Fracture of the distal radius including sequelae--shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study

Classification and treatment of ulnar styloid nonunion

Symptomatic nonunion of the ulnar styloid is an uncommon problem that is usually best treated by simple excision of the ulnar styloid fragment. Two types of nonunion of the ulnar styloid are described here on an anatomic basis, and their treatment differs. Type 1 is defined as a nonunion associated with a stable distal radioulnar joint. Type 2 is defined as a nonunion associated with subluxation of the distal radioulnar joint. The postoperative follow-up period for the two types ranged from 4 months to 13 years, with a mean of 5 years 2 months. Eleven type 1 wrists were treated with excision of the fragment, and all patients had satisfactory relief of pain. Nine type 2 wrists required restoration of the anatomy of the traingular fibrocartilage complex. Three of these had large fragments that were treated by open reduction and internal fixation. All three patients were completely relieved of their discomfort. Six other patients underwent excision of the fragment and repair of the triangular fibrocartilage complex to the distal ulna. This group had four excellent, one good, and one fair result. If the distal radioulnar joint is stable on presentation or if its stability is restored, then long-term relief of pain from ulnar styloid nonunion is achieved by treatment of the nonunion.

Internal fixation of oblique metacarpal fractures. A biomechanical evaluation by impact loading

Internal fixation of oblique metacarpal fractures was studied in a cadaver model by impact loading. One hundred twenty fresh-frozen human metacarpals underwent compressive and bending impacts after oblique osteotomy and internal fixation. Dorsal plating with lag screws, 2 dorsal lag screws (2-screws), crossed Kirschner wire tension band (crossed K-wire), 5 stacked intramedullary Kirschner wire (5-rod), and paired intramedullary Kirschner wire (2-rod) were used. The failure occurred within 6 msec in the compressive impact and was almost immediate in the bending impact. The dorsal plate and the intramedullary rod fixations were the strongest and were not significantly different from the intact specimens in compressive impact; they were, however, 19% weaker in bending impact. The 2-screws was the weakest fixation in this group. This fixation was 59% weaker in compressive impact and 47% weaker in bending impact compared with the dorsal plating.

Ulnar nerve laceration in a closed both bone forearm fracture

Ulnar nerve injury is rarely associated with closed forearm fractures. This report describes a case of ulnar nerve laceration secondary to a closed fracture of the radius and ulna. Although a case report of an ulnar nerve laceration in an open fracture has been described, a review of the literature failed to reveal any cases in closed injuries. The standard surgical approach was modified to allow treatment of the fractures and microscopic repair of the nerve.

Dynamic external fixation versus non-operative treatment of severe distal radial fractures

Severe distal radius fractures often lead to impairment of wrist function, particularly in younger patients. This paper reports 55 consecutive patients younger than 65 years with displaced intra-articular fractures of the distal radius. Twenty-nine were treated with dynamic external fixation, and 26 with closed reduction and plaster cast immobilization. At least 1 year after the injury the anatomical and functional results were assessed using the scoring system of Lidstrom. In a retrospective analysis, both the anatomical and functional end score were significantly better in the dynamic external fixation group than in the group treated non-operatively (0.02 P < 0.05 using chi 2 analysis with Yates' correction). We conclude that dynamic external fixation is a good alternative for non-operative treatment in younger patients with severe distal radial fractures. Prospective evaluation of this subject is necessary.

Treatment of comminuted distal radius fractures: an approach based on pathomechanics

Following dorsally displaced fractures of the distal radius, the classic position of immobilization is with the wrist flexed and in ulnar deviation. This is not the position of function and entails morbidity in the form of finger stiffness, which may require prolonged rehabilitation. We treated 20 consecutive, comminuted, intraarticular distal radial fractures using a new external fixation system with the wrist in a neutral to extended position, thereby promoting metacarpophalangeal joint flexion by relatively relaxing the finger extensor tendons. Supplemental pin fixation was used in eight cases. Most patients were performing active digital motion on the day of surgery and 95% maintained functional finger motion during treatment. All fractures healed uneventfully. Palmar tilt was restored in 55% of patients in spite of a wrist neutral or extended position. This method of fixing distal radial fractures allows restoration of anatomy while avoiding hand stiffness.

