Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture?
Department of Trauma Surgery and Sportsmedicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. firstname.lastname@example.org
INTRODUCTION Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation. METHOD We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer. RESULT Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations. CONCLUSIONS Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated.
Centro Traumatologico Ortopedico-Roma-ASL RMC, U.O.C. Chirurgia della Mano, Microchirurgia e Reimpianto Arti, Rome, Italy. email@example.com
BACKGROUND The purpose of this study was to evaluate the outcome of fractures of the distal radius with metaphyseal and diaphyseal involvement treated with fixed angle volar plates. MATERIALS AND METHODS Twenty-one patients with fracture of the radius involving the diaphyseal, metaphyseal and epiphyseal parts were treated with fixed angle plate fixation through an extended volar Henry's approach. Circle wire loops, screws and intrafocal wire fixations were associated in 12 cases. Coexisting ulnar fractures were fixed with plates or K-wires in 8 cases. All patients were prospectively followed using radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores. RESULTS All fractures except one, which needed a secondary bone graft to achieve consolidation, united by an average of 90 days. One case developed a radioulnar synostosis. Radiographs showed optimal reduction in 17 of 21 cases, with restoration of radial length in all cases and a neutral average ulnar variance. Nonanatomical reduction was associated with the worst results (P = 0.0006). Flexion and extension averaged 62.8° and 73.8°, and pronation and supination 85.2° and 80.2°, respectively. The average DASH scores were 30 points at 3 months, 14 points at 6 months, and 6.7 points at the time of final follow-up (at an average of 11 months). According to the Mayo wrist rating system, 14 patients showed excellent results, 5 showed good results, and 2 showed fair results. CONCLUSION Fixed angle volar plates were demonstrated to be a safe and efficient treatment in these challenging fractures.
[Intraarticular fractures of the proximal interphalangeal joint : Dynamic early functional therapy with an external fixation system.]
Plastisch- und Handchirurgische Klinik, Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
The results of treating fracture dislocations of the proximal interphalangeal joint are often unsatisfactory for the patient because conservative methods cannot prevent stiffness of the joint. Thus, early functional treatment with external fixation systems is increasingly favoured. This therapy combines the principles of ligamentotaxis and the possibility of early movement of the injured joint. The frequently modified pins and rubbers traction system is especially effective. It is cheap, easy to apply, and well accepted by patients due to its light weight and small size. This paper gives an overview of the therapeutic options and the clinical results of treating fractures of the proximal interphalangeal joint.
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A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating.
Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria. firstname.lastname@example.org
OBJECTIVES To compare final functional and radiographic outcomes of closed reduction and casting (CAST) with open reduction and internal fixation (ORIF) with palmar locking plate for unstable Colles type distal radius fractures (DRFs) in low-demand patients older than 70 years. DESIGN Retrospective, clinical study. SETTING Level 1 university trauma center. PATIENTS Over a mean period of 4 years and 7 months, 130 consecutive patients older than 70 years were treated for an unstable dorsally displaced DRF of which 114 or 87% were followed for 1 year or longer. INTERVENTION ORIF (n = 53) using volar locking plate or closed reduction and casting (n = 61). MAIN OUTCOME MEASUREMENTS Objective and subjective functional results (active range of motion; grip strength; disabilities of the arm, shoulder and hand (DASH) score; patient-rated wrist evaluation (PRWE) score; visual analog scale; and Green and O'Brien score) and radiographic assessment (dorsal tilt, radial inclination, radial shortening, fracture union, and posttraumatic arthritis) were assessed. RESULTS At final follow-up, there was no significant difference between the 2 groups for mean ranges of motion, grip strength, DASH score, PRWE score, and Green and O'Brien score. Pain level was significantly less for the patients in the CAST group. An obvious clinical deformity was present in 77% of cast group and none in the ORIF group. At final follow-up, in the ORIF group, there was a mean loss of dorsal tilt of 1.3 degrees, radial inclination of 0.3 degrees, and radial length of 0.5 mm compared with the postoperative measurements. No primary acceptable reduction was achieved in 44% of the CAST group. At final follow-up, in the CAST group, dorsal tilt, radial inclination, and radial shortening averaged -24.4 +/- 12 degrees, 19.2 +/- 6.5 degrees, and +3.9 +/- 2.7 mm, respectively. Malunion occurred in 89% primarily reduced fractures. Dorsal tilt, radial inclination, and radial shortening were significantly better in the ORIF group. CONCLUSIONS Radiographic results (dorsal tilt, radial inclination, and radial shortening) after unstable dorsally displaced DRFs are significantly better in patients treated by ORIF using a volar fixed-angle plate rather than those treated by cast immobilization (P < 0.05). At a mean follow-up time of 4 years and 7 months, the clinical outcomes of active range of motion, the PRWE, DASH, and Green and O'Brien scores do not differ between the 2 methods of treatment. The pain level was significantly less in the CAST group (P < 0.05), and this group experienced no complications. There was no difference between the subjective and functional outcomes for the surgical and the nonsurgical treatments in a cohort of patients older than 70 years. Unsatisfactory radiographic outcome in older patients does not necessarily translate into unsatisfactory functional outcome. Nonoperative treatment may be the preferred method of treatment in this age group.
