Colles' Fracture: An Epidemiological Nationwide Study in Italy from 2001 to 2016

The present study aimed to evaluate the yearly number of Colles' fractures in Italy from 2001 to 2016, based on official information found in hospitalization records. A secondary aim was to estimate the average length of hospitalization for patients with a Colles' fracture. A tertiary aim was to investigate the distribution of the procedures generally performed for Colles' fractures' treatment in Italy. An analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health, concerning the 15 years of our study (from 2001 to 2016) was performed. Data are anonymous and include the patient's age, sex, domicile, length of hospital stays (days), primary diagnoses and primary procedures. From 2001 to 2016, 120,932 procedures for Colles' fracture were performed in Italy, which represented an incidence of 14.8 procedures for every 100,000 adult Italian inhabitants. The main number of surgeries was found in the 65-69- and 70-74-year age groups. In the present study, we review the epidemiology of Colles' fractures in the Italian population, the burden of the disease on the national health care system (in terms of length of hospitalization) and the distribution of the main surgical procedures performed for the treatment of the disease.

The Sauve–Kapandji Procedure and the Darrach Procedure for Distal Radio–Ulnar Joint Dysfunction after Colles’ Fracture

This retrospective study evaluated the results of the Darrach procedure and the Sauve–Kapandji procedure for the treatment of distal radio–ulnar joint derangement following malunion of dorsally displaced, unstable, intraarticular fractures of the distal radius in patients under 50 years of age. Twelve of 18 possible patients in the Sauve–Kapandji group completed the disabilities of the arm, shoulder, and hand survey at a mean of 4 years postoperatively and nine of the 18 returned for a follow-up examination at a mean of 2 years. Twenty-one of 30 possible patients in the Darrach group completed the disabilities of the arm, shoulder, and hand survey at a mean of 6 years postoperatively and 13 of these 30 returned for follow-up examination at a mean of 4 years. The Darrach procedure and the Sauve–Kapandji procedure yielded comparable and unpredictable results with respect to both subjective and objective parameters.

Complex transradial carpal dislocation in a Professional Pianist: Case Report

Carpal fracture-dislocation associated to distal radius fractures is an uncommon injury of the wrist. Clinical assessment, instrumental diagnosis and treatment are all challenges for the surgeon. In addition, the prognosis in high-functioning patients is nearly always poor. The authors describe an early diagnosis of scapholunate dissociation and joint capsule tear associated with radial styloid and triquetral fractures in a 39-year-old professional piano player. A dorsal approach was used to reduce and fixate the fracture with k-wires, and to repair soft-tissue injuries with a Titanium micro-anchor. Early controlled mobilization was prescribed post-operatively. No other similar investigations were found because of the various associated fractures in the current case study, which normally excludes subjects from retrospective outcome studies on wrist ligament repair. Early diagnosis and surgical management associated with early controlled mobilization resulted in excellent clinical outcomes, according to radiograph imaging, the Italian version of the DASH score (Disabilities of the Arm, Shoulder and Hand), goniometry and dynamometry.

[Clinical analysis of acute carpal tunnel syndrome after reduction of Colles' fracture in twenty-two patients]

OBJECTIVE

To investigate the etiology, diagnosis, and treatment of acute carpal tunnel syndrome (ACTS) after reduction of Colles' fracture.