Computed tomography scanning with image reconstruction in evaluation of distal radius fractures

Seventeen patients with 18 intraarticular distal radius fractures underwent computed tomography (CT) scanning and image reconstruction to evaluate their distal radius fractures. All patients were selected prospectively because of intraarticular extension and/or displacement of their fractures on pre- or post reduction plain films. Patients who were not surgical candidates for open reduction and internal fixation of their fracture were not included in the study. X-ray films and CT scans were viewed separately and in random order by a senior radiologist not familiar with the cases. Both x-ray films and CT scans readily showed extension of fracture lines into the radiocarpal joint, radial shaft, and the ulnar styloid, but CT scans were better than x-ray films at demonstrating fracture involvement of the distal radioulnar joint, the extent of articular surface depression, and the amount of comminution. Due to the cost, it is recommended that the test only be used for patients who are surgical candidates for open reduction and internal fixation or when more information about the extent of comminution and joint depression is required.

Dorsal pin placement and external fixation for correction of dorsal tilt in fractures of the distal radius

Insertion of a dorsal fixation pin was performed in 10 patients treated for distal radius fractures associated with dorsal angulation of the distal fragment. These fractures did not improve position with direct traction. Reduction was achieved with the use of a dorsal pin, used as a lever, to correct dorsal tilt of the fracture and to reestablish anterior angulation of 10 degrees in the distal joint surface of the radius. The dorsal pin was then fixed to an external fixator bar. All of these fractures healed in good position with appropriate alignment and without complications.

Simultaneous scaphoid and distal radial fractures

Simultaneous fractures of the distal radius and scaphoid are uncommon. In a prospective 3-year study we registered 2,330 distal radial fractures and 390 scaphoid fractures, and 12 were combined. Ten of these had high energy trauma; six were styloid fractures, four Colles' fractures, one was a greenstick fracture and one Salter-Harris Type 2 epiphyseal fracture. All but one of the 12 scaphoid fractures were stable and healed without problems, and one was a trans-scaphoid, trans-styloid peri-lunate fracture-dislocation. The study supports the opinion that the distal radial fracture constitutes the principal injury that determines the outcome and hence the treatment. If the scaphoid fracture is unstable or dislocated, we recommend internal fixation of the scaphoid. Only a small proportion of these injuries represent a more serious disruption with carpal instability.

The results of external fixation of the radius in the treatment of comminuted intraarticular fractures of the distal end

14 unstable comminuted intraarticular fractures of the distal radius were treated by the use of the A/O mini-external fixator. The distal pins were inserted in the distal fragment, thus leaving the wrist joint free to mobilize. Clinical results were assessed at 3 to 12 months using the Sarmiento demerit point system. Nine were male and five female, with a mean age of 37 years. Ten fractures were closed and four were open. 11 patients (78.5%) had an excellent functional score and three (21.5%) had a good score. All patients had normal wrist morphology with an average radial length of 11 mm, radial angle of 23 degrees and a mean volar angle of 12 degrees. 12 patients had anatomical radio-carpal and radio-ulnar joints and two patients had a step less than 2 mm at the radio-carpal surface. This method has proved in our experience to be reliable in maintaining the position as well as allowing early functional recovery.

