Buttress pinning in the unstable distal radial fracture. A modification of the Kapandji technique

Between 1989 and 1993, 20 patients with distal radial fractures were treated with a buttressing technique felt to be safe, effective and simple. Out of the initial 20 patients, 16 have been followed-up and are reported. The technique uses an intramedullary styloid pin and a combined extramedullary-intramedullary dorsal buttress pin. The insertion technique and the use of a medial corner pin are illustrated. Results are evaluated from both final X-ray appearance as well as return of function using the five X-ray parameters of Abbasazadegan et al (1989) and the Mayo modification of the Green and O'Brien wrist score (Cooney et al, 1987). The average score on return of function was 78 (two excellent, eight good, six fair). Final axial shortening averaged -1.4 mm (+5 mm--4 mm), radial displacement averaged 0.68 mm (0 mm-5 mm), radial angle averaged 24.75 degrees (18 degrees-34 degrees), dorsal angle averaged +8.25 degrees (-5 degrees-25 degrees) and dorsal displacement averaged +1.31 (0 mm(-)+12 mm). From this study we recognize the need for a posterior medial pin, and that routine stress views after pinning can yield information concerning carpal instability, palmar instability and the need for bone grafting.

Decision making in distal radius fractures

In distal radius fractures, function follows restoration of preinjury anatomic landmarks. The allowable deviation from these measurements is relatively small if optimal results are to be achieved, particularly in younger individuals. A hierarchy of treatment options--characterized by increasing invasiveness--exists for treating these injuries. As this hierarchy is ascended, treatment-related complications increase. It appears reasonable to select the least invasive treatment option capable of achieving satisfactory anatomic alignment. Hand and extremity function must be addressed early, and a conscientious effort must be exerted to avoid residual stiffness or the development of reflex sympathetic dystrophy.

Prediction of secondary displacement in Colles' fracture

In a prospective study, 645 consecutive Colles' fractures treated conservatively were followed until union. The fractures subsequently lost some of their manipulated position during the immobilization period. However, the anatomical end result was significantly improved compared with the initial deformity. The mean shortening of the radius during plaster-cast treatment was 3 mm, and the mean increase of dorsal angulation was 7 degrees. Multiple regression analyses showed that initial dorsal angulation, age, and Older type were important predictor variables for the end result of dorsal angulation. Initial radial length, age and initial dorsal angulation were of importance for the end result of radial length. The strongest linear relationship was found between the end result of radial length and the initial radial length (r = 0.67). This may indicate that the patients who will malunite with radial shortening are those with significant radial axial shortening at the initial presentation. Thus, these patients should be treated with a more stable fixation device.

Treatment of complex intra-articular distal radius fractures

Techniques for reduction and fixation of intra-articular distal radius fractures have improved in recent years such that fractures that were once thought doomed to a poor result may now be successfully treated operatively. This article explores open, semi-open, and arthroscopically assisted techniques for reduction and fixation of complex distal radius fractures. The reader should gain an appreciation of which fractures can benefit from operative treatment and which techniques may be most useful for specific fracture types. A number of fixation techniques are described, and familiarity with diverse methods will aid the surgeon in complex cases.

[Resection of the ulnar head in post-traumatic wrist pain]

In a retrospective study, the effect of distal ulnar resection using the Darrach procedure was evaluated in 42 patients with post-traumatic distal radio-ulnar disability. Thirty women and 12 men, mean age 43 years were seen an average of seven years after the operation. In 57% of the cases the primary trauma was a Colles fracture. The main indication for operation was pain radiating from the distal radio-ulnar joint (83%), but seven patients were without substantial pain. 79% of the patients felt relief of pain after the operation, but 62% still suffered from occasional wrist pain. Twenty-six patients had a supination and a pronation of > or = 150 degrees postoperatively. Thirty-three patients had a dynamic handpower of > 60% of the opposite hand postoperatively. Ten patients stopped working or changed to less physically demanding jobs after the primary trauma. Three patients from this group could after the operation return to their primary physically demanding jobs. Radiographs showed no progress of radiocarpal osteoarthritis during the follow-up period. The Darrach procedure could relieve post-traumatic distal radioulnar pain conditions without adverse effect on radiocarpal function and alignment. Patients who only had mild pain symptoms preoperatively presented unsatisfactory postoperative results.