METHODS

Between December 2006 and June 2010, 22 patients with ACTS after reduction of Colles' fracture were treated with expectant treatment and surgical treatment. There were 9 males and 13 females with an average age of 46.2 years (range, 23-60 years). Fractures were caused by traffic accident in 9 cases, falling in 8 cases, falling from height in 2 cases, hitting in 2 cases, and crushing in 1 case. The mechanism of fracture was direct violence in 3 cases and indirect violence in 19 cases. According to Gartland & Werley classification, there were 2 cases of type I, 5 cases of type II, 14 cases of type III, and 1 case of type IV. Closed reduction was performed in 19 cases and open reduction and internal fixation (ORIF) in 3 cases. The average symptom time of ACTS after reduction of Colles' fracture was 11.6 hours (range, 1 hour 30 minutes to 48 hours) in patients undergoing closed reduction and was 24 hours in 1 patient and 2 weeks in 2 patients undergoing ORIF. Expectant treatment was performed first, the forearms were put in neutral position in closed reduction cases; if there was no relief of ACTS symptom 1 week later, the mixture of 1 mL glucocorticosteroid and 1 mL 2% lidocaine was injected into carpal tunnel once a week for 2 weeks. The mixture was injected into carpal tunnel directly once a week for 2 weeks in ORIF cases. In the patients who failed to expectant treatments, ORIF was performed.

RESULTS

In 7 cases of type III that failed expectant treatment, ACTS symptoms were relief completely after ORIF. All the 22 patients were followed up 12 months on average (range, 8-18 months). The average time of complete disappearance of median nerve compression symptom was 11 days (range, 2-25 days). All the patients had normal finger motion, sensation, and opposition of thumb with no sensation of anaesthesia and pinprick. The results of Tinel test, Phalen test, and Reverse Phalen test were all negative. The X-ray film showed good fracture reduction and healing with an average healing time of 6 weeks (range, 3-14 weeks). According to GU Yudong's criteria for functional assessment, the results were excellent in 18 cases and good in 4 cases; the excellent and good rate was 100%.

CONCLUSION

Malposition, displacement of fracture fragments, and ulnar deviation of the wrist after plaster immobilization are the most important risk factors for ACTS. Expectant treatments are recommended in patients with Colles' fracture of types I, II, and IV, but surgical treatment is the first choice for Colles' fracture of type III.

[Bone disease with Pain. Colles' fracture]

The distal radius is one of the most commonly fractured long bone. Colles' fracture results from a fall on the dorsiflexed and pronated hand. The dinner-fork deformity is the typical deformity of the Colles' fracture. For patients with no or a little displacement, conservative treatment is applied. The non-bridge type external fixator is applied for patients without an intra articular fracture. For patients with a comminuted fracture, the locking plate (volar approach) is recommended. During the healing period, shoulder, elbow and finger exercise should be insisted.

[Trauma to the triangular fibrocartilaginous complex (TFCC)]

PURPOSE OF THE STUDY

The triangular fibrocartilaginous complex (TFCC) can be injured either due to trauma or by chronic strain. Based on these findings, Palmer devised a classification system distinguishing traumatic (I) and degenerative (II) TFCC lesions. Traumatic TFCC injury may be single or involved in a combined injury of the distal radius. The aim of this study was to evaluate the results of surgical treatment in patients with traumatic TFCC injury at six-month follow-up.

MATERIAL AND METHODS

In the years 2000 to 2004, 23 patients with injury to the wrist were treated. The group comprised 16 men and 7 women at an average age of 34 years (range, 17 to 54 years). Nine patients were diagnosed with a distal radial fracture and 14 had no damage to the bony structures. Of these, seven showed clinical signs of TFCC injury and were indicated to acute arthroscopy of the wrist. The remaining seven, due to persisting complaints, were examined by arthroscopy within 3 months of injury. During the arthroscopic procedure, the Palmer type of injury was identified and arthroscopic treatment, open or closed, was carried out at the same stage. All patients were followed up for 6 months for pain relief and return to full physical activity.

RESULTS

The arthroscopic examination revealed the following TFCC lesions: 11 central ruptures (I.A), 6 ulnar tears (I.B), 4 palmar (I.C) and 2 radial (I.D) avulsions. During arthroscopy, partial resection of the disc was performed in 13 cases (I.A, I.D), and reattachment of the disc to the styloid process of the ulna was carried out in six cases (I.B). In four of these patients the intervention was done at the stage of acute lesion within 4 weeks of injury, and in two within a longer period. Four patients with type I.C injuries underwent open disc reattachment from the palmar approach. Subjective evaluation showed that 65 % of the patients had no complaints, 26 % reported pain after excessive activity and 9 % had pain associated with daily activities. Nome of the patients reported rest pain.

