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PubMed1991

[Results and analysis of poor results after conservative therapy of distal radius fracture].

The authors report on the results of a follow-up study of 120 conservatively treated distal radius fractures. Follow-up averaged 35 months (25 to 48 months). The quality of initial reduction has a crucial impact on the final outcome. 87 fractures showed nearly perfect anatomical reduction, of these, 48 resulted in excellent, 16 in good, 15 in satisfactory, and 8 in poor final anatomical outcomes. In comparison, in 33 fractures with unsuccessful initial reduction, only two cases gave excellent and 12 cases good results (42%); 11 fractures were considered satisfactory and 8 poor. The necessity of a second reduction was significantly lower in the first group of initially well-reduced fractures when compared to the second group: 8 (9.2%) to 14 (42.4%) respectively. Evaluation of the functional outcome according to the Sarmiento scheme showed a strong correlation between the AO fracture classification and the final outcome. In group A fractures, 78% gave excellent or good, 22% satisfactory or bad results. Type B fractures gave 82% excellent or good and 18% satisfactory or poor results. In group C, only 50% reached excellent or good results, the C 3 fractures having the worst prognosis, achieving excellent or good results in only 20% of the cases. Regression analysis demonstrated a significant correlation between anatomical and functional outcome.

Adult↗
PubMed2003

[Dislocation of the Ulnar Head following Malunion of Distal Radius Fracture in Childhood].

Four children between the age of 10 and 13 years with distal radius fractures healed with dorsal angulation presented to us in our out-patient department. All had been treated conservatively with an upper-arm cast, all fractures had healed with an average dorsal angulation of 10 degrees. Despite this dorsal angulation, the patients were pain free. Subsequent minor injury resulting in pain to the wrist was now the reason for their presentation. On examination we found a spontaneous palmar dislocation of the ulnar head during supination. This proved to be resistant to conservative therapy. In all cases corrective osteotomy of the radius at the level of angulation was performed. Redislocation of the ulnar head was prevented by this method in all cases.

Adolescent↗
PubMed2001

Treatment of the unstable distal radius fracture with external fixation and a hydroxyapatite spacer.

A prospective study was performed on 25 patients (15 women, 10 men) with unstable fractures of the distal radius selectively treated with a dynamic type of external fixation combined with a hydroxyapatite spacer. The fractures ranged from type VI to type VIII according to Frykman's classification. The patients' mean age at surgery was 49 years (range, 19-75 years). The mean follow-up period was 2.5 years, and overall outcome was assessed using Gartland and Werley's demerit point system as modified by Sarmiento. Radial inclination was 26 degrees +/- 4 degrees at the time of reduction and 26 degrees +/- 5 degrees at follow-up, palmar tilt was 9 degrees +/- 2 degrees at reduction and 8 degrees +/- 3 degrees at follow-up, and ulnar variance was 1.4 +/- 0.6 mm at reduction and 2.1 +/- 0.9 mm at follow-up. The mean range of motion at follow-up was 80 degrees +/- 10 degrees in flexion, 80 degrees +/- 10 degrees in extension, 85 degrees +/- 10 degrees in supination, and 80 degrees +/- 5 degrees in pronation. The outcome in 24 of 25 patients was evaluated as excellent. In the surgical treatment of unstable fractures of the distal radius using external fixator, the fracture reduction should be supported with bone graft or a bone substitute, and a hydroxyapatite spacer was considered to be a useful substitute for a bone graft.

Adult↗
PubMed2004

Pseudo-rupture of Extensor Pollicis Longus following Kischner wire fixation of distal radius fractures.

We report two cases of extensor pollicis longus tendon tethering following K-wire insertion to treat unstable distal radius fractures, an unusual complication. In both cases, extensor pollicis longus function returned with conservative management. The structures considered "at risk" during K-wire insertion are described, and the common complications are discussed. Operative approaches to minimise soft tissue damage during K-wire insertion are reviewed. This case report is the first to demonstrate the potential for ultrasound scanning to aid in the diagnosis of extensor pollicis longus tethering.

Accidental Falls↗
PubMed1996

Contact stress distributions in malreduced intraarticular distal radius fractures.

Residual articular incongruity of the distal radius following intraarticular fracture has been correlated with early osteoarthritis (OA) and a poor clinical outcome. We developed a simple in vitro fracture model of the distal radius to investigate the relationship between degree of articular incongruity and the resulting distribution of radiocarpal contact stress. Twelve fresh-frozen cadaver arms were dissected, packets of Fuji Pressensor film were inserted into the wrist, and the wrist was loaded through its flexor and extensor tendons. We created a simple intraarticular fracture that allowed controlled distal radius articular incongruity. Loading trials were performed for the intact distal radius, for a fully reduced case, and for step-offs of 0.4, 1, 2, and 3 mm. Mean contact stress was significantly greater than the anatomically reduced case at only 3 mm of step-off. Contact area was greater than the anatomically reduced case at 0.4, 1, and 2 mm of step-off. The elevations in contact stress that we observed were only modest, suggesting that other factors may be involved in the pathogenesis of radiocarpal OA in the presence of residual articular incongruity.