A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.
Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck (MUI), Anichstrasse 35, Innsbruck, Austria. email@example.com.
BACKGROUND Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older:(1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting). METHODS A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance. RESULTS There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05). CONCLUSIONS At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.
[Stabilization of perilunate and transscaphoid perilunate fracture-dislocations via a combined palmar and dorsal approach].
Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Innsbruck, Osterreich. firstname.lastname@example.org
OBJECTIVE: Restoration of the intercarpal alignment and the radio- and ulnocarpal joint in order to avoid the development of a carpal collapse with concomitant arthritis of the radiocarpal and midcarpal joint. INDICATIONS: All perilunate and transscaphoid perilunate fracture-dislocations. An exception is a pure ligamentous injury with anatomic carpal alignment following closed reduction (computed tomography scan). CONTRAINDICATIONS: General contraindications to an operative procedure. SURGICAL TECHNIQUE: It is crucial that all involved bony and ligamentous structures are addressed, using a bilateral approach. Depending on their location, scaphoid fractures are stabilized from proximal or distal, and bony avulsions are fixed at their origin. The typical rent across the palmar ligaments is closed, and the avulsed scapholunate ligament and the dorsal intercarpal ligament are reattached to the adjacent bones. Temporary Kirschner wire fixation is essential for healing. POSTOPERATIVE MANAGEMENT: Forearm plaster cast with short thumb for 12 weeks. Kirschner wire removal after 8 weeks. RESULTS: 25 patients (15 perilunate dislocations and ten perilunate fracture-dislocations) could be included for follow-up 5 years after the trauma. Perilunate fracture-dislocations achieved slightly better results than perilunate dislocations. The DASH Score (Disability of the Arm, Shoulder and Hand) averaged 11.3 and 14.2 points, the PRWE Score (Patient- Related Wrist Evaluation) 20.7 and 27.7 points, respectively. The Mayo Wrist Score amounted to 81.5 and 82.7 points. Active range of wrist motion was reduced by one third compared with the opposite side. Grip strength was reduced by 15-20%. The pain level ranged between 2 and 4 on a scale from 0 to 10. In pure ligamentous injuries, degenerative arthritis was more common in the midcarpal joint, whereas radiocarpal arthritis predominated in the fracture-dislocation group.
[Modified Ishiguro extension block technique for fracture-dislocation of the distal interphalangeal joint]
Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstrasse 35, Innsbruck, Austria. email@example.com
OBJECTIVE: Reconstruction of the anatomic configuration of the articular surface and restoration of complete movement of the finger joint. INDICATIONS: Fracture of the distal interphalangeal (DIP) joint involving > or = 30% of the articular surface. Luxation or subluxation of the distal phalanx. Fracture-dislocation > or = 2 mm. CONTRAINDICATIONS: Old fractures. Closed reduction impossible. SURGICAL TECHNIQUE: Closed reduction and pin fixation modified from Ishiguro technique without penetrating the fracture fragment. POSTOPERATIVE MANAGEMENT: Cast fixation for 4 weeks with the finger in functional position or with the proximal interphalangeal joint flexed to relax the pulley. After 4 weeks, removal of the cast and the pin and start of active motion exercises. RESULTS: Twelve patients with fracture-dislocation of the DIP joint involving more than one third of the articular surface were treated with the modified extension block technique according to Ishiguro. Time from injury to surgery was 5 days (range, 0-8 days). At a mean follow-up of 15 months (range, 9-31 months), pain on the visual analog scale (VAS, 0 = no pain, 10 = maximum pain), the active range of motion, and criteria according to Warren et al. were evaluated. Eleven patients were pain-free and one patient suffered from mild pain during strenuous work. The mean active range of motion was from -3 degrees extension (range, 0-10 degrees ) and flexion to 79 degrees (range, 45-100 degrees ). The results according to Warren et al. were very good in ten and good in two cases.
Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstrasse 35, Innsbruck, Austria. firstname.lastname@example.org
OBJECTIVE: Reconstruction of extensor functions after extensor tendon injuries of the hand. INDICATIONS: Acute injuries of extensor mechanism with corresponding loss of function. CONTRAINDICATIONS: Complex injuries with loss of soft tissue. Limited possibility of extensor tendon reconstruction with combined injuries of the interphalangeal joints (in situations with irreparable joints: primary arthrodesis). SURGICAL TECHNIQUE: The treatment of extensor tendon injuries depends on the various levels of tendon laceration. Zones 1 and 2: in case of tendon disruption close to the base of the distal phalanx, refixation of tractus terminalis using a pull-out suture. In case of disruption more proximally, primary repair using mattress sutures. Temporary pinning of the distal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 3: mattress sutures of the tractus intermedius. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 4: reconstruction of the central slip and the lateral slip of extensor tendon using modified Becker sutures and mattress sutures. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zones 5 and 6: four-strand modified Becker sutures with additional epitendinous suture. Zones 7 and 8: core sutures using modified Kirchmayr techniques with additional epitendinous suture. POSTOPERATIVE MANAGEMENT: Zones 1-4: immobilization of the finger for 6 weeks with removal of the transarticular wire at 4 weeks. Zones 5-8: dynamic postoperative treatment in intrinsic-plus splint for 6 weeks. RESULTS: It is postulated that dynamic postoperative treatment leads to improved functional outcome after extensor tendon injuries. While for zones 1-4 no better final clinical results are observed using the dynamic postoperative protocol, early protected motion for zones 5-8 is superior to static post operative treatment.
Long-Term Subjective and Radiological Outcome After Reconstruction of Kienböck's Disease Stage 3 Treated by a Free Vascularized Iliac Bone Graft.
Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck (MUI), Innsbruck, Austria.
PURPOSE: Various vascularized bone grafts are used for surgical treatment of Kienböck's disease. Long-term results of free vascularized iliac bone grafts for treatment of Kienböck's disease are not reported in the literature. The purpose of this study is to report the over-10-year results and to compare them with the 5-year results to determine whether the favorable intermediate-term results were maintained. METHODS: Eighteen patients with Lichtman stage III were treated with free vascularized iliac bone grafting and followed up for a mean period of 13 years. Assessment included active range of wrist motion, grip strength, level of pain measured using the visual analog scale (VAS), and patient disability and functional outcome measured by the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire as well as the Green and O'Brien score. Radiological evaluation included Ståhl index, Youm carpal height index, radioscaphoid angle (RSA), radiolunate angle (RLA) and integration of the free vascularized bone graft. The long-term results were compared with both the preoperative condition and the 5-year results. RESULTS: Postoperative x-rays showed definite osseointegration of the vascularized bone graft in 89%(16/18). The average flexion-extension arc, the wrist deviation arc, pain, and grip strength improved considerably after surgery, and the results were maintained for a long period. Pronation and supination were not restricted in pre- and postoperative range of motion. The mean DASH score at final follow-up was 8.4 points. The Green and O'Brien score showed 50% excellent, 31% good, and 19% fair results. The average Ståhl index and the average Youm index, improved postoperatively and could be maintained for over 10 years follow-up. Two patients presented with a resorption of the bone graft, with ongoing radiologic progression of Lichtman stage, reduced range of motion, and high pain level. CONCLUSIONS: Free vascularized iliac bone grafting for Kienböck's disease is a reasonable treatment option, and clinical and radiological improvements last for a long period of time. Long-term restoration of carpal height could be demonstrated. Progression of disease could be prevented in 89%(16 of 18) of patients over a mean time of 13 years. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate.
Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria. email@example.com
OBJECTIVES The increasing number of fixed-angle plate systems used to treat distal radius fractures carries with it the problem of determining the optimal fixation for unstable fractures. Our goal was to analyze the clinical and radiological outcomes of patients with displaced, unstable distal radius fractures treated with a palmar fixed-angle plate. DESIGN Prospective protocol; multicenter clinical study; retrospective analysis. SETTING Level 1 university trauma centers. PATIENTS Over a mean 15-month period (range, 12 to 27 months), 141 consecutive patients were treated for an unstable dorsally displaced distal radius fracture of which 114 or 81% were followed for 1 year or longer. INTERVENTION Open reduction and palmar internal fixation with a fixed-angle plate (2.4 mm LCP Distal Radius Plates; Synthes, Salzburg, Austria). Indication for surgical treatment was the inability to obtain or maintain fracture or articular alignment after initial closed reduction. MAIN OUTCOME MEASURES In a follow-up period, which had to be longer than 12 months, objective and subjective functional results (active range of motion; strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS); Green and O'Brien Score) and radiographic assessment (palmar tilt, radial inclination, ulnar variance, fracture union) were assessed. Potentials for complications were given special attention. RESULTS In the 114 patients followed for a minimum of 12 months, there were 21 men and 93 women with a mean age of 57 years (17 to 79 years). Fractures were classified according to the AO/ASIF classification system as type A2 (n = 39), A3 (n = 16), C1 (n = 24), C2 (n = 30), or C3 (n = 5). The modified Green and O'Brien Score revealed 31 excellent, 54 good, 23 fair, and 6 poor results. Active wrist motion averaged 54 degrees extension (82% as compared with the uninjured side) and 46 degrees flexion (72% as compared with the uninjured side). The average pronation was 81 degrees (95% as compared with the uninjured side), and the average supination was 82 degrees (95% as compared with the uninjured side). Mean grip strength at final follow-up was 70% of the uninjured side. Low residual pain values in the wrist were demonstrated: 81 patients (71%) were pain free, 17 patients (15%) had mild pain, 10 patients (9%) had moderate pain, and 6 patients (5%) had severe pain. The DASH score averaged 13 points (range, 0 to 39 points). Fracture union was achieved in all patients. A mean loss of palmar tilt of 3.4 degrees (range, 0 to 8 degrees), radial inclination of 0.4 degrees (range 0 to 2 degrees), and of the ulnar variance of 1.2 mm (range, 0 to 6 mm) was measured. The overall complication rate was 27%(31/114). The most frequent problems were flexor and extensor tendon irritation (57% of the total number of complications), including 2 ruptures of the flexor pollicis longus tendon, 2 ruptures of the extensor pollicis longus tendon, 4 cases of extensor tendon tenosynovitis, and 9 cases of flexor tendon tenosynovitis. Carpal tunnel syndrome was observed in 3 patients, and complex regional pain syndrome occurred in 5 patients. In 2 cases, loosening of a single screw was seen. Delayed fracture union occurred in 3 patients, and intraoperative intraarticular screw displacement was recognized in 1 patient. Neither clinical outcome nor complication rate were dependent on fracture type (intraarticular versus extraarticular). CONCLUSION Fixation of unstable dorsally displaced distal radius fractures with a fixed angle plate provides sufficient stability with minimal loss of reduction. Nevertheless, very distal palmar plate position can interfere with the flexor tendon system, too long screws can penetrate the extensor compartments, and distal screws in comminuted fracture patterns can cut through the subchondral bone and penetrate into the radiocarpal joint. Mindful of these problems, we consider that the complex fracture pattern of an unstable distal radius fracture cannot be treated by a single plate system and approach.
