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PubMed1999

Bone turnover and cortical bone mineral density in the distal radius in patients with hyperthyroidism being treated with antithyroid drugs for various periods of time.

OBJECTIVE: Whether patients, who have lost bone mass, can be restored to age-matched control levels by some means is still controversial. We investigated how the thyroid status after antithyroid drug therapy for various periods of time affects bone metabolism in patients with hyperthyroidism by assessing currently used biochemical markers of bone turnover and distal radius bone mineral density (BMD). DESIGN AND PATIENTS: The biochemical markers of bone turnover and BMD at the distal one third of the radius were measured in 79 women with hyperthyroidism treated with antithyroid drugs for various periods of time. The patients were divided into two groups according to thyroid function at the time of study: a hyperthyroid group (serum thyroid stimulating hormone (TSH) < 0.4 mU/l) and an euthyroid group (TSH 0.4-4.0 mU/l). Second, each group was further divided according to the duration of therapy: short-term (less than 3 years) and long-term (3 or more years). MEASUREMENTS: Urinary type I collagen degradation products (CTx) were measured by the CrossLapsTM ELISA kit. Urinary pyridinoline (Pyr) and deoxypyridinoline (Dpyr) were measured by high performance liquid chromatography (HPLC) after acid hydrolysis. Serum N-mid osteocalcin (OCN-mid) was measured by a recently developed enzyme-linked immunosorbent assay. Serum alkaline phosphatase (ALP) was determined by routine laboratory methods. Bone mineral density (BMD) at the distal one third of the radius was measured using dual energy X-ray absorptiometry (DEXA; DCS-600EX, Aloka, Tokyo). RESULTS: There were statistically significant positive correlations of FT3 and FT4 with the biochemical markers of bone turnover. There were significant negative correlations between the biochemical markers and BMD only in patients undergoing long-term therapy. In a comparison between hyperthyroid and euthyroid groups based on duration of treatment (long-term and short-term), and in a comparison without regard for length of treatment (all patients), it was evident that ALP and CTx levels were significantly higher in the hyperthyroid than in the euthyroid groups. Significantly lower BMD Z-scores in the hyperthyroid group compared to those in the euthyroid group were observed only in patients undergoing long-term therapy. CONCLUSIONS: Urinary type I collagen degradation products were a sensitive marker for evaluating the bone turnover in patients with hyperthyroidism. Our data suggested that it might be important to control the levels of TSH within normal ranges during long-term antithyroid drug therapy in order to prevent bone loss.

Adult↗
PubMed1999

Supplemental pinning improves the stability of external fixation in distal radius fractures during simulated finger and forearm motion.

External fixation is commonly used in the treatment of distal radius fractures. In this in vitro study, we investigated changes in fracture stability when using supplemental radial styloid pinning in combination with external fixation. Eight previously frozen cadaveric upper extremities were mounted in a computer-controlled wrist-loading apparatus. This device was used to generate finger and forearm motions through loading relevant tendons. An unstable extra-articular distal radius fracture was simulated by removing a dorsal wedge from the distal radius metaphysis. An electromagnetic tracking system measured fragment motion following randomized application of a Hoffman external fixator, a Hoffman external fixator with 2 supplemental radial styloid pins, and a dorsal 3.5-mm AO plate. Regardless of the fixation technique used in this unstable fracture model, fragment motion occurred when postoperative finger and forearm motions were simulated. The addition of radial styloid pins to a construct stabilized by an external fixator significantly improved fragment stability, approaching that achieved with the dorsal AO plate.

Biomechanical Phenomena↗
PubMed1999

Treatment of unstable distal radius fractures with cancellous allograft and external fixation.

Unstable fractures of the distal radius continue to pose a challenge to the hand surgeon. Adjunctive bone grafting is often required to augment structural integrity and aid healing. Because of the risks inherent to bone autograft harvest, however, freeze-dried, irradiated cancellous bone allograft has been used to treat unstable distal radius fractures with severe metaphyseal comminution. Seventeen patients with such fractures (mean age, 70 years; 2 males and 15 females) were treated with bone allograft and external fixation with or without internal fixation. The outcome was evaluated using the modified Mayo wrist score, demonstrating 3 excellent, 8 good, 6 fair, and no poor results on follow-up examination (mean follow-up period, 23 months; range, 7-43 months). The patients were requested to return for follow-up review between 1997 and 1998. These results show that cancellous bone allograft is a useful adjunct to external fixation in the treatment of unstable distal radius fractures.

Aged↗
PubMed1999

Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the pi plate on the volar surface of the distal radius.