Opening wedge osteotomy for malunion of the distal radius with neuropathy. 13 cases followed for 6 (1-11) years

13 patients with malunion of the distal radius after Colles' fractures and electroneurographically verified median nerve compression underwent an opening wedge osteotomy without a simultaneous release of the transverse carpal ligament. 12 patients had reduction of the typical night pain with normal or almost normal sensibility within the first 2 months. In 1 patient a release of the carpal ligament was necessary after 6 months. 6 years postoperatively all patients had acceptable wrist function with normal function of the median nerve in all but one.

Algodystrophy: an under-recognized complication of minor trauma

Algodystrophy is a poorly recognized condition of uncertain aetiology which presents with pain and tenderness, vascular instability, swelling and stiffness of an affected limb. It is most commonly seen after trauma. In order to ascertain its incidence, natural history and the degree of morbidity induced we studied prospectively 274 patients with Colles' fracture. Algodystrophy, as judged by the presence of bone pain or tenderness, vasomotor symptoms, swelling and stiffness of the hand was noted in 28% of patients. There was a significant association between the presence of these features (P < 0.0001). The degree of trauma sustained was identified as a predisposing factor. Actuarial analysis showed a gradual resolution of symptoms. Six months after injury, the proportion of patients complaining of pain and swelling had fallen to 20-30%, vascular instability and tenderness to 50% and stiffness to 80%. Failure to improve was associated with a significant loss of hand function (P < 0.0001). By 1 yr, pain and tenderness, vascular instability and swelling had decreased still further but stiffness was still apparent in 50%. We believe that algodystrophy is a neglected disorder and is far more common than formerly appreciated. Although it often resolves spontaneously, it is associated with a significant increase in short-term morbidity in the majority of patients and persistent dysfunction in a minority.

[Colles fracture and instability of wrist joint]

We reviewed 51 cases of colles fracture patients with 3-6 years follow-up and found 20 cases had dorsal carpal subluxation (DCS) in this group. Long term results were analysed and compared between the simple Colles fracture and the Colles fracture with DCS. It was shown that the remote function of the wrist in the simple Colles fracture was much more satisfactory than in that with DCS. That indicated the DCS is a very important factor to the late results of the wrist after Colles fracture. The authors pointed out that the DCS occurs frequently in the severely displaced type caused by high energy force and in the fracture associated with scapholunate dissociation. During the close reduction of the Colles fracture associated with DCS, correction of the palmar angulation and decrease of the angle of palmar tilt should be required, as well as the neutral or light dorsal flexion fixation of the wrist after reduction.

Colles' fractures: the use of the metacarpal index as a prognostic indicator investigated

The radiographs of 25 patients who presented to the Whittington Hospital with Colles' fractures were studied. Measurements of dorsal angulation and radial shortening were made on radiographs taken at presentation, following reduction (where performed) and 5 weeks after injury. The presence, and degree, of osteoporosis was assessed using the metacarpal index. There was a strong correlation between the degree of osteoporosis and age. There was no correlation between the degree of osteoporosis, as determined by the metacarpal index, and either the severity of the injury or the final result. Thus, the metacarpal index is not a useful prognostic indicator as to the radiological outcome of Colles' fractures. The single most important factor influencing the radiological result was the quality of the initial reduction.