Department of Trauma Surgery and Sports Medicine, University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. Robert.Zimmermann@uklibk.ac.at
INTRODUCTION The purpose of this retrospective study was to investigate the frequency and extent of clinical and radiological late sequelae and to identify predicting factors. MATERIALS AND METHODS A total of 220 patients of growing age with 232 closed, conservatively treated fractures were re-examined clinically and radiologically at a median follow-up time of 10 years (range 5-16 years). Clinical and radiological findings were summarised as an overall result. RESULTS Of the total of patients, 19% reported pain in the injured wrist, and wrist mobility was limited in 5% of patients. Forearm rotation was decreased in 16%, primarily in epiphyseal separation of the ulna ( p=0.0033). Radial inclination was different in 6% of patients, palmar tilt in 2%, and ulnar variance in 37%, compared with the contralateral side. Ulnocarpal impaction syndrome was present in 75% of the patients with positive ulnar variance. Overall outcome was excellent in 72%, good in 19%, moderate in 6%, and poor in 3% of patients. The younger the children were at the time of injury, the more favourable the results were ( p=0.009). Children who were older than 10 years when they suffered a severe fracture dislocation had the poorest results ( p=0.008). Further factors having a negative influence on outcome were repeated reduction maneuvers and an additional fracture of the ulna. CONCLUSION Our follow-up examinations showed that the majority of patients achieved good results, especially in children under 10 years old. Large dislocations at the time of fracture healing do not influence long-term results in this age group and thus can be tolerated. Patients over 10 years old, whose fractures healed with an angular deformity of more than 20 degrees and/or fragment dislocation over half the breadth of the shaft showed the poorest results. Thus, such dislocations should not be tolerated, and reduction should be attempted in this age group by only one reduction maneuver.
Treatment of distal radioulnar joint disorders with a modified Sauvé-Kapandji procedure: long-term outcome with special attention to the DASH Questionnaire.
Department of Trauma Surgery and Sports Medicine, University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. Robert.Zimmermann@uklibk.ac.at
INTRODUCTION: An intact distal radioulnar joint (DRUJ) is essential for normal functioning of the upper limb. Osteoarthritis of the DRUJ often leads to ulnar wrist pain, limitation of forearm rotation and reduced grip strength, all of which limit activities of daily living. Once the joint is damaged, salvage procedures are recommended. MATERIALS AND METHODS: Between 1986 and 1996 a modified Sauvé-Kapandji procedure was performed in 117 patients with painfully limited forearm rotation and osteoarthritis of the distal radioulnar joint (DRUJ). Of the 117 patients, 73 women and 32 men, whose ages at operation ranged from 22 to 74 years (average 58 years), were retrospectively reviewed clinically and radiologically 8 years (range 5-12 years) after the operation. The DASH questionnaire was used with 53 patients, 43 patients were accepted for the study, and 10 were excluded. RESULTS: Forearm rotation improved in all patients, ulnar wrist pain was reduced in 97% of the patients, and 9% had mild pain at the proximal ulnar stump. Grip strength improved from a preoperative mean of 38% to a postoperative mean of 55% compared with the contralateral side. The mean DASH score was 28 points (range 0-53 points). In all cases the arthrodesis fused within 8 weeks. The radiographs showed approximation between the proximal ulna stump and the radius compared with the preoperative situation in 74% of the patients. CONCLUSION: Our clinical and radiological findings suggest that the Sauvé-Kapandji procedure is indicated in symptomatic, non-reconstructable disorders of the DRUJ. The DASH questionnaire provides a general view of the functional outcome after the Sauvé-Kapandji procedure. The DASH questionnaire is very helpful in evaluating the effect of the Sauvé-Kapandji procedure on the entire upper limb.
Injectable calcium phosphate bone cement Norian SRS for the treatment of intra-articular compression fractures of the distal radius in osteoporotic women.