DISCUSSION

In our group, 91 % of the patients reported excellent and very good results at six months of follow-up. The two patients experiencing pain in daily activities (9 %) had type I.B. injury and were indicated for arthroscopy at a time longer than 6 weeks after injury.

CONCLUSIONS

TFCC lesions are wrist injuries which, if diagnosed early and treated appropriately, show good healing. If the triangular fibrocartilage complex is damaged by a central tear, disc resection gives good results. However, if the distal radioulnar ligaments are torn, their reattachment is necessary in order to prevent instability of the distal radioulnar joint. Open surgical procedures interfere with integrity of the distal radioulnar joint ligaments, which may lead to joint instability and prolonged healing.

Leukocytes in Complex Regional Pain Syndrome Type I

OBJECTIVE

The pathophysiology of Complex Regional Pain Syndrome type I (CRPS I) is unclear. An inflammatory reaction may cause the syndrome in which leukocytes may play an important role.

MATERIALS AND METHODS

In this pilot study of six patients with acute warm CRPS I, we performed radiolabeled autologous leukocyte scans of both hands, in order to assess leukocyte accumulation. Comparison was made with the unaffected limb, and with three control patients with a Colles fracture without CRPS I.

RESULTS

Images of the CRPS I patients obtained 4 h after leukocyte injection provided the clearest results. At 4 h post-injection, there was clear, asymmetrical leukocyte accumulation in the affected extremity with a mean ratio of 1.49+/-0.19. In control patients, no asymmetry was observed between hands (mean ratio 1.09+/-0.06), indicating the absence of specific leukocyte accumulation. There was a statistically significant difference between CRPS I and control subjects 4 h post injection (p=0.012).

CONCLUSION

We found a significantly increased accumulation of leukocytes in patients with CRPS I. This is the first study to show a possible role for leukocytes in the pathophysiology of acute CRPS I.

[Distal radioulnar joint injuries associated with Colles fracture]

OBJECTIVE

To study the diagnosis and treatment of Colles fracture with dorsally dislocated ulna.

METHODS

From July 2004 to November 2004, 20 cases of Colles fracture with dorsally dislocated ulna treated with supination-cast were evaluated.

RESULTS

Fractures were healed in all cases, and no recurrent dislocation was found in duration of 6 - 10 months follow up. Evaluation with Gartland and Werley score system showed that 100% of patient restored excellent function of wrist and forearm.

CONCLUSIONS

Supination-cast is an effective option for the acute cases. Well understanding of this injury and early diagnosis are critical.

A study of male patients with forearm fracture in Northern Ireland

Osteoporosis, although considered less common, still occurs in men. We present a cross-sectional study of a group of Northern Ireland men with low-trauma forearm fractures to determine the presence of osteoporosis and screen for secondary causes of low bone mineral density. Male patients aged 30-75 years, presenting with distal forearm fracture in 2000-2001 in Northern Ireland, were identified through a Colles fracture database. A total of 37 subjects consented to have bone mineral density measurements undertaken at the femoral neck, spine and forearm using a Lunar expert bone densitometer. Twenty-seven percent of the men had osteoporosis at the spine, femoral neck or forearm, as defined by a bone mineral density score of less than -2.5. We also found that 49% of patients had vitamin D insufficiency or deficiency, 27% had low serum testosterone, 14% had abnormal liver function test results, and 14% had raised parathyroid hormone. Only one patient received advice or treatment regarding osteoporosis at the time of fracture. Increased awareness of male osteoporosis and the need for screening for potential secondary causes in this group of patients is required, both at primary and secondary care level.

Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles' or spine fracture: Colles' fracture as an early and sensitive marker of skeletal fragility in white men

Based on data searches and life-table analyses, we determined the long-term (remaining lifetime) and short-term (10- and 5-year) absolute risks of hip fracture after sustaining a Colles' or spine fracture and searched for potential gender-related differences. In aging men, Colles' fractures carry a higher absolute risk for hip fracture than spinal fractures in contrast to women. These findings support the concept that forearm fracture is an early and sensitive marker of male skeletal fragility.

INTRODUCTION

Colles' fracture occurrence has been largely ignored in public health approaches to identify target populations at risk for hip fracture. The aim of this study was to estimate the long-term and short-term absolute risks of hip fracture after sustaining a Colles' or spine fracture and to search for potential gender-related differences in the relationship between fracture history and future fracture risk.

MATERIALS AND METHODS

To determine the long-term (remaining lifetime) and short-term (10- and 5-year) absolute risks of hip fracture, we applied life-table methods using U.S. age- and sex-specific hip fracture incidence rates, U.S. age-specific mortality rates for white women and men, pooled hazard ratios for mortality after Colles' and spine fracture, and pooled relative risks for hip fracture after Colles' and spine fracture, estimated from cohort studies by standard meta-analytic methods.

RESULTS

Our results indicate that the estimated remaining lifetime risks are dependent on age in both genders. In women, remaining lifetime risks increase until the age of 80 years, when they start to decline because of the competing probabilities of fracture and death. The same pattern is found in men until the age of 85 years, the increment in lifetime risk being even more pronounced. As expected, the risk of sustaining a hip fracture was found to be higher in postmenopausal women with a previous spine fracture compared with those with a history of Colles' fracture. In men, on the other hand, the prospective association between fracture history and subsequent hip fracture risk seemed to be strongest for Colles' fracture. At the age of 50, for example, the remaining lifetime risk was 13% in women with a previous Colles' fracture compared with 15% in the context of a previous spine fracture and 9% among women of the general population. In men at the age of 50 years, the corresponding risk estimates were 8%, 6%, and 3%, respectively. Similar trends were observed when calculating 5- and 10-year risks.

CONCLUSIONS

In aging men, Colles' fractures carry a higher absolute risk for hip fracture than spinal fractures in contrast to women. These findings support the concept that forearm fracture is an early and sensitive marker of male skeletal fragility. The gender-related differences reported in this analysis should be taken into account when designing screening and treatment strategies for prevention of hip fracture in men.

Loss of bone mass after Colles' fracture: a follow-up study

BACKGROUND

Colles' fracture usually associated with osteoporosis is regarded as the predictor of subsequent osteoporotic fracture. However, it is not clear how the local changes of bone mass take place during the course of treatment and whether the changes are related to clinical practice. The objective of the current study was to investigate the local changes of bone mass in patients with Colles' fracture and their possible clinical relevance in a follow-up study.

METHODS

The radiograms of the second metacarpal in 64 patients with Colles' fracture were assessed for bone density immediately after fracture, 6 weeks, 6 months and 1 year after fracture, respectively. Functional results were evaluated at one year.

RESULTS

Bone mass six weeks after Colles' fracture was significantly decreased without returning to normal at one year though increased bone mass had been identified 6 months after fracture (P < 0.05), (P < 0.01). At one year significant (P < 0.05) or highly significant (P < 0.01) correlations were observed between bone mass indices of metacarpal and functional results, indicating that poor function is associated with lower bone density. Significant differences (P < 0.05) between fracture patterns also suggested that patients with more severe fractures have a more pronounced bone loss.

CONCLUSIONS

Bone loss during the course of treatment will have a direct effect upon the prognosis, so different treatment should be proposed for different patterns of fractures. Active exercise should be made to improve the recovery of bone mass.

Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis

BACKGROUND

In postmenopausal women, a history of any fracture is an important risk factor for a future hip fracture. Whether similar findings apply to aging men remains to be established. We conducted a systematic review and meta-analysis of the literature to compare men and women with respect to the relative risk of hip fracture after a wrist or spine fracture.