Treatment of complex fractures of the distal radius. Combined use of internal and external fixation and arthroscopic reduction

A group of fractures of the distal radius are inherently unstable and cannot be treated by closed reduction and cast or external fixation. These fractures are high-energy motor vehicle accidents often seen in young adults but possible in nearly every age group. They are not typical Colles's fractures because they are intra-articular with displacement of the joint articular surfaces. The goals of treatment are to obtain an anatomic reduction and then to proceed with treatment techniques to maintain the reduction by whatever methods are available or necessary within the experience of the treating surgeon. Previous admonitions that Colles's fractures should not be treated by open reduction are incorrect. Like other intra-articular fractures, the goal is anatomic alignment. Limited open reduction or newer arthroscopic techniques may be sufficient. A more aggressive approach of open reduction, internal and external fixation, and autogenous bone grafting is now indicated in most high-energy distal radius fractures to achieve the treatment goals defined earlier: anatomic joint surface reduction, restoration of radial length, and correction of dorsal malangulation.

Function ten years after Colles' fracture

There are no data in the literature concerning the outcome of Colles' fracture beyond six years. One hundred consecutive patients with displaced Colles' fractures were reviewed ten years after the injury. Function, radiographic anatomy, osteoarthrosis, and reflex sympathetic dystrophy (algodystrophy) were all objectively assessed. By the time of this review, 35 patients had died. Eighty-five percent of those surviving had a satisfactory outcome. Forty-two percent had improved functionally in ten years and 20% had deteriorated. Initial and ten-year radial shortening and early finger stiffness significantly correlated with final outcome. Dorsal angulation influenced early but not ten-year function. Sixty-two percent of those with an unsatisfactory result had objective features of reflex sympathetic dystrophy, compared with only 6% of those with a satisfactory result. Osteoarthrosis was found in 37%, but in only 4% was it associated with an unsatisfactory outcome.

The distal radio-ulnar joint in Colles' fractures

The effect of involvement of the distal radio-ulnar joint on subsequent function was studied in 170 patients with Colles' fractures, reviewed for one year after cast removal. Patients with involvement of this joint had significantly weaker grips and a significantly greater incidence of pain and tenderness over the joint at all stages of follow-up. They also had a poorer range of supination at six months and at one year. The presence or absence of an ulnar styloid fracture was not related to the functional results.

Changes in cortical and trabecular bone in algodystrophy

We studied the pattern of bone loss in the hand of 77 patients with Colles' fracture using metacarpal morphometry, single photon absorptiometry and a radiographic scoring system. Forty-four patients had post-traumatic algodystrophy and the remainder served as controls. Both groups were immobilized in the same manner and for the same period of time and both showed loss of bone during immobilization. The loss of bone 7 weeks after fracture was significantly greater in algodystrophy than in controls both at cortical (P < 0.05) and at trabecular sites (P < 0.001). Recovery of bone occurred in the control patients by 19 weeks after fracture at cortical sites and by 31 weeks in trabecular bone. In contrast, the bone loss seen in patients with algodystrophy persisted for the 6-month duration of the follow-up, and up to 1 year in all nine patients studied for longer. These findings indicate that post-traumatic algodystrophy is associated with regional skeletal losses greater than those following uncomplicated fracture and may result in irreversible changes in the structure and thus the strength of the bony architecture.

No effects of piroxicam on osteopenia and recovery after Colles' fracture. A randomized, double-blind, placebo-controlled, prospective trial

In a randomized double-blind study involving 42 postmenopausal women with a displaced Colles' fracture, we investigated whether piroxicam, a nonsteroid anti-inflammatory drug, can reduce posttraumatic osteopenia and improve the rate of recovery. In an earlier study [3] we found a bone-sparing effect caused by piroxicam after external fixation of the rabbit hindleg. The patients were treated with a below-elbow paster slab for 4 weeks after the reduction. The bone mineral content of the forearm bones was measured with a single-photon absorptiometer 8 weeks after the fracture. There was a mean 7% bone mineral decrease in the radius and 5% in the ulna among the patients treated with piroxicam versus 10% in the radius and 7% in the ulna in the placebo group. However, this difference was not significant. Piroxicam did not decrease the rate of fracture healing. The patients who received piroxicam had significantly less pain during plaster treatment, but there was no difference in the rate of functional recovery between the groups.