The pi plate (Synthes Ltd, Paoli, PA) was designed to fit the unique contour of the dorsal aspect of the distal radius. Complications of pi plate fixation of the dorsal distal radius have been previously reported to include both extensor tenosynovitis and delayed extensor tendon rupture. We report a case of rupture of the flexor pollicis longus tendon associated with inappropriate placement of the pi plate on the volar surface of the distal radius.

Aged↗
PubMed2001

Bone graft harvesting from the distal radius, olecranon, and iliac crest: a quantitative analysis.

The purpose of this study was to quantify the volume and density of cancellous bone available from 3 commonly used bone graft sites in upper extremity surgery: the distal radius, olecranon process, and anterior iliac crest. Sixteen cadavers (age range, 59-98 years) with no prior history of bone harvest or metabolic conditions affecting bone were used. Cancellous graft was obtained using standardized techniques designed to simulate the clinical setting. Packed cancellous bone volume was determined as the volume occupied by the harvested bone after compression packing with a uniform load. Defect volume was determined by measuring the volume of the site from which bone was harvested. The distal radius and olecranon provided similar volumes of packed cancellous bone (2.7 and 2.8 cc, respectively). The anterior iliac crest provided approximately twice this amount (5.3 cc). The packed cancellous bone volume/defect volume ratio was not different between the 3 sites studied. Male gender was associated with a significantly greater amount of packed cancellous bone volume for all sites. We believe the olecranon to be an alternative to the distal radius as a source of bone graft for upper extremity procedures. We suggest using the anterior iliac crest when a large volume of cancellous bone is required.

Aged↗
PubMed2001

Surgical management of delayed union and nonunion of distal radius fractures.

Ten patients with malaligned fractures of the distal radius that demonstrated either delayed healing or the development of an atrophic or synovial nonunion on standard radiographs were treated with surgical realignment, stable internal fixation, and autogenous iliac crest bone grafting. All 10 fractures healed with acceptable radiologic alignment within 3 months of the index procedure. After an average follow-up period of 3 years 6 months (range, 2 years to 8 years 6 months) patients had an average of 105 degrees wrist flexion and extension, 145 degrees forearm rotation, and 73% grip strength compared with the opposite limb. In the treatment of malaligned, ununited fractures of the distal radius, specific techniques and implants must be tailored to the deformity of the distal radius and the shape of the distal fragment. A stable, well-aligned wrist with preservation of at least 50 degrees mobility in flexion and extension was achieved in every patient, but the final result was compromised by associated problems in 3 patients.

Adult↗
PubMed2001

Ilizarov hybrid external fixation for fractures of the distal radius: Part I. Feasibility of transfixion wire placement.

The advantages of Ilizarov external fixation, allowing early motion of adjacent joints during fixation of periarticular fractures, have not yet been applied to distal radius fractures. A magnetic resonance imaging study of 10 normal volunteers evaluated the safety of passing percutaneous transfixion pins across the distal radius in 3 forearm positions. Even in the optimal forearm position, the safe zones between the transfixion pin, vessel, nerve, or tendon was small, suggesting that open placement would be required. A cadaver study in 8 specimens demonstrated that the pins could be placed with an open technique using an aiming device and that the pins could be placed without limiting forearm rotation. The proximity of vital structures to transfixion pins dictates open placement to safely apply Ilizarov fixation to distal radius fractures.

Adult↗
PubMed2001

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius.

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.

Adult↗
PubMed2001

Intra-articular distal radius fractures: arthroscopic assessment of radiographically assisted reduction.

The optimal means of assessing articular displacement during closed reduction of distal radius fractures is unknown. The purpose of this study was to evaluate the in vivo accuracy of fluoroscopy (C-arm) and plain radiographs (XR) in measuring articular step-off and gap and to determine if postreduction arthroscopy can identify malreduced intra-articular fractures that would benefit from reduction. Fifteen intra-articular distal radius fractures underwent closed manipulation and percutaneous pinning. Reduction was assessed sequentially by C-arm, XR, and wrist arthroscopy. The width of gapping between articular surface fragments was underestimated to a statistically significant degree by both C-arm and XR. The magnitude of articular step-off measured with arthroscopy was not statistically different than that measured radiographically. In 5 (33%) cases, the optimal reduction obtained using C-arm and XR was found to have an articular displacement of >1mm by adjunctive arthroscopy. Complete reduction and pinning was performed with satisfactory results. These results suggest that adjunctive arthroscopy may detect residual gapping of the articular surface that is not seen by C-arm or XR. Residual displacement noted by adjunctive arthroscopy may prompt another reduction effort and result in an improved articular alignment of intra-articular distal radius fractures.

