an average follow up of 9 months, no evidence of carpal subluxation or loss of reduction was noted. Four patients needed hardware removal due to irritation of flexor tendonswith the plates.15In our technique, even small fracture fragments, up to 2–3 mm in length, are amenable to fixation and none of our patients experienced any flexor tendon problems requiring implant removal. Obray et al. used volar hook plate extensions for dealing with distal radius fractures with volar rim fragments. The authors also described successful use of these implants in fragments sized smaller than 5 mm – none of the patients had flexor tendon related complications which was attributed to the low profile design and smooth surfaces of these plates.16However, it should be noted that these plates are fragment specific (volar lunate), whereas our technique can be used for both lunate and scaphoid facet rim fragments. A low profile, fragment-specific hook plate (Aptus Wrist Distal Radius System 2.5, Medartis AG, Switzerland) has also been used for such fractures. These plates have 1.5 mm self-drilling screws and can be used alone or with conventional volar plates. In a study on 23 patients, the implant demonstrated good radiological and functional results. An average 90° flexion arc, a 150° pronation and supination arc and 89% average grip strength compared to the opposite side was achieved.19

K-wires, loop wire techniques and headless screws have been scantly reported in literature for these fractures. A loop technique using tension band wiring principle for volar lunate fragment stabilization was described by Chin et al. with good results. However, it is specific to the volar lunate fragment and can be difficult to perform unless in expert hands.17Another implant which has been tried for the fixation of the volar lunate fragment is headless screws. Harness described the used of 2 mm headless screw fixation for volar lunate fragments along with volar locking plate. Good functional and pain scores were noted. However, again this would require large fragment size and run the risk of fragmentation.18Moore et al.20 described the use of thin K-wires for ‘spring wire’ fixation as a supplementation to volar plating. In this technique, thin K-wires were utilized for fixation of fragments perpendicular to the fracture line and engaging the dorsal metadiaphyseal area. The K-wires are then bent over the volar surface and fixed under the plate. Good range of motion and function was reported, and no patient required hardware removal for tendon irritation. However, in this technique, reduction must be achieved prior to K-wire insertion and drilling of thin K-wires into the far cortex can be a tedious job. More recently, a loop wiring technique with the use of soft wires and K-wires has also been described by Minato et al.5 However, this technique requires the tying of a loop from volar onto dorsal side so dorsal cortex must be intact which is not necessary with our technique. Also, a dorsal as well as a volar incision is required for this technique whereas our technique requires a single volar incision. Some surgeons also use sutures to secure fixation of these minute fragments but again the rigidity of such fixation is quite poor.

Specially designed implants such as hook extension plates and fragment-specific fixation plates are not readily available in developing countries. Since most of these implants need to be imported from North America and Europe, a limited inventory exists in such countries. Besides, the major part of the population in such countries is not covered by healthcare insurance policies and the cost of the implant is an out-of-the-pocket expense for the patient. With such factors commonly dictating the treatment meted out to patients, it is imperative to develop and report the use of techniques where comparable outcomes can be achieved at a more reasonable cost. The surgical technique we report uses low cost implants (K-wires) which are readily available in a hospital’s inventory. Our functional results have been comparable to previous studies with a mean pronation-supination arc of over 146.7°, mean flexion-extension arc of 110.8° and a mean grip strength of 79.3% compared to the opposite side with no major complications related to flexor tendinopathy, neural injury or arthritis.

5. Conclusions

Volar rim fractures have substantial anatomical significance in light of the important capsular and ligamentous attachments to the small, marginal fracture fragments having implications on wrist congruity and stability – and hence, merit the surgeon’s attention during fixation of distal radius fractures. Existing strategies described in literature are mostly for larger fragments (>5 mm size) and require additional implants which are not readily available in developing countries. The “AIIMS hairpin loop technique” offers an indigenous,cost-effective technique for fixation of these fracture fragments which can be easily adopted and used by surgeons in developing countries.

Declaration of competing interest

Dr. Bhavuk Garg, Dr. Tungish Bansal and Dr. Nishank Mehta declare that they have no conflict of interest.

Acknowledgements

None.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2020.10.049.

Contributor Information

Bhavuk Garg, Email: drbhavukgarg@gmail.com.

Tungish Bansal, Email: tungish10@gmail.com.

Nishank Mehta, Email: mehta.nishank@gmail.com.

Funding statement

There is no funding source for this publication/study.

Ethics approval

Approval was obtained from the ethics committee of All India Institute of Medical Sciences, New Delhi. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

E- Content 1.

E- Content 1

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A) Pre-operative PA and lateral view of the right wrist. (Case 5, Table 1) depicting ‘extreme’ volar rim fragments and a large dorsal fragments. The fracture can be classified as a AO 2R3C1 fracture. B) Preoperative computed tomography (CT) scan of the patient representing Sagittal and coronal images of the same patient. The volar and dorsal fragments can be appreciated clearly. C) Postoperative radiographs (AP and lateral view) at a follow up of 36 months. D) Clinical photographs depicting flexion and extension in postoperative follow up period. The right hand is the affected side.

E- Content 2.

E- Content 2

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A&B)PA view and lateral view of right wrist of the patient (Case 2, Table 1) depicting dorsal sublaxation of wrist with dorsal and volar fragments. C) A 3 D reconstruction Computed tomography image showing the volar fragment D) A Sagittal cut of CT scan showing the volar and dorsal fragments. E) PA view and F)Lateral view at final follow up. G&H) Image showing good flexion and Extension at final follow up. I&J) Images showing good pronation and supination at final followup.

E- Content 3.

E- Content 3

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A) Pre operative PA view and B) Lateral view of left wrist for the patient (case 6, Table 1) showing a very distal volar fragment. C) Intra operative image showing the distal fragment fixed with a hairpin loop D) Intra operative image showing the application of plate over the loop preventing its translation. E) Post operative PA and F) Lateral images at 6 weeks follow up showing generalized osteopenia suggestive of features of CRPS 1. G) PA and H)Lateral images at final followup.

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