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ORIGINAL ARTICLE

Fracture Distal End Radius, Evaluation Of Cosmetic And Functional Outcome Following Various Methods Of Treatment

 Amit Kumar Srivastava*, Santosh Kumar Jena*,   Srivastava D C** , Varma AN***            

*Senior  resident, Dept. of Orthopaedics,UCMS/GTB Hospital, Delhi
***Prof & Head, Dept. Of Orthopaedics, M.L.N.Medical College, Allahabad.
**Lecturer, Dept. Of Orthopaedics, M.L.N.Medical College, Allahabad, India

Address for Correspondence:  

Dr. Santosh Kumar Jena
Dept. Of Orthopaedics, UCMS/GTB Hospital, Delhi,
Dilshad garden, Delhi-95, India
E-mail : drsanjena@gmail.com
 

Abstract:

95 Cases of Colleís fracture graded I-VIII (Frykmannís 1967), were treated by various modalities according to random allotment of treatment modality. The modalities were closed reduction and plaster in 25 cases (Group-A), functional cast brace in full supination in 25 cases (Group-B), pin plaster after reduction in 25 cases (Group-C), and uniplanar ligamentotaxis in 20 cases (Group-D).

Results (Using Scheckís criteria -1962) in group A were excellent in 48% cases and good in 52% cases, in (Group-B), excellent in 84% cases and good in 16% cases, in group C 92% had excellent and 8% had good outcome, and in Group D 60.00% had excellent 30.00% had good and 10.00% had poor outcome.

Overall results were excellent in 71% cases, good in 26.50% cases, and poor in 2.50% cases. The poor and non-excellent results had been noted in those cases in which the volar tilt of distal radial articular surface could not be maintained either because of comminution, loss of reduction or improper case selection.

J.Orthopaedics 2008;5(3)e6

Keywords:
Colleís fracture, ligamentotaxis, functional cast brace

Introduction:

Fractures of distal radius continue to be one of the most common skeletal injuries treated by orthopedic or trauma surgeons. These injuries account for one sixth of all fractures seen and treated in emergency rooms 1, 2&3.

The rapid expansion of knowledge regarding the functional anatomy of the hand and wrist, the recognition by treating physicians of the ever increasing functional demands of senior citizens, and improved methodologies of achieving and maintaining anatomic restoration of these fracture have generated a renewed interest in addressing these fractures in a more precise manner.

However, several investigations of factors affecting the functional outcome of fractures of the distal radius have more convincingly shown that the patients function more effectively when anatomy is restored 4&5. Instability of radio carpal articulation must also be considered in the assessment and management of some unstable fractures of distal radius 6.

 Reversal of normal palmer (volar) tilt of the distal radius has been shown to have exceedingly deleterious effect. Short and coworkers 7 noted a marked transfer of load onto ulna with progressive dorsal angular deformity. Pain, decreased grip strength and a midcarpal instability pattern as seen on lateral radiographs are hallmark of the dynamic intercarpal instability 8, 9&10.

 Clinicians have begun to recognize that fractures of the distal radius may involve patterns other than the classic extraarticular fractures described by Colles11 or Smith12.Infact recent system of classification have focused, in part, on the mechanism of injury and indeed reflect an expanded understanding of the various patterns of fracture.    

In this present series, an attempt has been made to treat fracture distal radius, both extraarticular as well as intraarticular type by nonoperative and operative approach.         

 We tried to evaluate functional and cosmetic outcome using Scheckís scoring criteria -1962(TABLE-2). We used Frykmannís13 classification (1967) to classify the fractures in our study (TABLE-1).

Table-I (Frykmanís Classification-1967)     
 

Fractures

 

Distal Ulna Fracture Absent

Distal Ulna Fracture Present

Extra-Articular

I

Ii

Intra-Articular

  I-Radiocarpal Joint

 Ii-Radioulnr Joint

Iii-Radiocarpal  And          

    Radio Ulnar Joints

 

Iii

V

Vii

 

Iv

Vi

Viii

 Results had been assessed using Scheckís scoring system in all groups.

Material and Methods :

95 Cases of distal radius fracture with grade I-VIII (Frykmannís classification1967), from 2004-2007 were treated by various modalities. The modalities were closed reduction and plaster in 25 cases (Group-A), functional cast brace in full supination in 25 cases (Group-B), pin plaster after reduction in 25 cases (Group-C), and ligamentotaxis with uniplanar forearm distractor in 20 cases (Group-D). 