Adult↗
PubMed2006

Volar versus dorsal locking plates with and without radial styloid locking plates for the fixation of dorsally comminuted distal radius fractures: A biomechanical study in cadavers.

PURPOSE: To compare the stability and stiffness of dorsal and volar fixed-angle distal radius constructs in a cadaveric model. METHODS: A locking distal radius system was used in a combination of a dorsal and styloid plate (group 1), a single volar plate (group 2), and a combination of a volar and styloid plate (group 3) configuration. In addition a single volar 3.5-mm steel locking plate was used in group 4. Each construct was tested on 6 fresh-frozen radii with simulated unstable dorsally comminuted extra-articular distal radius fractures. Specimens were tested on a material testing machine with an extensometer and subjected to axial compression fatigue and load-to-failure testing. RESULTS: No construct failed in fatigue testing of 250 N for 5,000 cycles. Two specimens in each group were tested for 20,000 cycles without failure. The plastic deformation in the double-plate groups was lower compared with the single-plate groups, although the difference was not statistically significant. Group 1 had the highest and group 4 the lowest failure load and stiffness, respectively. The differences between group 1 and the other groups, except failure load compared with group 3, were statistically significant. Groups 2 and 3 had a significantly higher load to failure and group 3 had a significantly higher stiffness compared with group 4. CONCLUSIONS: All constructs offer adequate stability with minimal deformation on fatigue testing under physiologic conditions. Dorsal fixed-angle constructs are stiffer and stronger than volar constructs. The addition of a styloid plate to a volar plate did not significantly improve stability in this model of simulated extra-articular dorsal comminution loaded in axial compression.

Aged↗
PubMed1997

Normal wrist kinematics and the analysis of the effect of various dynamic external fixators for treatment of distal radius fractures.

The purpose of this study was to evaluate the effect that external fixation devices used for distal radius fractures have on normal carpal kinematics, using high speed video data acquisition. Cadaver forearms were stabilized, allowing free excursion of the wrist for passive range of motion. Synergistic muscle tension was simulated by looping the extensor and flexor pairs of the wrist. Global wrist flexion and extension, intercarpal angles, and the instantaneous screw axis (ISA) were studied. These parameters allowed a quantification of normal carpal kinematics and comparison to the kinematics of the carpal bones with external fixators attached. This study shows that normal carpal kinematics during wrist flexion and extension do not have an ISA fixed in or limited to the capitate. In addition, the ISA data provide evidence that translational motion is a real and measurable component of normal carpal motion. This would change the understanding of carpal kinematics in previous studies that suggested that the center of rotation was fixed in the capitate. The proximal carpal (radiolunate) joint contributes more motion (has a greater rotation angle) in normal global wrist flexion and the midcarpal (capitolunate) joint contributes more motion in normal global wrist extension. In addition, the global range of motion and intercarpal joint angle of the wrist are limited with the application of any of the external fixators tested. None of the external fixators allowed normal ISA vector surfaces during wrist motion.

Adult↗
PubMed1997

Treatment of unstable distal radius fractures: methods and comparison of external distraction and ORIF versus external distraction-ORIF neutralization.

Twenty-six closed unstable distal radius fractures were treated using a combination of internal fixation, external distraction (intraoperative), and, in some cases, up to 4 weeks of postoperative external fixation (neutralization). Intraoperative stability check determined the need for external neutralization. This combined technique allowed a comprehensive approach to even the most unstable fracture by merging the advantages of internal and external fixation. Up to 4 weeks of external fixation (neutralization) was not associated with the complications of external fixation usually reported.

Absenteeism↗
PubMed1993

[Distal intra-articular radius fractures. Indications for and technique of open reduction and plate osteosynthesis].