Features of algodystrophy ten years after Colles' fracture

The long-term outcome of algodystrophy is unknown. Ten years after Colles' fracture, 26% of 55 cases showed features of the syndrome. The finding of poor finger function three months following the fracture correlated significantly with the presence of components of algodystrophy after ten years.

Long-term prognosis of displaced Colles' fracture: a 10-year prospective review

In all, 85 per cent of Colles' fractures are clinically satisfactory after 10 years. Clinical results improve little after 3 months. Displaced intraarticular fracture, wrist deformity and algodystrophy are associated with an unsatisfactory outcome.

Bony transfixion of the median nerve following Colles' fracture. A case report

Reported herein is the case of a 45-year-old man with a Colles' fracture complicated by median nerve transfixion by a bony spike. This seems not to have been reported previously and reinforces the belief that early median nerve exploration should be performed if there is nerve dysfunction associated with a volar bony spike on the postreduction roentgenograms.

Minor axial shortening of the radius affects outcome of Colles' fracture treatment

Functional disability after a Colles' fracture was correlated to the degree of axial shortening of the radius measured at the site of distal radioulnar joint. According to the sum of demerit points, the functional end result was unsatisfactory (fair or poor) in 4% of the patients with an acceptable anatomic result, in 25% of the patients with grade 1 shortening (corresponding to a shortening of 3 to 5 mm), and in 31% of the patients with grade 2 shortening (shortening of more than 5 mm). The results suggest that even a minor axial shortening of the radius, without concomitant malalignment of the articular surface, carries an increased risk of permanent disability.

Radiographic changes in algodystrophy of the hand

It is not certain to what extent the radiographic features of post-traumatic algodystrophy can be differentiated from disuse atrophy following trauma. A semi-quantitative scoring system has been devised, grading the dominant features seen on radiography in both conditions following Colles' fracture. The technique had intra- and inter-observer errors of 14% and 17% respectively. When applied prospectively 7 weeks after Colles' fractures, there was a significantly greater score in patients with algodystrophy (p less than 0.001) than those without. Analysis of the scores was performed to identify a score for the optimal identification of algodystrophy. At a score of four or greater, 87.5% of patients with algodystrophy were positively identified with a positive predictive value of 83%. It is suggested that use of this scoring system will aid in the early diagnosis of algodystrophy.

Factors associated with Colles' fracture in the elderly

We have measured sway, hearing and eyesight in a group of elderly patients with Colles' fracture (3 males, 21 females, mean age 75.9 years) and in a control group of elderly fallers (5 males, 19 females, mean age 76.9 years) who had no fractures. The Colles' fracture group had better eyesight than the control group (p = 0.022), but worse hearing, particularly at lower frequencies (p less than 0.0001 at 500 Hz), suggesting a conductive hearing loss. We conclude that those individuals with better eyesight would try to stretch their arm to break a fall, so breaking their wrist. Osteoporotic changes in the auditory ossicles is proposed as a possible cause for the hearing loss in the Colles' fracture group. We conclude that those individuals presenting with Colles' fracture may also have hearing loss and conversely, patients presenting with a conductive hearing loss may be at risk of developing the further symptoms of osteoporosis.

External fixation or plaster cast for severely displaced Colles' fractures? Prospective 1-year study of 46 patients

In a prospective randomized study of 47 severely displaced Colles' fractures, 23 had external fixation and 24 had a dorsal plaster cast. Five fractures in the plaster-cast group redislocated and were externally fixed at rereduction after the 11-day follow-up. Three patients in the external-fixation group had a noncomplicated pin-tract infection, and 1 patient had a transient sensory disturbance arising from the cutaneous branch of the superficial radial nerve. After 1 year, the patients allocated to primary external fixation had a better radiographic and functional end result; according to Lidström's grading, 19/22 were excellent or good after external fixation as compared with 12/19 after plaster-cast treatment.