Original Article Journal of Trauma & Orthopaedic Surgery |July-Sep 2022 |17(3):22-25

Novel 5-pin technique for distal radius fractures

Rajanish Ra1, Manikandan Thangarasu1, Arunlal Kpa1, Jim Thomas Malayila1, Hari shankara1

Abstract
Background: Distal radius fractures are one of the most common skeletal injuries encountered in orthopaedic department. The treatment options
include POP casting, volar/ dorsal plating, external fixation, and K-wiring. This study was conducted to assess the functional and radiological
outcome of a novel percutaneous 5-pin technique in distal radius fractures.
Materials and methods: This is a retro-prospective observational study from January 2018 to June 2020. Novel percutaneous 5-pin technique in a
sequential configuration following a closed reduction was performed, followed by physiotherapy, and functional outcome was assessed at 3&6 months
following K-wire removal using Cooney’s modification of Green and Obrien scoring and evaluated for functional status, pin loosening, tendon
impalement, and nerve injury. Radiological outcome was assessed at 6 months using Sarmiento scoring system (Modified lidstorm criteria)
Results: All 31 patients were assessed. The mean age of patients was 58.45 years, 61.3% was females, with domestic low energy falls being most
common mode of injury. All patients were followed up for 6 months post-K-wire removal and 51.6%of patients had excellent outcome, 25.8% had good
outcomes and 22.6% of patients had fair outcome with a functional range of supination and pronation movements. All fracture unions were satisfactory
and 3 patients (9.7%) developed CRPS, 1 patient developed pin loosening. None of them developed tendon impalement or nerve injuries.
Conclusion: The novel percutaneous 5-pin technique includes two additional ulnoradial wires which provide superior rotational stability and avoid
the chance of late collapse and maintain radial height, unlike conventional K-wire techniques. Thus, avoiding the need for more invasive techniques
and allows early mobilization of wrist and fingers preventing stiffness, resulting in an excellent outcome.
Keywords: Distal radius fractures, Green and Obrien scoring, K-wire, Novel 5 pin technique

Introduction technique at Baby memorial hospital - meeting the inclusion

The distal radius fractures are one of the most common skeletal and exclusion criteria in the mentioned time frame. The time
injuries encountered in orthopaedic departments. The history frame was 2018 -2020. This is a prospective Observational
of fractures of distal radius reflects the evolution of the study. Fisher’s exact test was used when appropriate for
understanding of many conditions in orthopaedic trauma. analysing categorial variables. Statical significance was defined
Reported lifetime risks of distal radius fractures from the age of as P < 0.05.
50 onward range from 12% to 52.7% for women and 2.4% to Calculation:
6.2% for men. Percutaneous pinning of fractures of distal end Single Proportion - Absolute Precision
of Radius was first suggested in early 20th century and many Expected Proportion 0.96 Precision (%) 7
different constructs of pins have been described. This study is Desired confidence level (1- alpha) % 95
intended to assess the results of fracture distal end of radius Required sample size 30
treated with closed reduction and percutaneous pinning – five
pin technique. It is a minimally invasive and economically
cheaper technique compared to other methods and available
studies shows good outcomes.
Where, p - Expected proportion; d – Precision; Z1-α/2 - Two-
sided Z value for corresponding α (1.96).
Material and Methods Selection criteria: Inclusion criteria a) Fracture distal end of
All patients more than 18 years of age and less than 90 years of radius b) Age greater than 18 years to 90 years c) Patients
age with fracture distal end of radius treated by five pin willing for regular follow up at 3 months,6 months d) Patients
fit for surgery e) Patient willing for treatment and given written
¹Department of Orthopaedics, Baby memorial hospital, Calicut, Kerala, India
informed consent Exclusion criteria a) Patients with open
physis b) Compound injuries c) Patients with distal ulnar shaft
Address for correspondence: fracture (23 A1) and Volar/Dorsal Barton fractures (23 B3) d)
Dr. Manikandan Thangarasu, Smokers.
Department of Orthopaedics, Baby memorial hospital, Calicut, Kerala, India Scoring systems used were for functional status – Cooney
E-mail: tmani156@gmail.com modification of Green and O’Brien’s score at 3 and 6 months &
Radiological scoring - Sarmiento scoring system (Modified
Submitted: 10 May 2022; Reviewed: 20 May 2022; Accepted: 20 June 2022; Published: 10 July 2022

DOI:10.13107/jto.2022.v17i3.440
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License https://creativecommons.org/licenses/by-nc-sa/4.0/ ,
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Ra R et al www.jtojournal.com

Figure 2: C-Arm images showing second k-wire from ulnar corner in AP and lateral views

