Fractures of the distal radius are like mini-skirts, at least fixing them is. Fixation fashions seem to come full circle every few years.
Conservative management, pinning, external-fixation, dorsal and volar plating have all had their peaks of A-list celebrity fashion trends but have also spent years in between shunned on the sidelines as if they had committed some heinous leopard-print faux-pas at a gala dinner.
John Charnley’s fantastic book on the Closed Treatment of Common Fractures1 was originally published in 1950 and many of its tenets remain true. It was out-of-print for several years; made a comeback in 2003 in a Technicolour frock for eight glorious years but again went out of print last year.
The 100th anniversary of the K-wire went largely unnoticed in the Orthopaedic world (2009). There were no barge processions down the Thames but rarely has a small, simple device been so influential and helped so many patients but also created so much controversy. K-wires must surely be the Marmite of the Orthopaedic world; you either love them or hate them.
Volar plates seemed to arrive and be gold-standard treatment in less than a generation (of trainees) despite little evidence at the time for their use. Volar plates have of course been around for far longer but better plates and an understanding of the mechanics of the fractures, not to mention a comprehensive marketing campaign by the industry, led to their swift uptake. I hesitate to make the analogy with the “shell suit” from the 1980’s but it seemed that overnight they were everywhere you looked. Will volar plates turn out to be flammable too?
Multi-centre trials are surely the way forward and Derriford is one of a number of hospitals involved in DRIFT (Distal Radius Internal Fixation Trial). We eagerly await the results, at least for “Low Impact Wrist Fractures”. As far as fashions go, will the next generation of trainees be showing the current cohort how to “pin a wrist”?
There is little doubt that restoration of the joint surface, radial length, volar cortex and tilt is ideal but how good is “good enough”?
Our patients are not all the same and neither are their injuries. As ever we have to treat each patient individually, respecting his or her needs, wishes, and concerns. Combine this with clinical history, one’s own technical ability and preferences or interpretations from the literature and hey presto, you have your answer! “Simples”…
It seems we can still wear what we like on the catwalk, so don’t throw away your Versace Plate, your K(enzo)-wires or your Plaster of Prada just yet. The fashions will cycle and maybe the next Stella McCartney / Jorge Orbay is just around the corner.
Mr Alistair Phillips, Specialist Registrar, Trauma and Orthopaedics, Peninsula Deanery, UK
References
1. Chamley J. The Closed Treatment of Common Fractures. Edinburgh: E. & S. Livingstone Ltd, 1950.
2. Kirschner M. Ueber Nagelextension. Beiträge zur Klinischen Chirurgie 1909;64:266-279.