Factors affecting functional outcome of displaced intra-articular distal radius fractures

Open reduction and internal fixation is often required in comminuted, displaced intra-articular fractures of the distal radius when closed manipulation has failed to restore articular congruity. Results of surgical stabilization and articular reconstruction of these injuries are reviewed in this retrospective study of 49 patients with 52 displaced, intra-articular distal radius fractures. Forty-three patients with a mean age of 37 years (range, 17-79 years) were available for evaluation. The mean follow-up time was 38 months (range, 22-69 months). When rated by the system proposed by the Association for the Study of Internal Fixation (ASIF), 19 were ASIF type C2 and 21 were ASIF type C3. An injury score system based on the initial injury x-ray films was used to classify severely comminuted intra-articular fractures and to identify those associated with carpal injury. Postoperative fracture alignment, articular congruity, and radial length were significantly improved following surgery. Grip strength averaged 69 +/- 22% of the contralateral side, and range of motion averaged 75 +/- 18% of the contralateral side after surgery. A combined outcome rating system that included grip strength, range of motion, and pain relief averaged 76 +/- 19% of the contralateral side. Using regression analysis, a significant decrease was found in the combined rating with more severe fracture patterns as defined by the ASIF system, Malone classification, and the injury score system. The injury score system presented here and, in particular, the number of fracture fragments correlated most closely with the outcome of all classification systems examined. Operative treatment of complex distal radius fractures with reconstruction of articular congruity with internal fixation and/or external fixation can significantly improve functional outcome. The degree to which articular step-off, gap between fragments, and radial shortening are improved by surgery is strongly correlated with improved outcome, even when the results are corrected for severity of initial injury, whereas correction of radial tilt or dorsal tilt did not correlate with improved outcome.

Predicting palmar radio-carpal ligament disruption in fractures of the distal articular surface of the radius involving the palmar cortex

12 adult cadaver wrists were dissected to identify the regions of origin of the four palmar radio-carpal ligaments. A non-dimensionalized value, called the radio-carpal ligament ratio (RLR), was defined as the width of ligament origin from the radius divided by the length of the capitate. Both values were measured directly from radiographs of the cadaver specimens. The RLRs for the four palmar radio-carpal ligaments were found to be statistically consistent. We applied the RLR concept retrospectively to 20 wrists with intraarticular distal radius fractures requiring open reduction. It was found that those fracture patterns in which the fracture fragment ratios (FFR: widths of the fracture fragments divided by the length of the capitate) were outside the limits of corresponding RLRs had clear intra-operative evidence of palmar radio-carpal ligament disruption, while those with FFRs within the limits of corresponding RLRs were noted to have no ligament disruption.

Fracture of the distal radius: classification of treatment and indications for external fixation

A number of classifications have been created for fractures of the distal radius. We describe those of Older et al., Frykman, Thomas, Melone, McMurtry, Fernandez, the Mayo and the AO/ASIF. These classifications help to identify unstable fractures and offer insight into the indications for external skeletal fixation.

[Morphologic causes and consequences of fracture of the distal radius]

Age and stress related changes in the distal epiphysis of the radius are viewed as cause and effect of losses in stability due to pathological stress. 15 in 97 distal radii show typical osseous alterations which can be evidenced after healing of a radial fracture by means of determining the subchondral cortex density. A dorsally directed inclination of the distal radius epiphysis following a healed fracture often be observed. This inclination leads to a redirecting of the resultant force vector which in turn results in a thickening of the subchondral corticalis directed towards the palmar socket margin. The densitometric evaluation based on X-ray depictions enables the morphological characterisation of the restructuring of corticalis and spongiosa in long bones as cause and effect of a fracture.

Over-distraction of the radio-carpal and mid-carpal joints following external fixation of comminuted distal radial fractures

Seven patients with Frykman type 7 and 8 distal radial fractures, who had been treated with external fixation, were noted to have significant over-distraction of 5-8 mm in the radio-carpal and mid-carpal joints. One patient, who also had abnormal negative ulnar variance of 2 mm, had a fair result using modified Gartland and Werly (1951) criteria. The remaining six patients had good results, indicating that over-distraction does not significantly alter the final outcome, so long as a normal distal radio-ulnar relationship is maintained.

Effect of guanethidine on the natural history of post-traumatic algodystrophy

OBJECTIVES

To determine the effect of intravenous regional guanethidine on post-traumatic algodystrophy.