Adult↗
PubMed2002

Dynamic splinting of forearm rotational contracture after distal radius fracture.

The results of dynamic forearm rotational splinting for the treatment of forearm rotational contractures in patients with acceptably aligned, healed distal radius fractures are documented. Fifteen patients with distal radius fractures that healed with < or =+5 mm ulnar variance and < or =20 degrees dorsal tilt had dynamic forearm rotational splinting for contractures that had failed conventional hand therapy. Average pronosupination arc before splinting was 83 degrees. Dynamic forearm rotational splinting increased forearm rotation by 52% to an average of 126 degrees. Only one patient with development of ectopic bone in the interosseous space during splinting failed to obtain at least 30 degrees pronation and supination after splinting. Dynamic forearm rotational splinting effectively treats rotational contractures in patients who have healed distal radius fractures that are in acceptable alignment.

Adult↗
PubMed1999

[Results of therapy after primary conservative management of distal radius fractures in patients over 65 years of age].

BACKGROUND: In the clinical routine of our City Hospital Triemli, Zürich, Switzerland, we prefer to treat old patients with fractures of the distal radius conservatively. It was our aim to examine the long-term effects of this treatment on anatomical position, mobility, strength, and patient satisfaction. PATIENTS AND METHODS: We reviewed the data of 102 consecutive patients over 65 years of age. 95 were treated with a plaster cast and controlled weekly in our outpatient department, finally discharged after 50 days. After an average time of eight months, 79 patients could be controlled clinically and radiologically. RESULTS: Although a significant (p < 0.001) reduction of joint mobility and grip strength was found in all cases, we documented no loss of independence in every-day life. Radiological malalignment of the distal radius with a dorsal or palmar angle of more than 20 degrees in the lateral view or a radio-ulnar angle of less than 15 degrees in the dorsopalmar view was associated with increased complaints and patients dissatisfaction. CONCLUSION: In old-aged patients with distal radius fractures, the indication for surgical treatment should be made very carefully, since certain degrees of radiological malalignment are tolerated well.

Aged↗
PubMed1999

[Bowers hemi-resection-interposition arthroplasty for treatment of post-traumatic arthrosis of the distal radio-ulnar joint after distal radius fractures].

UNLABELLED: Arthrosis of the distal radioulnar joint (DRUJ) is a common problem following fractures of the distal radius. The treatment options include the hemiresection-interposition technique (Bowers procedure) or Kapandji-Sauvé procedure. In a retrospective study, we assessed the results of the Bowers procedure. MATERIAL AND METHODS: From 1992 to 1997, 24 patients were treated by the hemiresection-interposition technique (Bowers procedure) for arthrosis of the DRUJ following fracture of the distal radius. The average follow-up time was 30.5 (9 to 55) months. RESULTS: The average preoperative pronation was 67 degrees, the supination 45 degrees. Postoperatively, we found a pronation of 80 degrees and a supination of 62 degrees. Grip-strength compared to the opposite site could be improved from 38 to 57% postoperatively. Pain was reduced markedly in 78% of the patients. However, ten patients developed a postoperative instability of the distal ulna. In only two patients did painful instability necessitate revision procedures. CONCLUSION: The hemiresection-interposition technique is a salvage procedure for the destroyed DRUJ, leading to good clinical results in most patients. Painful instability of the distal ulna and remaining functional deficits can be the reasons for failure. Therefore, adequate primary reduction of fractures of the distal radius or secondary reconstruction of the anatomy is necessary to prevent secondary arthrosis of the DRUJ.

Adult↗
PubMed2000

[Simultaneous management of multi-fragment distal radius fractures with palmar and dorsal approach].

Reconstruction of the articular anatomy can be extremely difficult in distal radius fractures with severe comminution of both the dorsal and palmar cortices. In these cases, neither open reduction using an unilateral approach nor closed reduction with ligamentotaxis and fixateur externe will be successful. Reconstruction of both the dorsal and palmar cortical column is necessary. Sixteen of nineteen patients with unstable bicolumnar distal radius fractures treated by a combined plate osteosynthesis were studied retrospectively. Follow-up time averaged 32.5 months (8 to 74). At the time of re-examination the average grip strength and range of motion were reduced by 30% compared with the uninjured side. The average DASH-score was 11.2 points. Radiographic measurements revealed a satisfactory restoration of the radius concerning length and form. There were no signs of higher graded arthrosis.

Adult↗
PubMed2001

[Arthroscopic diagnosis of concomitant scapholunate ligament injuries in fractures of the distal radius].