Clinical assessment of pain, deformity (widening of wrist & prominence of ulnar styloid), loss of movements (dorsiflexion, volarflexion, radial & ulnar deviation at wrist and supination-pronation at forearm), and grip strength of affected and normal side was done for comparison. 

Preoperative anteroposterior and lateral radiograph of affected and normal wrist was taken. Radiological assessment of radial angle, radial length, dorsal angle, and dorsal shift of affected and normal side was done.

Table -2(Scheckís Scoring Criteria-1962)

1-Subjective Evaluation
 

GRADE

DESCRIPTION

POINTS

EXCELLENT

No pain, weakness or limitation of movement, no restriction in activity

0

GOOD

Occasional discomfort after activity, slight limitation of movement, minor restriction in activity

1

POOR

Deformity, pain, weakness and limitation of movement, canít continued former occupation

2

2-Visual Examination Of Wrist

GRADE

DESCRIPTION

POINTS

EXCELLENT

Normal appearance

0

GOOD

Just notable deformity due to broadening of wrist & prominence of ulnar styloid

1

POOR

Obvious deformity

2

3-Wrist Finger Motion, Pronation/Supination

GRADE

DESCRIPTION

POINTS

EXCELLENT

0-15 loss of movement

0

GOOD

16-30

1

POOR

>30

2

4-Grip Strength In % To Normal Side

GRADE

DESCRIPTION

POINTS

EXCELLENT

100

0

GOOD

99-85

1

POOR

<85

2

5a-Radial Angle (In Degree)

GRADE

DESCRIPTION

POINTS

EXCELLENT

22-18

0

GOOD

17-10

1

POOR

<10

2

5b-Dorsal Angle (In Degree)

GRADE

DESCRIPTION

POINTS

EXCELLENT

11-06

0

GOOD

06-00

1

POOR

negative

2

5C-RADIAL LENGTH IN Mm

GRADE

DESCRIPTION

POINTS

EXCELLENT

10-13

0

GOOD

5-9

1

POOR

<5

2

Final radiological assessment (derived from sum of 5A; 5B, &5C)

       Excellent    0-1 points

       Good          2-3points

       Poor          >3 points

Overall Functional Results

          Excellent   0-3 points

        Good         4-8 points

         Poor        >8 points
 

Method Of Treatment And Postopreative Management

As described earlier we had made four groups according to randomized treatment modality. All cases underwent closed reduction after giving appropriate anesthesia (brachial block in most cases) and later on contained by different methods as described below.

GROUP-A: - Closed reduction was done, first by giving traction and counter traction and disimpaction was done by hyperdorsiflexion followed by volar flexion and ulnar deviation in pronation. Below elbow slab/cast applied and check radiograph get done.

GROUP-B: - Closed reduction was done as described earlier and below elbow pop slab applied initially and as the fracture became sticky (7-14 days) functional cast bracing with supracondylar extension was done in supination. Dorsal extent was distal to metatarsals head (knuckles) while volar extent was shortened to flexion crease of wrist so that patient can move his wrist in volar direction only. At the same time dorsoradial extent at 1st CMC and MCP joints increased to facilitate ulnar deviation but radial deviation was completely restricted . 

 GROUP-C: - After achieving reduction by closed method, two 3.5mm Schanz pin was inserted in forearm 2.5-3.0 cm proximal to fracture site from radial aspect, while two 2.0 mm Schanz pin was inserted in 2nd &3 rd metacarpal shaft from radial aspect and all the four pins were incorporated in plaster with traction on and reduction maintained, in pronation, volar flexion and ulnar deviation (fig.-1).
 

 (Fig.-1). Pin & plaster method

GROUP-D: - After adequate anesthesia and part preparation, two 3.5mm Schanz pin was inserted in forearm 2.5-3.0 cm proximal to fracture site from dorsal aspect, while two 2.0 mm Schanz pin was inserted in 2nd metacarpal shaft from radial aspect and all the four pins were incorporated in pin holes of uniplanar distractor after giving traction and attainment of adequate reduction and reduction maintained, in pronation, volar flexion and ulnar deviation by adjusting the distractor with the help of wrench (fig.-2).
 


 


 

(Fig.-2). Preop, immediate postop and 6th week postop treated with uniplanar distractor.
 