METHODS

Studies published in full from January 1982 through September 2002 in English, French, or German were identified from the PubMed database and from reference lists of retrieved articles. We included cohort studies that reported fractures associated with minimal trauma of the wrist or spine as a risk factor for a subsequent hip fracture among (white) women and men who were fifty years old or older. Data were extracted by two independent reviewers and were checked for accuracy in a second review. Differences in assessments were resolved by consensus of the two reviewers.

RESULTS

Nine cohort studies were included in this meta-analysis: five studies were conducted in the United States and four, in Europe. After homogeneity of association was demonstrated across all studies, a fixed-effects meta-analysis was used to calculate pooled relative risks with 95% confidence intervals. Among postmenopausal women, the relative risks for a future fracture of the hip after a fracture of the wrist or spine were 1.53 (95% confidence interval, 1.34 to 1.74; p < 0.001) and 2.20 (95% confidence interval, 1.92 to 2.51; p < 0.001), respectively. In older men, these relative risks were 3.26 (95% confidence interval, 2.08 to 5.11; p < 0.001) and 3.54 (95% confidence interval, 2.01 to 6.23; p < 0.001), respectively. Fractures of the distal part of the radius increased the relative risk of hip fracture significantly more in men than in women (p = 0.002). The impact of a spine fracture, conversely, did not differ between genders (p = 0.11). Sensitivity analyses with use of random-effects methodology confirmed these findings to be robust.

CONCLUSIONS

This meta-analysis suggests that a previous spine fracture has an equally important impact on the risk of a subsequent hip fracture in both genders. The prospective association between a Colles fracture and a subsequent hip fracture, however, is significantly stronger among men than among postmenopausal women. Men with a Colles fracture are at high risk for a future hip fracture and should be evaluated as candidates for preventive measures.

The effect of vertebral fracture as a risk factor for osteoporotic fracture and mortality in a Spanish population

There is little data concerning the morbidity, mortality, and epidemiology of vertebral fracture. The aim of this study was to evaluate the effect of prevalent and incident vertebral fractures as risk factors for further osteoporotic fractures and mortality. The study was performed on a cohort of 316 women and 308 men older than 50 belonging to the EVOS study, randomly selected from our city register. At the beginning of the study and 4 years later, lateral dorsal and lumbar X-rays were performed. In addition, evaluation of the incidence of osteoporotic nonvertebral fractures was performed throughout 8 years. The incidence of all osteoporotic fractures was higher in women than in men (two-fold increase in vertebral fracture incidence and five-fold increase in Colles' and femur incidence). Vertebral fracture was a strong risk factor for a new vertebral fracture [RR=4.7 (1.8-11.9)], hip fracture [RR=6.7 (2.0-22.7)] and Colles' fracture [RR=3.0 (1.1-7.8)]. Prevalent and incident vertebral fractures were associated with a higher risk of having a hip fracture [RR=10.0 (2.0-50.2)] and Colles' fracture [RR=5.5 (1.3-23.4)]. In addition, in women, the vertebral fracture was associated with a higher mortality. By contrast, no association was found in men. These results demonstrate the association between a previous vertebral fracture with increments in the incidence of osteoporotic fractures of any type. In addition, we found a significantly higher mortality rate in women having vertebral fractures. These findings support the necessity of preventing the occurrence of vertebral fractures to limit their strong negative impact on mortality.

Rupture of the extensor pollicis longus tendon after wrist trauma

In the period of 1976 to 1997 our clinic treated 33 patients after Colles fracture with ruptured extensor pollicis longus tendon. The occurrence of functional loss was observed after the trauma in 3 to 9 weeks. In 30 cases the surgical treatment of extensor indicis proprius tendon, in 2 cases a direct suture of the ruptured tendon was performed as a primary repair and in one patient a palmaris longus interposition was utilised.

Carpal tunnel syndrome after 22 years of Colle's fracture

Delayed carpal tunnel syndrome is rare. We describe the electrophysiological findings in a patient with Colle's fracture, who developed carpal tunnel syndrome 22 years after a wrist injury.