To investigate the occurrence of carpal ligamentous injuries in patients with fractures of the distal radius, the results of 122 wrist arthroscopies were analysed within a retrospective study. Indications for arthroscopy included suspected carpal instability according to radiographic findings and/or the necessity for internal fixation of the radius fracture. Arthroscopy revealed acute scapholunate ligament tears in 84 patients. Scapholunate separation was found to be of prognostic value for ligament tears. There was no association between ligamentous lesions and carpal angles or fracture dislocation. Scapholunate ligament tears were most frequent in sagittal articular fractures. In these cases, wrist arthroscopy should be performed during operative treatment of the radius fracture to allow direct visualization and subsequent repair of ligamentous tears.

Adolescent↗
PubMed2001

[Primary arthroscopic treatment of TFCC tears in fractures of the distal radius].

The primary simultaneous diagnosis and therapy of TFCC tears in distal radius fractures is still the exception. We present our results of arthroscopic treatment of these injuries. From January 1998 until September 1999, we treated 21 patients with a type C fracture (AO classification) of the distal radius and one patient with a scaphoid fracture and TFCC tears. The Palmer 1A (n = 5) and 1 C (n = 4) tears have been arthroscopically shaved as well as the meniscal tear (n = 1). The Palmer 1B tears were refixed either in an outside-inside technique (n = 6) or in a new all-inside technique (n = 6). Palmer 1D tears were refixed in the Fellinger technique (n = 5). In the clinical follow-up examination six to fifteen months later, we saw symptoms of ulnar-sided wrist pain only in one case of a Palmer 1B tear treated in an outside-inside technique. Especially the patients treated by the new all-inside technique were free from symptoms of TFCC instability. We conclude, that arthroscopic treatment of TFCC tears in acute radius fractures is possible with good results. The new technique of all-inside repair is minimally invasive and shows good results.

Adolescent↗
PubMed2003

[Combined palmar and dorsal approach for complex distal radius fractures].

PURPOSE: The purpose of this paper was to describe our management of complex fractures of the distal radius using a combined dorsal and palmar approach and to evaluate the radiological and clinical outcome. PATIENTS AND METHODS: Twenty out of 26 patients with complex fractures of the distal radius, which were operated on from 1996 to 2000 using a combined dorsal and palmar approach, were followed-up on an average of 28 months. According to AO fracture classification, there were one A3, two B3, three C1, two C2 and twelve C3 fractures. Six patients had associated injuries. The treatment was standardized: closed reduction on the day of injury; depending on the soft-tissue situation an external fixator or a forearm splint was applied; every patient underwent a computed tomography before the definitive surgical procedure, which was performed between one and 28 days after the injury when the swelling had subsided. According to the fracture patterns, the distal radius was stabilized using double plates (3), a palmar plate (11) or a dorsal plate (4), screws (1) or K-wires (1) combined with the initially applied external fixator (6). Follow-up included a radiological and clinical examination. The results were graded with use of the modified Mayo Wrist Score. Disability was assessed using the DASH score. RESULTS: All fractures healed, some with minor malunion. Fourteen of the 20 patients had osteoarthrotic changes. Compared to the opposite wrist, range of motion for flexion/extension was reduced by 25 %, radial/ulnar deviation by 20 % and forearm rotation by 5 %. Grip strength averaged 15 % less than that of the opposite side. Modified Mayo Wrist Score revealed 65 % excellent, 30 % good and 5 % poor results. DASH score averaged 18 points.

Adult↗
PubMed2005

A rare and serious complication of the radial forearm flap donor site: osteomyelitis of the radius.

Although the radial forearm flap has become a workhorse for the reconstructive surgeon, it has some known disadvantages, especially relating to donor area complications. The authors present a serious but rare complication of the radial forearm donor site. Osteomyelitis of the radius at the flap donor site was observed in a 48-year-old man 5 weeks after flap surgery. Although the flap was raised fasciocutaneously without a bony portion, infection of the radius was determined. The infection was successfully treated with surgical debridement and simultaneous administration of a proper antibiotic regimen. One should keep in mind that osteomyelitis of the radius may be encountered as one of the serious donor site complications of the radial forearm flap that may have detrimental effects on hand functions.

Humans↗
PubMed1998

Free vascularized fibular graft in the treatment of Salmonella typhi osteomyelitis of the distal radius.

The authors report a rare case of Salmonella typhi osteomyelitis involving the distal radius. The patient was treated successfully by wide resection and reconstruction of the distal radius with a vascularized fibular transfer. Local recurrence of infection did not occur. The free vascularized fibular graft is an effective procedure for the treatment of osteomyelitis of the distal radius.

Aged↗