METHODS

Ten of 20 consecutive patients with algodystrophy after Colles' fracture were treated with serial intravenous regional guanethidine blockades and the other 10 were treated with physiotherapy alone. Patients were assessed before and after each block and then monthly over a six month period.

RESULTS

The treated patients had subjective and objective improvements in the assessed features of algodystrophy; treatment resulted in a significant reduction in finger tenderness at five and six months.

CONCLUSIONS

Guanethidine blockade induces short term benefits in the symptoms of algodystrophy but improves finger tenderness only in the long term.

Effects of radial deformity on distal radioulnar joint mechanics

A cadaver experiment was performed to study the effects of radial deformity on the kinematics of the distal radioulnar joint and the anatomic configuration of the triangular fibrocartilage. Radial shortening caused the greatest disturbance in kinematics and the most distortion of the triangular fibrocartilage. Decreased radial inclination and dorsal angulation caused intermediate changes. Dorsal displacement produced minimal changes. Radial deformity did not produce distal radioulnar joint dislocation. These results provide biomechanical evidence of an important relationship between radial malunion and persistent symptoms in the distal radioulnar joint.

Geometric variables from DXA of the radius predict forearm fracture load in vitro

The purpose of this investigation was to determine the cross-sectional geometry of the radius in female and male cadaveric specimens using dual-energy X-ray absorptiometry (DXA), to measure the accuracy of this technique compared with a digitizing procedure, and to measure the correlation between these DXA-based geometric variables and the load required to produce a forearm fracture. Paired intact forearms were scanned at a distal site and at a site approximately 30% of the forearm length from the distal end. The cross-sectional area and the moments of inertia of two sections at 10 and 30% of the forearm length were computed from the X-ray attenuation data. One member of each pair was then sectioned at the 30% location, which is mostly cortical bone, and the section was traced on a digitizing pad. The other forearm was loaded to failure in a servohydraulic materials test system. The DXA-based area and moment of inertia at 30% correlated significantly with the digitized results (r2 = 0.93 for area; r2 = 0.95 for moment; P < 0.001). The conventional bone mineral density from DXA did not associate significantly with failure load, but the minimum moment of inertia and the cross-sectional area at 10% correlated in a strong and significant manner with the forearm fracture force (r2 = 0.67 for area; r2 = 0.66 for moment; P < 0.001). The determination of radial bone cross-sectional geometry, therefore, should have better discriminatory capabilities than bone mineral density in studies of bone fragility and fracture risk.

Scaphoid fractures: assessment and treatment

The scaphoid is the most commonly fractured carpal bone. The fracture pattern and its relationship to the blood supply have significant implications regarding treatment and prognosis. Prompt recognition and treatment are fundamental to successful management.

Open reduction and internal fixation for distal radius fractures

From a series of 650 dorsally angulated fractures of the distal radius, 32 intra-articular fractures were treated by open reduction and internal fixation. The 32 fractures were classified according to the Frykman criteria as type VII (5) or type VIII (27). On the basis of the location of intra-articular involvement, the fractures were further subdivided into Mayo type II (4), type III (18), and type IV (10). Results were analyzed by the methods of Gartland and Werley (functional) and Lidström (radiographic). After open reduction and internal fixation, 90% of the patients had satisfactory results on the basis of the subjective criteria of minimal deformity, absence of pain, and good strength. Objective assessment demonstrated that the patients had 80% of normal motion and 73% of normal grip strength at a minimum of 2 years after the operation. On the basis of radiographic and functional evaluation, results were good to excellent in 87%. When intra-articular step-off exceeded 2 mm or the radius was shortened more than 5 mm, the results were only fair and posttraumatic arthritis was evident.