Department of Trauma and Sports Medicine, University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. Robert.Zimmermann@uklibk.ac.at
BACKGROUND Distal radius fracture often presents a metaphyseal void which is more extended in elderly, osteoporotic patients. Bone graft and bone substitutes are reported to be beneficial in maintaining metaphyseal reduction. METHODS We performed a prospective study on 52 menopausal, osteoporotic women with unstable intra-articular distal radius fractures to compare the outcome of percutaneous pinning and immobilisation in a cast for 6 weeks with that using injectable calcium phosphate bone cement (Norian Skeletal Repair System, SRS) to supplement pin and screw fixation and immobilisation in a cast for 3 weeks. All patients were reviewed 2 years (range 21-29 months) after surgery. RESULTS Patients treated with SRS had better functional outcome, restoration of movement and grip strength ( p<0.001). In this group there was 1 mm loss of radial length, 3 degrees loss of radial inclination and 7 degrees loss of palmar tilt. In the control group radial length decreased 3 mm, radial inclination decreased 11 degrees and palmar tilt 12 degrees. Loss of reduction was significantly higher in the control group ( p<0.001). CONCLUSION We conclude that the use of Norian SRS to supplement pin and screw fixation is effective in maintaining the reduction of unstable intra-articular distal radius fractures in osteoporotic patients and provides a better clinical outcome than percutaneous pinning.
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Mali Med. 2007 ;22 (3):43-6 19434993
Service de chirurgie pédiatrique du centre Hospitalier Universitaire de Yopougon.
OBJECTIVE: To describe epidemiology and to bring back the results of the treatment of the fractures of the forearm fracture. POPULATION AND METHOD: During 3 years and 3 months, we studied the forearm fractures of the children from 0 to 15 years. For each one of them, we studied, the age, the sex, the aetiology and the characteristics of the fracture, the treatment carried out and their evolution. RESULTS: Sixty-nine forearm fractures were listed, the frequency was 23 fractures per years. The sex ratio was 2,63 and the average age was 8 years and 2 months with 13 month and 15 years as extremes. The accidents of play accounted for 93% of the aetiologies. The cutaneous injuries were associated to the fracture in 30 cases (43%). The fractures with displacement was observed in 25 cases (36%), green steak fracture in 21 case (30%), fracture without displacement in 13 case (19%) and other displacements 10 cases (15%). The treatment was orthopaedic (reduction and immobilisation) in 97% of the cases. We observed 3 cases (4%) of secondary displacements under plaster and 6 cases (9%) of the vicious cal. CONCLUSION: The orthopaedic treatment is usually indicated for the Key words: fractures with anatomical restitution. The failures of the orthopaedic treatment need to be treated surgically.
Weight loss and distal forearm fractures in postmenopausal women : The Nord-Trøndelag health study, Norway.
Section for Preventive Medicine and Epidemiology, Institute of General Practice and Community Medicine, University of Oslo, Oslo, Norway, firstname.lastname@example.org.
Weight loss is a risk factor for hip fractures, but few studies have evaluated the effect of weight loss on distal forearm fracture risk. In this longitudinal study including 7,871 postmenopausal women, weight loss of 5% or more was associated with an increased risk of distal forearm fractures. INTRODUCTION: Weight loss is an established risk factor for hip fractures, but little is known about weight loss and distal forearm fractures risk. METHODS: The study included 7,871 women aged 65 years or more in the Nord-Trøndelag health study (HUNT) in 1994-1995 (HUNT II) who also had their height and weight measured in 1984-1986 (HUNT I). Forearm bone mineral density (BMD) by single energy x-ray absorptiometry was available for 5,688 women (HUNT II). Fractures sustained after HUNT II were registered during an average of 5.8 years. RESULTS: A total of 536 women sustained a distal forearm fracture. After adjustments for age and body mass index (BMI) at HUNT I, women who lost >/=5% of their weight between HUNT I and HUNT II had a relative risk of fractures of 1.33 (95% confidence interval: 1.09, 1.62) compared with the rest of the women. The higher risk of forearm fracture among women with weight loss was at least partially explained by their lower forearm BMD. CONCLUSION: Weight loss of 5% or more was associated with a 33% increased risk of distal forearm fractures.
Department of Orthopaedic Surgery Temple University Hospital, Philadelphia, USA.
Fractures of the forearm represent common injuries. Understanding the anatomy and function of the radius, ulna, interosseous membrane, proximal and distal radioulnar joints is critical to appropriate management. Diagnosis can readily be made by examination and radiographs. Well established surgical approaches including the anterior Henry, dorsal Thompson, and ulnar approaches provide excellent access to both the radius and ulna. Multiple fracture patterns are recognized including isolated radius and ulna fractures, combined fractures, Galeazzi fractures, and Monteggia fractures. Surgical management regularly requires open reduction internal fixation with plates (DCP) and screws with vigilance being paid to stable reduction of the proximal and distal radioulnar joints. New directions in the management of forearm fractures include the use of intramedullary fixation and locking plate technology.