Association between Colles' fracture and low bone mass: age-based differences in postmenopausal women

Colles' fracture (CF) in postmenopausal women has been linked to low bone mass at the lumbar spine and hip. However, the diverse methodological approaches of previous studies make the results difficult to compare and thus the implications of CF in osteoporosis daily clinical practice are not clear. We explored the association between CF and low bone mineral density (BMD) in an incident case-control study in 58 postmenopausal Spanish women aged 45-80 years with recent CF and in 83 population-based controls of the same age range. The BMD of ultradistal distal forearm, lumbar spine and hip was measured by dual-energy X-ray absorptiometry (DXA) and WHO criteria were used to define osteoporosis and osteopenia. BMD was significantly lower in cases for all three areas ( p<0.001). Osteoporosis was more prevalent in cases than controls in the wrist (60% vs. 35%, p<0.001), lumbar spine (47% vs. 20%, p<0.005) and hip (19% vs. 6%, p<0.005). After adjusting for age, menopausal status and body mass index, osteoporosis and osteopenia remained significantly associated with CF only in women aged 65 years or less (ultradistal forearm OR 5.7 (95% CI 1.2-27.2), lumbar spine OR 3.9 (95% CI 1.1-14.3)). We conclude that CF in postmenopausal women aged 65 or less may be used as a sentinel finding to identify patients with generalized osteoporosis. Additionally, 70% of all CF patients regardless of their age had low bone mass ( T-score<-1SD) in any studied site.

[Evaluation of carpal instability after distal radius fracture]

In this study carpal stability was assessed in a group of patients with distal fractures of the radius. The aim of this study was to: assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, determine the type of instability and its correlation to fracture type and patient age, assess the influence of bone fragment dislocation on the type of instability. For a clinical evaluation of carpal instability results of physical examination and X-ray examination performed in both static and dynamic conditions were taken into account. In 33% of the examined cases different types of instability were noted. Carpal instability was found more often among younger patients, predominantly of the dorsal type. The type of observed instability depended mainly on the injury mechanism and fracture type of the distal radial epiphysis. Fracture type did not influence the frequency of carpal instability, whereas direction and degree of bone fragment displacement did correlate to the type of primary or secondary instability.

[Clinical aspects of osteoporosis]

The main clinical presentation of osteoporosis is fracture and its consequences. However a number of diseases and factors can induce bone loss and increase the risk of fracture. Therefore the clinical approach should be initially directed to exclude secondary osteoporosis. Vertebral fractures are the most common osteoporotic fractures; they are characterized by back pain, typical physical changes such as kyphosis and height loss, functional impairment and social decline. On the other hand, hip fracture is the most severe consequence of osteoporosis, because of its higher morbility and mortality. The main pathogenetic determinants of hip fracture are represented by both bone loss and several factors contributing to fall in the elderly. Moreover, a number of conditions are responsible for the high mortality rate following hip fracture. Colles' fracture is rarely hospitalized; however, most patients complain a complex algodystrophic syndrome which impairs the quality of life.

Bone densitometry in the management of Colles' fractures: which site to measure?

This study assessed whether patients with Colles' fractures can be evaluated by measurement of peripheral bone mineral density (BMD) instead of the more established axial BMD technique. 205 consecutive patients who had sustained a recent Colles' fracture were invited to attend for BMD measurement at the lumbar spine, hip and forearm by dual energy X-ray absorptiometry (DXA) using a Hologic QDR4500C instrument. Hologic normal reference ranges were used for spine and ultradistal radius BMD, and the NHANES 111 reference range was used for the femoral neck. 158 patients attended, of whom only 61 had a T-score below -2.5 at one of the three measured sites (84 T<-2.0, 112 T<-1.5). 36 patients had bilateral forearm fractures and did not undergo a forearm measurement. After excluding these patients and using a T-score of -2.5 as a diagnostic threshold, a spine and hip measurement strategy missed 26% of osteoporotic patients and a forearm only strategy missed 33%. If a forearm strategy is adopted, with axial BMD performed only on those patients with an ultradistal radial T-score of <-1.5 and >-2.5, 27 further scans would be required and only four patients with T<-2.5 at the spine or hip would be undetected. Where axial BMD measurement is performed, this should be accompanied by forearm BMD measurement in some patients with Colles' fractures. A peripheral bone mineral densitometry strategy using forearm BMD alone will miss many individuals with osteoporosis. Therefore where forearm, and probably any peripheral scanning method, only is used for patient assessment there should be close liaison with an axial BMD centre with agreed joint protocols, as some patients should be advised to have an additional axial BMD measurement following their peripheral BMD measurement.