Computerized tomographic evaluation of acute distal radial fractures

To learn whether computerized tomography offered additional useful information over conventional radiographic evaluation of acute distal radial fractures in the younger adult, we scanned 22 consecutive injured wrists. Of the distal radial fractures in 19 wrists, sixteen were defined on plain films as intra-articular. In contrast, computerized tomography demonstrated that all fractures of the distal radius had intra-articular extension. In 3 wrists interpreted as being normal on plain films, despite clinical suspicion of a fracture, fractures were confirmed by computerized tomography. As a result of computerized tomography, injuries were assigned a higher Frykman value in 5 cases, and consideration of alternative patient management became necessary in 5 of the 22 patients.

Pilon fractures of the wrist. Displaced intra-articular fractures of the distal radius

22 patients who sustained high energy wrist injuries are reported. These complex injuries resulted in articular disruption of the distal radius. Associated injuries included scapho-lunate dissociation (18%), central die-punch injuries (14%), ulnar fractures (41%) and diastasis at the distal radioulnar joint (23%). Nine fractures (41%) were open and almost a third of patients had other skeletal injuries. All patients were treated by external fixation and reviewed after a mean follow-up of 2 1/2 years. There were no excellent results and only ten good ones (45%). The mean functional impairment was 32%. The external fixator was effective in maintaining extra-articular alignment, but not in ensuring accurate reduction of the articular surface. Residual incongruity of the joint surface was an adverse prognostic feature. All five patients (22%) with an articular step of more than 2 mm. developed symptomatic arthritis. Failure to restore the joint line did not account for all the unsatisfactory results; persistent scapho-lunate dissociation and problems at the distal radioulnar joint were also important.

Correlations between photon absorption properties and failure load of the distal radius in vitro

The bone mineral content (BMC) and cross-sectional properties of cadaveric radii were assessed by single photon absorptiometry (SPA). A new multiple-angle scanning technique was used in conjunction with SPA to measure the area and moments of inertia of the radial cross section in intact forearms. The radii of the same forearms were then broken in a failure test to simulate a fall on the outstretched arm. Colles' fracture was produced in 16 of 18 radii tested. The BMC divided by the bone width, which is called bone mineral density (BMD) in clinical applications, did not correlate with the load at failure in cadaveric forearms. The BMC alone did correlate significantly with failure load (r2 = 0.62), and the cross-sectional properties gave the best correlation with failure load in a sequential multiple regression (r2 = 0.80). We conclude that if SPA is to be used in clinical studies to predict risk of radial fracture or of fractures at remote skeletal sites, then BMC should be used rather than BMD. An even better indicator of radial bone strength than BMC would be a biomechanical parameter derived from the cross-sectional area and moments of inertia, which can be obtained from multiple-angle SPA.

Treatment of displaced articular fractures of the radius

Forty patients with articular fractures of the distal radius in which anatomic reduction of the joint surface could not be obtained by closed manipulation or by ligamentotaxis with external fixators had a combination of percutaneous and/or open reduction techniques to restore articular congruity. X-ray films taken after treatment with an average follow-up of 4 years showed satisfactory extraarticular alignment in 85% of the cases, and 37 (92.5%) patients demonstrated an articular step-off of 1 mm or less at late follow-up examination. Radiographic evidence of radiocarpal arthritis was present in 5% of the cases at follow-up examination.

Early clinical experience with Orthofix external fixation of complex distal radius fractures

Twelve patients with complex fractures of the distal radius were treated with the Orthofix external fixation system (EBI Medical Systems, Fairfield, NJ). On follow up physical examination, the average wrist dorsiflexion was 46 degrees, and the average volar flexion was 55 degrees. The average grip strength in the involved hand was 38 lb force. The average final radial angle was 18 degrees, and the average residual radial height was 12 mm. Average volar tilt was 3 degrees. The complication rate was 42%. Very rigid axial stability is afforded by the fixator, but the large 3.5 mm tapered bone screw diameter precludes redrilling for screw adjustment. The apparatus needs frequent monitoring to reconfirm the security of the locking nuts and cam mechanisms, and the Orthofix system can be reused only four times.

Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt

Nineteen fresh cadaver wrists were divested of all dorsal and palmar tissues to the wrist capsule and extrinic and intrinsic ligaments. A Frykman VII type fracture was established across the radiocarpal and radioulnar joints. The dorsal and palmar wrist ligaments were left intact. The forearms were stabilized in an arm board and an external fixation device and traction applied through a Kirschner wire at the base of the third metacarpal. Three positions of wrist flexion; neutral, 15, and 30 degrees, with 10 and 20 pounds of traction were used to attempt to reestablish radiopalmar tilt. Only when the entire palmar ligamentous structures were transected at the radius was radiopalmar tilt reestablished. Ligamentotaxis alone is not a reliable method to reestablish radiopalmar tilt in intraarticular distal radius fractures.

Fascial implant arthroplasty for treatment of radioscaphoid degenerative disease

Twenty patients were evaluated up to 9 years (average, 3.8 years) after a hemiscaphoid fascial arthroplasty. All were men. Twelve had a chronic scaphoid nonunion, six had radioscaphoid arthritis from chronic scapholunate advanced collapse deformity, and two had irreducible transscaphoid perilunate dislocations. The degenerated or impinging portion of the scaphoid was replaced by a slightly oversized fascial implant; 4 being constructed of autograft and 16 of allograft fascia. Postoperative motion included a 30 degree or 73% gain in extension and a 19 degree or 38% gain in flexion, producing an overall 140 degree average arc motion. Grip strength increased 17% after operation. Pain was completely or dramatically relieved in all but one patient. All other patients returned to their preoperative occupations.

Algodystrophy following Colles' fracture

The prevalence of algodystrophy in the hand was determined at nine weeks and six months following Colles' fracture. At nine weeks, 27 of 109 patients showed signs of algodystrophy, all of whom demonstrated more than one feature of the disorder. Thereafter, no unaffected patient developed the disorder. At six months, 62% of the previously affected patients showed some residual abnormalities. In 66% of these, there was evidence of continuing vasomotor instability or swelling, suggesting that the syndrome was still active. These observations suggest that algodystrophy of the hand is a more common complication of Colles' fracture than is generally realised.

Carpal Malalignment in Colles’ Fractures

Thirty-two unilateral Colles’ fractures were reviewed after one year to assess the evidence for carpal malalignment. Various radiographic parameters on the injured and uninjured wrists were correlated with a functional score. There was significant correlation with respect to the angles measuring carpal alignment on the late films and the functional score which was not present on either the initial or post-manipulation films. The carpus aligns in a dorsal instability pattern. Radial angulation or shortening was not found to be as significant in either the early or late films. This suggests that dorsal instability as the cause of morbidity after Colles’ fracture is far commoner than originally thought.

The Unstable Colles’ Fracture

One hundred and twenty-one displaced Colles’ fractures were assessed radiographically until union. An acute loss of position occurred during the first week of splintage, necessitating re-manipulation in six fractures. In the remaining 115 fractures whose position had been retained after one week, chronic instability led to a mean increase of 8.22° dorsal angulation, a mean loss of 5.61° radial angle, and 3.26 mm radial shortening. The extent to which the chronic collapse of radial angle and length occurred was determined solely by the initial deformity and was not related to either intra-articular involvement or the presence of radiographically visible comminution. However, the absence of radiographically visible comminution of the dorsal radius did confer stability against mal-union in dorsal angulation.

Comparison of eleven external fixators for treatment of unstable wrist fractures

We compared 11 external fixators for treatment of wrist fractures on the basis of rigidity, weight, cost, design characteristics, and provision for allowing wrist motion, and found important differences between them such as rigidity varying as much as 11 times. The Roger Anderson, Hanson Baylor Mini Hoffman, Rectangular Mini Hoffman, and Ace Colles external fixators are lightweight and have low rigidity. The C-series Hoffman unilateral frame and the A.O. have intermediate rigidity. The newly developed methylmethacrylate fixator, the regular Hoffman, the C-series Hoffman bilateral frame, and the Clyburn are more rigid. Although both the Clyburn and the Orthofix allow wrist flexion and extension, the Clyburn is lightweight and the Orthofix has the highest rigidity. These factors are analyzed and reported in a format that will guide the surgeon in the selection of an appropriate fixator for his patient with an unstable wrist fracture.