In the past few years we have seen vast changes in both the assessment and the management of fractures of the distal radius. This is attributable to several factors. On the one hand, conservative treatment has shown poor results in a considerable number of patients, and on the other hand, more and more young patients are presenting with this common lesion. Furthermore, the spread of new methods of osteosynthesis and of modern materials, such as implants, etc., have greatly improved the results of operative procedures, even in complicated fractures of the radius. Therefore, in certain types of fractures far better functional results can be achieved by open reduction. Particularly in intra-articular fractures of the distal radius with or without compression zones and/or injury to the ligaments closed manipulation and subsequent immobilization by plaster is only partially successful. To achieve successful repair of the complex mechanisms in the wrist and the distal radio-ulnar jacket (DRU) joint, these fractures mostly require open reduction and plate fixation including additional support for the articular surface by a cortico-cancellous bone graft from the iliac crest. This enhances the stability of the reduced fragments and facilitates early mobilization which, in turn, greatly improves the functional results. In palmar displaced fractures a palmar approach is employed for both surgical repair and plate fixation, while dorsal compression fractures are reduced, filled and stabilized using a dorsal approach. In this study a special operative procedure for intra-articular comminuted fracture is described. A palmar approach is employed for fracture reduction, while the compression zone is filled by bone graft via an additional dorsal incision.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

[Distal radius fracture].

The treatment of fractures of the distal radius is in a state of flux, because the results of conservative treatment have so far been unsatisfactory in 20%-30% of cases. Instability resulting from dorsal compression, damaged ligaments (60%) and the presence of débris in the area of the metaphysis means that, while reduction is easy, retention is frequently difficult to achieve. Such fractures are reduced by using the ball of the little finger for extension while the ball of the thumb is positioned under the proximal fragment to provide support. A plaster cast based on the principle of three-point fixation is applied to immobilize the fractured part. The simplest surgical technique for unstable fractures of the distal radius is internal fixation with crossed Kirschner wires. For Smith's fractures [41], and especially those of type II (Thomas [44]), internal fixation with plates fixed to the volar bone surface is the procedure of choice. Comminuted fractures of the metaphysis and a tendency to shortening should be immobilized by external fixation. Early filling of the defect with cancellous bone leads to more rapid consolidation. In our own clinic we treated 409 cases of fracture of the distal radius in 2 years. The procedures applied were: conservative treatment in 39.6% of cases; internal fixation with wires in 55%; internal fixation with plates in 3.7%; and stabilization by means of external fixation in 1.7%.

Fracture Fixation, Internal↗
PubMed1989

Plasma lidocaine levels following hematoma block for distal radius fractures.

Venous plasma levels of lidocaine were determined in 8 patients presenting to the emergency department with acute distal radius fractures and who had had anesthesia with fracture hematoma block. The block was performed in an aseptic fashion via a dorsal approach with a dose of 2.2-2.4 mg/kg of lidocaine without epinephrine. Onset of anesthesia was in less than 5 min which reduced pain from manipulation of the fracture to modest levels. Plasma lidocaine levels determined by gas chromatography-mass spectrometry reflected rapid systemic absorption of lidocaine from the fracture hematoma. Maximum systemic concentrations were seen at 20-30 min and ranged from 100 to 1,100 ng/ml, well below the toxic threshold of 5,000 ng/ml.

Adult↗
PubMed2006

[Distal radius fracture. Correlation between radiological and functional results].

BACKGROUND: The purpose of the present study was to investigate the influence of the radiological parameters on the functional outcome of patients with a fracture of the distal radius and to find out to which extent a deformity can be tolerated. PATIENTS AND METHODS: A total of 344 patients with an isolated fracture of the distal radius were treated during a 3-year period; 211 of them were evaluated at an average of 16 months after the accident according to the score of Gartland and Werley as modified by Sarmiento. Furthermore, we developed our own score for evaluating the influence of radiological parameters on the functional outcome. RESULTS: According to the AO classification, there were 20 patients with an A2, 71 an A3, 11 a B, 35 a C1, 44 a C2, and 30 a C3 fracture. Of 211 patients, 28 (13%) had a step-off in the articular surface of over 1 mm, resulting in a 24% reduction of the range of motion compared to the non-injured wrist (p<0.05). Patients with a radial shortening of more than 3 mm (n=12) had a 21% reduction of pro- and supination compared to the non-injured side (p<0.05). The radial tilt and the palmar inclination did not have a direct influence on the functional outcome. Patients treated with K-wire pinning and with an initial palmar inclination of less then -15 degrees had a significantly higher secondary loss of palmar inclination of 9 degrees compared to all others (p<0.05) at the final follow-up. CONCLUSION: The main radiological factors influencing the functional outcome of fractures of the distal radius are radial shortening and a step-off in the articular surface.

Adolescent↗
PubMed1998

Augmented external fixation of distal radius fractures: a biomechanical analysis.