Closed Reduction and Standardised Percutaneous 5-Pin

Fixation - PN Vasudevan, BM Lohith, 2018.”
Figure 1: C-Arm images showing first k-wire from radial styloid in AP and lateral views
Fourth k-wire – (Distal radio-ulnar wire): k-wire inserted from
Lidstorm Criteria) at 6 months. distal fragment of the radius to the ulna (through DRUJ)
parallel to the wrist joint line at subchondral level in fully
Surgical method supinated position of forearm, all the while maintaining the
Under general/ regional anaesthesia, Closed manipulation of reduction with traction. This k-wires maintains radial length.
the fracture is done under traction and under C arm guidance, In unfractured forearms, the radiographically measured tilt
reduction of fracture is confirmed. The traction is maintained was significantly affected by rotation. Palmar tilt increased
from start to end of the procedure thus preventing any with supination and decreased with pronation. Sarmiento et
telescoping of fracture fragments. All rotations during the al. advocated immobilization in a position of supination to
procedure are ensured to be done at the shoulder joint thus decrease the deforming force of the brachioradialis, which may
eliminating the risk of supination and pronation at the fracture cause loss of reduction.
site. Fifth k-wire – (Proximal radio-ulnar wire): It is the most
2mm K-wire used for fixation important of all, passing from the radial shaft to ulna in full
First k-wire – (Radial styloid wire): It stabilises the radial supinated position. It controls the proximal radius and along
column. Adequate care must be taken while inserting the radial with the distal radio-ulnar wire and intact ulna works like an
styloid wire to avoid injury to the superficial radial nerve. external fixator sparing the wrist.
Second k-wire – (Ulnar corner wire): It goes from the dorso- All puckering of skin caused by the k wire entry were relieved
ulnar corner of distal radius to the lateral-volar cortex of with small stab incisions to prevent any chance of skin
proximal radius. It stabilises the intermediate column. necrosis/infection at the pin site.
Third k-wire – (Lister’s tubercle wire): Adequate care must be ⁴Jensen et al., “The Effect of Forearm Rotation on
taken not to injure the tendon of extensor pollicis longus Radiographic Measurements of the Wrist.”
(EPL) by staying radial to the tubercle to engage the volar ⁵Sarmiento et al., “Colles’ Fractures. Functional Bracing in
cortex of the proximal radius. This wire prevents dorsal tilt of Supination.”
the distal fragment . ⁶Vasudevan and Lohith, “Management of Distal Radius
¹Glanvill et al., “Superficial Radial Nerve Injury during Fractures – A New Concept of Closed Reduction and
Standard K-Wire Fixation of Uncomplicated Distal Radial Standardised Percutaneous 5-Pin Fixation.”
Fractures.”
²Yammine, Rafi, and Furhad, “Tendon and Neurovascular Postoperative care
Injuries of the Distal Radius after Pinning with Kirschner Postoperative splinting is performed with a removable wrist
Wires.” brace in functional position of the wrist. The limb is kept
³“Management of Distal Radius Fractures – A New Concept of elevated. Patient is encouraged to move his fingers from first
post-operative day. Antibiotics and analgesics continued as per
protocol. On postoperative day 2 check dressing done and
condition of wound noted. Check X-ray is taken in both
anteroposterior and lateral views. Patients are encouraged to
remove the splint themselves for 15 minutes each at least six

Figure 4: C--Arm images showing distal radioulnar k-wire (4th wire) in supination AP and
Figure 3: C-Arm images showing third k-wire from lister’s tubercle in AP view lateral views