Postoperatively all the cases were promoted for active movements of fingers as early as possible. Elbow and shoulder movement training was given. Patients of group C&D were given oral antibiotics for 5-7 days. Patients of group D were directed how to do pin site care. Immediate postoperative, 3rd week, 6th week and 6th month radiographs were taken at follow up. Radiological and clinical parameters were assessed at each follow up. At 6th postop week cast, functional cast brace, pin-plaster and distractor were removed in most of the cases. Hot saline fomentation and active movements was advised after removal of cast or other fixation devices.

Results :

Out of 95 cases, 52 were male and 43 were female. Average age of patients was 45.3 years Ī7.5 years ranging from 18-83 years. 49 were having right sided and 46 were left sided fracture. According to Frykmannís13 classification (1967), 45 cases were of grade I, 33 of grade II, 12 of grade III, 3 of grade IV, 2 of grade VI and. Mode of injury in al the cases was fall on the outstretched hand. All the cases treated in our study presented to us within 1-8 days with mean of 1.80 days.              

GROUP-A: 25 CASES

Functional result: excellent in12 (48%) and good in13 (52%)

Radiological results: excellent in 0, good in 13(52%) and poor in 12(48%) cases

Mean differences in values of various parameters at 6th week postop on affected side and normal side parameters

 Radial length-4.44mmwith SD-4.421 (normal-11.88, SD-1.36)

 Radial angle-8.44 degree with SD-5.151 (normal-23.37, SD -2.553)

 Volar tilt-23.63 with SD- 14.872 degree (normal- [-7.0], SD-7.004) 

In 3 cases > 30 degrees of restriction of motion occurred, in 10 cases 15-30 degrees, in12 cases it was <15 degrees.5 cases were having pain during heavy work. Grip strength was between 80-100%in all cases. Mild to moderate deformity was present in 23 cases with gross deformity in 2 cases. 

GROUP-B: 25 CASES

Functional results- excellent in 21(84%) cases, good in 4(16%), poor in none

Radiological results- excellent in 20(80%) cases, good in 5(20%), poor in none          Mean differences in values of various parameters at 6th week postop on affected side and normal side parameters                                                                             

 Radial length-1.52mm withSD-0.714 (normal 11.88, SD-1.36)

 Radial angle-2.98degree with SD -4.876(normal-23.37, SD-2.553)

 Volar tilt- 9.88degree with SD -7.65(normal-[-7], SD-7.04)

In all cases, range of motion at wrist and forearm was nearly full and painless with <10 degree of terminal restriction. Grip strength was >95% in comparison to normal side in all cases. 1 case has shown slight widening of wrist. 1case had Sudeckís Osteodystrophy. 

GROUP-C: 25 CASES

 Functional results-excellent in 23(92%) cases, good in 2(8%), poor in none           

 Radiological results- excellent-22 (88%) cases, good in 3(12%), poor in none

 Mean differences in values of various parameters at 6th week postop on affected side and normal side parameters

  Radial length-1.32mm withSD-2.260 (normal 12.08, SD-1.824)

  Radial angle-2.68degreewith SD -5.037(normal-24.96, SD-5.713)

  Volar tilt- 8.28degree with SD -7.895(normal-9.28, SD-8.028) 

After a period of follow up the appearance of wrist was identical to normal in 23 cases. 2 cases were having slight widening. 23 cases were having range of motion with <10 degrees restriction while 2 was having > 20 degree of restriction of supination.Grip strength was >95% of normal.  

GROUP-D: 20 CASES

Functional results-excellent in 12(60.00%) cases, good in 6(30.00%), poor in 2 (10.00%)           

 Radiological results- excellent-60.0%cases, good in 30%, poor in 10%.

Mean differences in values of various parameters at 6th week postop on affected side and normal side parameters

  Radial length-1.48mm withSD-2.260 (normal 12.08, SD-1.824)

  Radial angle-3.86degreewith SD -5.037(normal-24.96, SD-5.713)

  Volar tilt- 16.28degree with SD -7.895(normal-9.28, SD-8.028) 

After a period of follow up the appearance of wrist was identical to normal in14 cases. 4 cases were having slight widening and 2 had obvious widening with ulnar styloid prominence (these cases had gross displacement of reduction at 3rd follow up week, we removed the distractor, did osteoclasis and applied cast). 14 cases were having range of motion with <10 degrees restriction while 4 were having 10-20 degree of restriction of supination and 2 was having restriction more than 20 degrees in supination and radial deviation. Grip strength was >95% of normal in 18 cases while 2 had 85-95% of grip. 1 case had Sudeckís Osteodystrophy.