Osteoarthritis after Colles' fracture

Fifty-six patients with displaced Colles' fractures were examined 7 years after fracture. Slight radiographic changes of osteoarthritis were seen in 17 cases, moderate changes in 7 cases, and severe arthrosis in 1 case. At follow up, the occurrence of osteoarthritis was not related to radial shortening or residual dorsal angulation; it did show, however, a high correlation to the initial displacement of the fracture and the age of the patient. Radiographic osteoarthritis also influenced the function of the wrist, especially in the older patients.

Unusual fragment displacement in a distal radius fracture

A 25-year-old man sustained a closed comminuted intra-articular fracture of the distal radius. Tomography showed 180 degree rotation of a palmar medial articular fragment. This rare injury is mentioned only once in the literature. When recognized, open reduction and internal fixation are necessary.

Late displacement of Colles' fractures

A prospective radiological study was performed on 170 Colles' fractures which were reduced and treated in plaster. Twenty-nine fractures, which displaced and which needed a further reduction and external fixation, were excluded. The mean length of the radius decreased during plaster treatment to the same position as before the initial reduction. Radial angular compression also increased significantly during treatment. Among the seventeen fractures which were malunited, twelve had definitely displaced after the 11th day.

Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon into the distal radioulnar joint: the empty sulcus sign

Two cases of distal radioulnar joint (DRUJ) disruption and diastasis secondary to distal radial fractures were associated with displacement of the ulnar styloid and extensor carpi ulnaris (ECU) into the DRUJ. Both cases had a palpable empty ECU tendon sulcus. In one case surgical exploration revealed that the ulnar styloid, triangular fibrocartilage, and extensor carpi ulnaris tendon had dislocated into the DRUJ as a unit. The end result was good. In the second case lack of recognition and reduction of the ECU tendon and ulnar styloid led to persistent subluxation and diastasis. The end result was poor. Early recognition of the dislocation of the ulnar and ECU into the DRUJ and their significance may avoid poor results.

[Results of conservative treatment of distal radius fractures]

The results of conservative treatment of fractures of the distal radius in 303 patients over a period of two years are demonstrated. 226 patients could be followed-up. The healing of the fracture was satisfactory in 78%, while the results regarding the various age groups showed considerable differences. Along with the demonstration of the functional and anatomical results in relation to age, sex, and localization the technique of fracture treatment as well as follow-up treatment are discussed.

Radiologic examination and measurement of the wrist and distal radio-ulnar joint. New aspects

Following fractures of the distal radius, a relatively high incidence of complications is caused by malalignment in the distal radio-ulnar (DRU) joint; recent anatomic and clinical investigations have shown congruity of that joint to be of significant importance for restoring the function of the wrist. The radius forms a moderately arched bone, which moves around the ulna in pronation and supination. Biomechanically, the ulna may be regarded as the pillar around which the radius moves. In an anatomic investigation of 5 arm specimens, we have shown that the maximum cartilage contact in the DRU joint between the ulnar head and the distal radius occurs in the neutral rotation position. A proposed routine examination method of the wrist and forearm includes a true antero-posterior and a lateral projection of the radius and the ulna, performed with the forearm and wrist in a neutral rotation, a neutral wrist deviation and with the elbow angled 90 degrees. Such an examination implies a standardized and reproducible method. In a radioanatomic investigation, a series of 50 healthy wrists and forearms were examined. A simple measuring technique is presented, applicable to the DRU joint and wrist favouring the ulna as the bone through which a reproducible long axis of the forearm/wrist may be drawn. It is suggested that the length of the radius should be judged relative to the ulna. Ulnar head inclination and radio-ulnar angle are new concepts, being major characteristics of the DRU joint. These angles of the right and left wrist were equal and no difference was found between the sexes. Minor alterations of the distal radius may be revealed when estimating these angles.