An in vitro model of an unstable extra-articular distal radius fracture was created in 8 fresh-frozen cadaveric specimens and stabilized with an external fixator. Rotation and translation kinematics of the distal radial fracture fragment were measured in relation to the proximal radius during physiologic loading, using infrared light-emitting diodes and a 3-dimensional motion-sensing device. The effect of supplemental single and combination Kirschner wire (K-wire) fixation on fracture fragment stability was assessed. Fixation of supplemental K-wires to the fixator frame via a custom-developed outrigger assembly was also analyzed. Significant reductions in sagittal plane (flexion/extension) rotation and neutral zone were recorded when the fracture fragment was stabilized with a single styloid or dorsal transfixion K-wire. Equivalent stability was afforded by attachment of a nontransfixion K-wire to the fixator frame via the outrigger assembly. The dorsal constructs compared favorably to the styloid constructs in reduction of the sagittal plane neutral zone and coronal (radioulnar) rotation. These data lend biomechanical support to the concept of augmentation of distal radius external fixation and provide a physiologic model to test fixation methods for other fracture patterns.

Bone Wires↗
PubMed2004

Can external fixation maintain reduction after distal radius fractures?

BACKGROUND: The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction. METHODS: Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance. RESULTS: Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction. CONCLUSION: Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients.

Adult↗
PubMed1998

[Results of Kapandji-Sauvé operation after distal radius fractures].

Incongruity of the distal radioulnar joint represents a major problem following malunited fractures of the distal radius. A useful solution is the arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis as described by Kapandji-Sauvé. The results of this procedure are presented and the indication compared to alternative treatment options discussed. Between 1991 and 1997, 19 patients were treated with a Kapandji-Sauvé procedure, for rheumatoid arthritis in seven and for a malunited fracture of the distal radius in twelve patients. All of the patients with a malunion of the distal radius were followed up 5 to 70 months postoperatively by clinical and X-ray examination. For evaluation the protocol by Martini for malunited fractures of the distal radius was used. All but one patient agreed that the operation had been beneficial and would choose to undergo the same procedure again necessary. Mean forearm rotation improved from 99 to 166 degrees. Preoperative pain was reduced in eleven patients. Two patients were completely pain-free and seven noticed pain during heavy load only. Grip strength improved postoperatively in three patients, remained unchanged in four and was diminished in three. In two patients preoperative measurements were not available. Evaluation by the Martini protocol gave three very good, four good, four fair, and one poor result. In one patient, regeneration of the ulna across the resected segment occurred necessitating a secondary excision. This resulted in a return of forearm rotation of 140 degree and good patient satisfaction. Arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis reliably reduces pain and improves forearm rotation after malunited fractures of the distal radius. However, it cannot influence pain originating from the radiocarpal joint. Therefore, patients with advanced radiocarpal arthrosis are not suitable for the operation. We consider the procedure to be indicated when the distal radioulnar joint is compromised by the fracture itself or by posttraumatic degenerative arthrosis or when instability or subluxation of the distal radioulnar joint occurs that cannot be corrected. We have not observed persisting problems resulting from instability of the proximal ulna.

Adolescent↗
PubMed1998

A systematic approach to handling the distal radio-ulnar joint in cases of malunited distal radius fractures.

The distal radio-ulnar joint (DRUJ) is often the site of persistent symptoms after malunion of distal radius fractures. These malunions alter load transfer across the ulnocarpal joint, disturb DRUJ kinematics, and result in joint incongruity at the sigmoid notch. Treatment of distal radius malunions must not only correct position of the radial platform and joint incongruity but also restore anatomic relationship at the DRUJ. A systematic approach to the surgical reconstruction of these multiplanar deformities using clinical and radiographic parameters is outlined.

Algorithms↗
PubMed2002

Treatment of distal radius fractures with external fixation: technical considerations for rehabilitation.

Wrist external fixation with or without K-wire stabilization has been shown to be a reliable treatment method for unstable fractures of the distal radius. The technique of external fixation of the wrist has been historically based on the premise that fracture reduction can be achieved and maintained using the principles of ligamentotaxis. It is now well recognized that sustained longitudinal traction applied with a wrist external fixator can lead to complications. This review outlines the authors' preferred technique of using the external fixator as a neutralization device rather than as a traction device. The absence of sustained radiocarpal traction during distal radius fracture healing may facilitate postoperative rehabilitation.

Journal Article↗
PubMed2003

The functional importance of malunion in distal radius fractures.

The purpose of our study was to investigate which radiological parameter had the maximal detrimental effect on functional outcome following malunion of distal radius fractures. Sixty-four women over 40 years of age who had sustained low-energy wrist fractures were included in the study. The mean age of the patients was 64 years. We compared the ulnar variance, radial inclination and palmar tilt of the fractured wrist to the non-injured contralateral side on radiographs obtained after fracture healing. The functional outcome was assessed at a mean follow-up of 28 months. Wrist mobility, grip strength, and pain with daily activities were determined and combined to give a final outcome rating. An increase in ulnar variance was found to be the most important radiological parameter affecting functional outcome and the outcome tended to be influenced by age, hand dominance and the presence of articular involvement.

Adult↗