Discussion :

There are a lot of controversies whether anatomical reduction of distal radial fractures is essential but there is no controversy that maintaining satisfactory reduction is often difficult by simple plaster cast. Bacorn and Kurtzke14 (1953) analyzed the results of 2000 Colleís fractures and they observed that the poor functional results were directly related to the degree of radiological deformity secondary to loss of position at the fracture site in the plaster cast. Frykman13 (1967) also observed the same in his study.

There is no controversy that maintaining satisfactory reduction in Colleís fracture treated by simple method is often difficult. Bacorn and Kurtzke14 (1953) and Frykman (1967) both reported that lasting disability is greater in patients with severe residual deformity. Other workers like Cassebaum (1950) 15, Lidstrom (1959) 16, Sarmiento17 et al (1975&1980), Stewart et al (1984) 5 found a correlation between the anatomical and functional results at three months but Stewart et al (1984) 5 reported that this correlelation was lost by 6 months.

 This finding of Stewart et al (1984) is confirmed in the present prospective study, in which it was found that in spite of less satisfactory radio graphical results (excellent 59.65%, good 26.81%, poor 13.54%), the functional (clinical) result was (excellent 76.66%, good25.83 %, poor 2.5%) with one having poor functional results using the Scheckís (1962) grading system or the evaluation of end results.

 These Scheckís systems includes all the parameters and details of subjective, objective and radiological finding and have graded them with appropriate scoring system by which it becomes very easy to obtain the functional and radiological results. The same basis has been used for the comparison of the functional and radiological results obtained in various other series.

This and all other assessments based on radiological and objective measurements following distal fracture of the radius have several limitations.

 An accurate radiological measurement depends on comparable view. A little change in the angulations of the x-ray beam or positioning of the patients considerably alters bony relationships. Measurements of the range of motion of the wrist joint were considerably between examiners and in the same patients at different times of the day, depending on previous activity.

 Indeed   the range of motion of the wrist joint does not necessarily denote function. A stiff painless wrist is for more functional than a painful mobile one. Assessment of the function is the best indication of the final result and is of major concern to the patient.                         

 In the recent years, achieving and maintaining anatomical reduction to improve ultimate function have been widely advocated, particularly for intraarticular fractures. In spite of this, initial poor anatomical alignment and secondary displacement have been frequently accepted with distal radial fractures.

Anatomical reduction is not difficult to obtain, but as a result of comminution of distal end of radius, the fracture is unstable in reduced position. Garland and Warley18 (1951) reviewing the final position of Colleís fracture treated with reduction and below elbow plaster immobilization, noted that in 60% cases union had occurred in a position, typical of a fresh unreduced Colle's fracture. Mal alignment of the radio carpal and distal radio-ulnar joints is inevitable. Cooney et al19 (1979) reported that post-traumatic arthritis was the second most common complication of Colleís fracture leading to pain, weakness of grip and limitation of motion. They attributed this to malaignment of the sigmoid notch of the distal end of the radius with the ulnar head because of radial deviation and dorsiflexion of the distal fragment or due to inadequate restoration of length to ensure the normal radio-ulnar relationship.

 In present series, radiological results in comparison to each others are as given in the table:

Radiological results

 

Closed reduction & cast (%)

Functional cast brace

(%)

Pin plaster technique

(%)

Ligamentotaxis

(%)

Excellent

0

80.00

88.00

60

Good

52.00

20.00

12.00

30

Poor

48.00

-

-

10

Over all functional result in different series are:

Functional results i

Closed reduction & cast (%)

Functional cast brace

(%)

Pin plaster technique

(%)

Ligamentotaxis

(%)

Excellent

48.00

84.00

92.00

60

Good

52.00

16.00

8.00

30

Poor

-

-

-

10

Pin plaster and ligamentotaxis as a method for achieving the reduction and maintaining it, eliminating the possibility of secondary displacement and provides better radiological and functional results compared to conventional cast immobilization method.

Though the number of patients in the present series is small for satisfactory statistical analysis, but it appears that initially in the first week of fracture treatment, there was significant association of better function with improved anatomical position. But as the time advances, this correlation gradually disappears and at one year, function is almost normal.