The distal radio ulnar joint. The influence of geometry and ligament on simulated Colles' fracture. An experimental study

In five fresh frozen arm specimens Colles' fracture was simulated by a dorsal wedge osteotomy of the distal radius. A spring load was applied to the cortex of the distal radius fragment exerting a constant traction force in proximal direction. The distal radius fragment showed minimal dorsal angulation as the forearm was positioned in neutral or pronation, assuming the distal radio ulnar joint including its radio ulnar ligament was kept intact. As the forearm was moved into supination the distal fragment angulated dorsally to close the dorsal open gap in spite of the ligament being intact. When the radio ulnar ligament was detached the stability was however lost in any forearm position. The result supports the concept of immobilizing a satisfactorily reduced Colles' fracture in neutral position, possibly in slight pronation but never in supination.

Abraham Colles: fracture of the carpal extremity of the radius

Colles' fracture of the wrist is among the most common bony injuries encountered in emergency practice, and accounts for 10% to 20% of all fractures. Described in an excellent clinical treatise some 8 decades before the advent of radiographs, this fracture of the distal radius continues to pose a source of some disability to large numbers of patients. Complications include residual deformity, loss of mobility, median and ulnar nerve injury, shoulder-hand syndrome, and rupture of the extensor pollicis longus tendon. Although encountered in patients of either sex and in all age groups, this injury classically affects postmenopausal women, who are predisposed to it as a consequence of osteoporosis. The technique of immobilization appears not to be as important in influencing final outcome as does the precision of reduction.

External fixator management of unstable colles' fractures: an alternative method

Eighty-seven comminuted Colles' fractures of the Frykman III-VIII variety have been treated with the Medium-C-Hoffmann® external fixator, as an alternative to pins in plaster management, over a three-year period, with an average length of followup of 19 months. A standard technique had been used. The results were assessed on the basis of subjective, objective, and roentgenographic findings. The overall goal of a painless wrist with excellent motion, good strength, and satisfactory cosmesis appears to have been achieved by this method of management.

Scapholunate ligamentous instabilities (dissociations, subdislocations, dislocations)

Scapholunate dissociation represents a portion of a perilunar dislocation or a residual thereof. It leads to a weak and painful wrist. Recognition is often delayed and adequate treatment challenging. Reconstruction using tendinous augmentation of the ligamentous structures is helpful but uncertain. Repair of the interosseous membrane to the scaphoid with capsular plication, reduction and temporary fixation, and ligamentous augmentation may restore alignment and function. Salvage procedures are necessary in instances of failed reconstruction, late or severe scapholunate dissociation.

An analysis of roller skating injuries

This study retrospectively examines 186 patients treated for roller skating-related injuries. The average patient age was 25.3 years, with males comprising 44% and females 56% of the patients. Of the 202 injuries, there were 130 fractures and 72 soft tissue injuries. The majority of the injuries involved the wrist (47%), while the elbow ranked second (14%) and the ankle third (10%). All fractures of the tibia-fibula and ankle involved a rotational mechanism, with 75% of ankle fractures involving the posterior malleolus. Ankle fractures accounted for 46% of all surgical cases. Although inexperienced skaters were involved in 77% of all accidents, experienced skaters' injuries required surgery twice as often. Female roller skaters were more frequently injured, but males had three times more operations. Over 90% of the skaters wore no protection. Skaters who seldom participated in other sports had a higher probability of being injured earlier, especially on their first try. This study indicates that roller skating injuries are influenced by skating experience, surface texture, skate type and quality, and protective equipment.

Stress fractures of the distal radius in adolescent gymnasts

Adolescent girl gymnasts sustained stress fractures of the distal end of the radius in the wrist on which a rotational vault was performed. The history and clinical progress were typical of stress fractures.