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 Ra R et al www.jtojournal.com
between age of the patient and mode of injury. In younger age
group is mainly resulted from high energy falls or road traffic
accidents . P value is significant. (P value - <0.001)
Functional outcome: Mean functional score mean at 3 months
was 73.55 +/- 10.26 and 6 months it was 87.42 +/- 9.12. In this
study, 51.6% patients had excellent functional status, 25.8%
had good functional status and 22.6% patients had fair
Figure 5: C-Arm images showing proximal radioulnar k-wire (5th wire) in supination AP and functional status at the end of 6 months. This correlates with
lateral views
Adawy El et al study showing, total of 36 (51.4%) cases got
excellent score, 18 (25.7%) cases were good, 12 (17.1%) cases
were fair, and four (5.7%) cases were poor at 18 months follow
up. Bhasme et al study says in patients treated by Five pin
technique, the scores were found to be excellent or good in
most cases (lower scores) and comparable to volar plate
fixation as found in other studies. In our study Functional
outcomes did not depend on Patient’s age, sex, mode of injury.
P value of above-stated parameters were not significant. In our
study, outcome depended only on fracture t y pes.
Figure 5: clinical image showing final position of all k-wires Comminuted intra articular fractures results in poorer
outcomes compared to extra articular fractures. P-Value of this
times a day and to mobilise the wrist, fingers, elbow and
association was significant. (P- value = 0.014). It’s evident that
shoulder within their tolerable limits. The patient is discharged
type of the fracture is a determinant of functional outcome .
on post-operative day 2 with Oral analgesics.
Radiological outcomes at 6 months: In this study, 13 (41.9%)
The wrist brace is to be continued for a period of six weeks.
patients had excellent radiological outcome, 11 (35.5%) had
good and 7 (22.6%) had fair radiological outcome at 6 months.
Follow up Radiological outcomes did not depend on Patient’s age, sex or
All patients had post op follow up visits on, follow-up at 2 mode of injury. P value of above-stated associations were not
weeks for Wound inspection and dressing, follow up at 4 weeks significant. It depended only on Fracture types. Comminuted
for radio-ulnar k-wires removal (4th and 5th) after check x-ray, intra articular fractures results in poorer outcomes compared
follow-up at 6 weeks for removal of remaining 3 K-wires to extra articular fractures. P Value of this association was
following check x-ray and assessing fracture union. Patient data significant. (P-value 0.016). It’s evident that type of the fracture
collected at 3 months, 6 months. is a single most important determinant of radiological
Patient is asked to start supination and pronation exercises outcome. Type C fractures treated by percutaneous pinning
after the removal of radioulnar k wires by the end of 4 weeks. with 5-pin technique gives good to fair radiological outcomes
After removal of K wires at 6 weeks, wrist ROM exercises and compared to more excellent results given in Type A and B
physiotherapy are started. fracture types.
Complications: In this study, 87.1% patients had no
Discussion complications, 9.7% patients had CRPS and 3.2% patient had
Our study comprised thirty-one patients with distal radius Pin loosening. A systematic review study by Franceschi et al
fracture who were treated with closed reduction and k-wire ⁷Nordvall, Glanberg-Persson, and Lysholm, “Are Distal Radius
fixation by Five pin technique. Overall final outcome was Fractures Due to Fragility or to Falls?”
assessed in terms of regaining the lost wrist function using ⁸Nellans, Kowalski, and Chung, “The Epidemiology of Distal
Cooney modification of Green and Obrien’s score and Radius Fractures.”
Sarmiento score for radiological outcomes. ⁹Meena et al., “Fractures of Distal Radius.”
This study consists of patients from 18 years of age to 88 years ¹⁰Cowie, Anakwe, and McQueen, “Factors Associated with
of age. Mean age of the patient was 58.45+/-15.03. This reflects One-Year Outcome after Distal Radial Fracture Treatment.”
that fracture distal end of radius is a fragility fracture occurs ¹¹Chavhan et al., “Functional and Radiological Outcome in
frequently in osteoporosis bone. Fracture was more common Distal Radius Fractures Treated with Locking Compression
in female gender (61.3%). In a study conducted by Kate W et al Plate.”
says, the women in this study were approximately 4.88 times says, complication rate is higher in K-wire group. CRPS in 1.7%
more likely than men to obtain a distal forearm fracture . 61.3% of the patients. In our study 9.7% patients developed CRPS.
patients had domestic falls, 29% patients were injured in road Pawan Kumar et al study shows Reflex sympathetic dystrophy
traffic accidents and 9.7% patients were injured in fall from (CRPS) developed in 3 (10%) patients which correlates with
height. This concludes most common cause of the fracture is this study and pin-tract infection was observed in 4 (15%)
slip and fall or low energy falls. there is a significant association cases which was controlled with short-term antibiotics. We had
6
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3.2% pin tract infection. 5 pin technique Study by Vasudevan et allows early mobilization as we use removable wrist splint
al shows, six patients (1.2%) experienced numbness and mild postoperatively. Wrist range of motion exercises started on first
neuralgia along the sensory branch of the radial nerve which postoperative day, this prevents stiffness of fingers, wrist and
resolved completely after removal of the wires and local CRPS. It has shorter operating time compared to open
massage. In our study, none of the patients experienced reduction and Plating. Minimal scaring compared to open
numbness or neuralgia along superficial radial nerve. reduction and plating and no scar related complications.
Cheaper means of fixation compared to volar locking plates.
Conclusion Re-operation rate is zero compared to plating where implants
5-pin technique is a minimally invasive and effective technique need to be removed after union in young patients. Fracture
in treating extra articular and displaced partial intra articular biology (periosteal blood supply and fracture hematoma) is
fractures of distal radius. It gives functional outcomes better undisturbed in closed reduction where it is violated in open
than conventional k-wire constructs (2 pins or 3 pins), as reduction.
regular k-wire constructs are always supported by plaster. It

Declaration of patient consent : The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given the consent for his/ her images and other clinical
information to be reported in the journal. The patient understands that his/ her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be
guaranteed.
Conflict of interest : Nil Source of support : None

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How to Cite this Article

Conflict of Interest: NIL Ra R, Ta M, Kpa A, Malayila JT, shankara H. Novel 5-pin technique for distal
Source of Support: NIL radius fractures. Journal of Trauma and Orthopaedic Surgery July-Sep
2022;17(3): 22-25.

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