The better functional and radiological results in the present study were due to, avoidance of secondary displacement and early finger exercises due to rigid immobilization especially pin plaster & ligamentotaxis by distractor thereby eliminating complications of conventional plaster technique which are the major advantages of pin plaster & ligamentotaxis.

Conclusion:

Based on clinical and radiological findings of fifty-five cases treated by various methods, the following conclusion can be drawn:

1.      It is easy to obtain reduction but difficult to maintain it by simple plaster cast

2.      Union in displaced position leads to poor functional and cosmetic results.

3.      Techniques used in-group B, C, &D is easy, requires minimum skill and can be done easily in minor OT under brachial block.

4.      There is no secondary displacement in-group C&D like in A&B.

5.      Closed reduction and plaster cast as well as functional cast brace should be used in stable non-comminuted extra-articular fractures.

6.      Pin plaster & ligamentotaxis by distractor should be used in unstable, comminuted and intra-articular fractures. Ligamentotaxis has the advantage that it can be used in cases where skin is having abrasions or lacerations, where pin-plaster is not possible.

7.      Overall results were excellent in 71.00% cases, good in 26.50% cases, and poor in 2.50% cases. The poor and non-excellent results had been noted in those cases in which the volar tilt of distal radial articular surface couldnít be maintained either because of comminution, loss of reduction or improper case selection.

Reference :

1. Golden GN: Treatments and programs of Collies fracture. Lancet 1; 511-14, 1963

2. Hollingsworth R, Morris J: The importance of the ulnar side of the wrist in fractures of distal radius. Injury 7: 263-66, 1976
3. Linschied RL: kinematic consideration of the wrist. Clin Orthop 202: 27-39, 1986

4. McQueen M, Casper J: Does the anatomic results affect the final outcome? JBJS 70B: 649, 1988.

5. Stewart HD, Innes AR, and Burke FD: The hand complications of Colleís fractures J Hand Surg 10B: 103-06, 1985.

6. Palmer AK: The DRUJ: anatomy, biomechanics, and triangular fibro cartilage complex abnormalities, hand clinic 3:31-40, 1987
7. Short WH, Palmer AK, Werner FW, et al: -A biomechanical study of distal radial fractures. J hand Surg 12a: 529-34, 1987

8. Fernandez DL: Avant-Bras segment distal. In Muller ME, nazarian s, Koch P: classification of AO des fractures des os longs. Berlin, Springer-Verlag, 1987: 106-15

9. Jupiter JP, Lipton HA: Operative treatment of intraarticular fractures of distal radius: the upper extremity pilon fracture. Clin Orthop, under publication at that time

10. Taliesink TM, Watson HK: Midcarpal instability caused by malunited fractures of distal radius. J hand Surg 9a: 350-57, 1984
11. Colleís A: On the fracture of carpal extremity of the radius. Edinburgh Med surg J10: 182-86, 1814.

12. Smith RW: Treatise on fracture in vicinity of joints and certain form of accidental and congenital dislocations. Dublin, Hodges & Smity, 1854

13. Frykman GK: - Fractures of the distal radius including sequelae ----shoulder hand finger syndrome. Disturbance in DRUJ and impairment of nerve function: a clinical and experimental study. Acta Orthop Scand Suppl. 108: 1-155, 1967

14. Bacon RW & Kurtzke JF: -Colleís fracture, a study of two thousand cases from the Newyork state workmanís compensation board. JBJS, 35-A: 3; 643-58.

15. Cassebaum WH: Colleís fracture, a study of end results. JAMA, 143:963.

16. Lidstram A: Fractures of the distal end of the radius: a clinical and statistical study of end results. Acta Orthop Scand Suppl-41

17. Sarmiento A, Pratt GW, berry mc et al: -Colleís fracture, functional cast bracing in supination. JBJS, 57-A: 311

18. Gartland JJ, Werley et al: -Evaluation of healed Colleís fractures. JBJS, 33-A: 895

19. Cooney WO, Linscheid RL, Dobyn SJH: - External pin fixation for unstable Colleís fractures. JBJS. 6-A: 6; 840-45.
 

This is a peer reviewed paper 

Please cite as :  Amit Kumar Srivastava : Fracture Distal End Radius, Evaluation Of Cosmetic And Functional Outcome Following Various Methods Of Treatment

J.Orthopaedics 2008;5(3)e5

URL: http://www.jortho.org/2008/5/3/e6

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