Department of Orthopedics Surgery, Jordan University Hospital, Amman, Jordan, email@example.com.
No published studies have addressed the role of hand dominance in various types of forearm fractures. The present study aims to investigate the effects of the dominant hand and gender in forearm fractures in children and adolescents. In a prospective study, 181 children aged 2-15 years presenting with unilateral forearm fracture were examined over a 6-year period, investigating the role of the dominant hand, fractured side, fractured site, and gender in different types of forearm fractures. Forearm fractures occur more often in boys and are more common on the left side (P = 0.001, 0.029, respectively). Isolated distal radius fracture is more common than distal radius and ulna fracture in right-handed children (P = 0.008). Increases in the number of middle forearm fractures in the dominant hand in left-handed children (P = 0.0056) may be due to mechanisms of injury other than a simple indirect fall or severe injury preventing the use of the dominant hand as a preventive measure. The mean age for boys and girls at the time of forearm fractures was 8.97 and 5.98 years, respectively, which may be attributed to older girls tending not to do as many outside-the-home activities as boys at this age. Overall, forearm fractures are more common in the non-dominant hand, in boys, and in both distal forearm bones.
Moscow City Clinical Hospital #20, Department of Traumatology, Russian Peoples' Friendship University, Department of Traumatology and Orthopaedics.
Although distal radius fractures are in the centre of orthopedic surgeons' attention, the rate of unsatisfactory treatment results remains very high. This study evaluates the analytical approach to distal radius fracture treatment. We observed 59 patients divided into 4 groups according to a modified Fernandez classification, regarding the patomechanism of injury: 1. bending extraarticular fractures; 2. shearing fractures; 3. comminuted fractures, and 4. malunions. We also took account of patients' compliance and demands. 1st and 2nd group patients underwent ORIF, the 3rd group was subjected to external fixation, and the 4th group underwent radial corrective osteotomy with plating. We obtained 53% good, 40% satisfactory and 7% poor results according to the Mattis score. We consider such analytical approach to distal forearm fracture treatment very promising and well-founded.
Centre of Endocrinology, The Hormone Laboratory, Aker University Hospital, 0514 Oslo, Norway. firstname.lastname@example.org
UNLABELLED The population of Oslo has the highest incidence of hip fracture reported. The present study shows that the overall incidence of distal forearm fractures in Oslo is higher than in other countries and has not changed significantly when comparing the incidence of 1998/99 with 1979. INTRODUCTION The population of Oslo has the highest incidence of hip fracture reported. The present study reports the incidence of distal forearm fracture in Oslo and the fracture rates of immigrants. METHODS Patients aged > or = 20 years resident in Oslo sustaining a distal forearm fracture in a one-year period in 1998/99 were identified using electronic diagnosis registers, patient protocols, and/or X-ray registers of the clinics in Oslo. Medical records were obtained and the diagnosis verified. The age- and sex-specific incidence rates were calculated and compared with those for 1979. Data on immigrant category and country of origin of the patients were obtained. RESULTS The age-adjusted fracture rates per 10,000 for the age group > or = 50 years were 109.8 and 25.4 in 1998/99 compared with 108.3 and 23.5 in 1979 for women and men, respectively (n.s.). The relative risk of fracture in Asians was 0.72 (95% CI 0.53-1.00) compared with ethnic Norwegians. CONCLUSIONS The overall incidence of distal forearm fractures in Oslo is higher than in other countries and has not changed significantly when comparing the incidence of 1998/99 with 1979. Furthermore, the present data suggest that Asian immigrants in Oslo have a slightly lower fracture risk than ethnic Norwegians.
Section of Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06504, USA. Lei.email@example.com
BACKGROUND Forearm fractures are common injuries in children. Displaced and angulated fractures usually require reduction. Ultrasound diagnosis and guided reduction offer several potential advantages:(1) the procedure does not involve ionizing radiation;(2) compared with fluoroscopy units, the newer ultrasound units are more portable; and (3) repeated studies can be obtained easily and quickly. OBJECTIVE The primary objective was to investigate the accuracy of emergency department (ED) physician-performed ultrasound in the diagnosis and guided reduction of forearm fractures in children. METHODS Children suspected of having forearm fractures were enrolled prospectively in an urban pediatric ED from June 2004 to November 2004. A bedside ultrasound of the forearm bones was performed by a pediatric emergency medicine physician. Ultrasound findings were compared with radiograph findings. Reductions were performed under ultrasound guidance. Postreduction radiographs were performed. Any need for further reduction was recorded. RESULTS During the study period, 68 patients were enrolled. Radiographs revealed forearm fractures in 48 patients. Twenty-nine subjects had fractures of the radius alone; 17 had fractures of both the radius and the ulna, and 2 had fractures of the ulna alone. Ultrasound revealed the correct type and location of the fracture in 46 patients. The sensitivity for the detection of forearm fractures was 97%(95% confidence interval [CI], 89%-100%) using ultrasound. The specificity was 100%(95% CI, 83%-100%). Twenty-six subjects underwent reduction of their fractures in the ED. Two subjects required rereduction after the initial reduction. The initial success rate of ultrasound-guided reduction was 92%(95% CI, 75%-99%). CONCLUSIONS Bedside ultrasound performed by pediatric emergency medicine physicians is a reliable and convenient method of diagnosing forearm fractures in children. It is also useful in guiding the reduction of these fractures.
Division of Epidemiology, Norwegian Institute of Public Health, Nydalen, P.O. Box 4404, 0403, Oslo, Norway.
The prevalence of forearm fractures increased with increasing degree of urbanization for both genders in the population-based study "Cohort Norway" with more than 180,000 participants. The differences were not explained by available risk factors. Prospective studies with information on bone mineral density and falls are warranted. INTRODUCTION: The purpose was to investigate urban-rural gradients in self-reported forearm fractures and assess the contribution of possible explanatory factors. METHODS:"Cohort Norway" comprises ten population-based surveys inviting 309,742 individuals age 20 years and older. All 181,891 participants underwent a standardized examination and answered 50 common questions, including one concerning former forearm fractures. Based on the home-addresses, participants were divided into three population density groups: cities, densely populated areas and sparsely populated areas. Analyses were limited to 149,725 participants 30 years or over with valid information on exposure and outcome. Of these, 21,627 reported having suffered a forearm fracture. RESULTS: The prevalence of forearm fractures increased with increasing degree of urbanization for both genders. After adjustment for age and explanatory factors, the odds ratio of having sustained a forearm fracture in men living in densely populated areas and in cities were 1.12 (95% CI, 1.04-1.21) and 1.38 (95% CI, 1.30-1.46), respectively, compared to rural areas. Similar odds ratios were observed among women. CONCLUSIONS: Prospective studies are needed to verify whether lower bone mineral density, different lifestyle and/or more falls may explain the higher proportion of self-reported forearm fractures found in urban compared to rural areas.
Connecticut Children's Medical Center, Department of Orthopaedics, Hartford, CT, USA.
Both-bone forearm fractures of the radius and ulna are a common injury in children. Closed reduction and casting has historically been the primary means of treatment in over 90% of these fractures. Unstable and irreducible fractures, however, often pose a therapeutic challenge, with little data available to compare outcomes. The authors performed a retrospective review of 50 children with both-bones fractures treated with closed reduction and cast immobilization, open reduction and internal fixation (ORIF), or intramedullary (IM) nailing. Complications were tabulated and separated by treatment modality and subdivided into minor/major complications. Statistical regression was performed. There were 54 operations in 50 patients with both-bones fractures. All fractures healed within 8 to 10 weeks, except for two delayed unions and one nonunion. The complication rate was 5% for closed treatment, 33% for ORIF, and 42% for IM nailing. Complication rates were significantly different between the closed and operative groups. When comparing treatments in pediatric both-bones fractures, there are significantly more complications with operative techniques. Patients with ORIF had more major complications, often requiring a return to the operating room. IM nailing, when done correctly, is as acceptable and safe a form of treatment.