Osteoporosis overview

Osteoporosis, a disease characterized by low bone mass, microarchitectural deterioration of bone, and susceptibility to bone fractures, can lead to debilitating pain and deformity. The disease represents a major health problem, particularly in older women. Approximately 1.5 million people in the United States suffer osteoporosis-related fractures annually, and many never gain full recovery. The direct annual health expenditures related to osteoporosis fractures were estimated at $13.3 billion in 1994, but quality of life costs related to osteoporosis are even more profound. Identifying people at risk for osteoporosis and early treatment can minimize its destructive effects. Nurses play an important role in the development of strategies to reduce the incidence of osteoporosis and osteoporosis-related fractures, pain, and deformity to help older adults lead healthy, productive lives in their later years.

Treatment of fractures of the distal radius with a remodellable bone cement: a prospective, randomised study using Norian SRS

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment.

Clodronate increases mineralization of callus after Colles' fracture: a randomized, double-blind, placebo-controlled, prospective trial in 32 patients

In a randomized study of 32 postmenopausal women with a Colles' fracture, we studied whether 8 weeks of treatment with clodronate, a bisphosphonate, could prevent posttraumatic osteopenia. The patients were treated with a plaster splint for 4 weeks. The bone mineral density (BMD) of the forearm bones was measured at 2 levels with dual-energy x-ray absorptiometry (DEXA) 2, 6 and 12 months after the fracture. At 2 months, in the clodronate group, there was a median 53% higher BMD in the fracture region of the radius than in the uninjured radius. In the placebo group, we found a 33% higher BMD in the fractured radius at that level than in the uninjured radius. This increase in BMD of the fractured radius, caused by clodronate, was statistically significant. At 12 months, the BMD of the fracture side had been reduced by 17% and 12%, respectively, at that time it was still significantly increased in the clodronate group alone. In the ulna at the same level, we found no significant changes in BMD in either group on either side at any time. At 2 months, at the level between the distal and middle thirds, in the fractured radius, the median BMD was 7% lower in the clodronate group and 6% lower in the placebo group than in the uninjured radius. Although the reduction in BMD at that level was significant, there was no difference between the two treatment groups. At this level, the ulna on the fractured side showed a similar pattern, with a 5% lower BMD in the clodronate group and a 4% lower BMD in the placebo group. This osteopenia showed a small but significant progression on the fractured side after 6 and 12 months.

Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years

Twenty-five sedentary, low-demand patients older than 60 years were retrospectively evaluated for function and radiographic results following nonoperative treatment of displaced distal radius fractures. The mean age was 72 years and the average follow-up period was 34 months. All patients had radiographic and functional evaluations. The radiographic assessment included a scoring system based on measurements of the final dorsal angle, loss of radial length, and the final radial inclination. The development of radiocarpal and distal radioulnar joint arthrosis was also investigated. The functional assessment included subjective and objective criteria. Overall satisfaction, ability to return to previous activity level or occupation, concern over wrist appearance, and a functional task questionnaire were part of the subjective assessment. Objective assessment included neuromuscular evaluation and measurements of range of motion and grip strength. The final radiographic scores revealed that 6 patients (24%) had excellent results, 11 (44%) had good results, 2 (8%) had fair results, and 6 (24%) had poor results. Six of 10 patients with intra-articular fractures developed progressive wrist arthrosis. Two of 6 patients with radiographic arthrosis had unsatisfactory functional outcome. Five of 8 patients with intra-articular fractures that healed with a residual stepoff >/=2 mm had satisfactory functional outcome; 3 of these 8 patients had unsatisfactory functional outcome. The functional assessment revealed that 22 patients (88%) had excellent or good results and 3 (12%) had fair or poor results. The radiographic outcome did not correlate with the functional outcome. Twenty-three of 25 patients (92%) were satisfied with the overall outcome of the treatment and 22 (88%) were able to return to their previous activity level or occupation. Despite an obvious clinical deformity in over half of the patients, none were unhappy with the clinical appearance of the wrist. According to the functional task questionnaire, jar opening was by far the most difficult task to perform after fracture healing. Functional outcome was satisfactory in most cases; a high level of personal satisfaction and return to previous activity level was observed, regardless of the radiographic result. Nonoperative treatment of distal radius fractures yields satisfactory outcome, especially in those with low functional demands. It also is indicated in poor operative candidates. (J Hand Surg 2000; 25A:19-28.

Role of metaphyseal cancellous bone defect size in secondary displacement in Colles' fracture

The purpose of this study was to evaluate the role of the metaphyseal cancellous bone defect size in secondary dislocation of Colles' fracture. Thirty-five patients with a dislocated Colles' fracture were examined by computed tomography (CT) for metaphyseal bone defects. The size of the defect was assessed and related to the surface area of the cross-section of the distal radius at the site of the defect. The relative size of the defect correlated with the severity of dorsal angulation of the fracture but not with the shortening of the radius seen after cast immobilization. We concluded that secondary displacement of the distal radius is partly mediated through the metaphyseal cancellous bone defect, and to prevent malunion in dorsal angulation, operative treatment or possibly filling of the defect should be considered even as early as during primary reduction if a large defect is suspected.

Algodystrophy and its association with Dupuytren's disease

Seventy-two patients were examined 9 weeks after sustaining a Colles' fracture of the wrist for evidence of algodystrophy. They were examined 18 months later for evidence of Dupuytren's disease to determine the incidence of the association between the two conditions. Forty-one per cent of all patients had evidence of Dupuytren's disease at 18 months following Colles' fracture. Sixty-seven per cent of patients with algodystrophy had evidence of Dupuytren's disease compared with 19% of patients who showed no features of algodystrophy.

Intra-articular fractures of the distal aspect of the radius

Intra-articular distal radius fractures are a heterogeneous group of injuries with different fracture patterns. The existing classification systems are helpful for describing the fractures but not for assessing their stability or for deciding which surgical approach to use. Patients who have a fracture with at least 1.0 mm of displacement of the articular surface may benefit from open surgical treatment. Improved diagnostic imaging with CT is helpful for fracture classification and surgical planning. The options for surgical treatment include limited open reduction and internal fixation, arthroscopically assisted internal fixation, and open reduction and internal fixation. The surgical approach is determined on the basis of the initial displacement of the fracture. Patients who have a displaced fracture of the volar rim may benefit from a volar approach; those who have a dorsally displaced fracture, from a dorsal approach; and those who have an impacted fracture such as a die-punch fracture, from a dorsal approach that provides better visualization of the articular surface. The long-term functional outcome is determined in part by the severity of the fracture as defined by the amount of comminution, the initial severity of displacement, and the number of fracture fragments. The accuracy of the reconstruction of the articular surface, with the goal of establishing congruency to within 1.0 mm, is also important in order to minimize the risk of late osteoarthrosis. Of all of the extra-articular parameters, restoration of the length of the radius is the most important for enhancing recovery of motion and grip strength and for preventing problems involving the distal radioulnar joint--the so-called forgotten joint in distal radial fractures.

Norian SRS versus external fixation in redisplaced distal radial fractures. A randomized study in 40 patients

We compared Norian SRS, an injectable calcium phosphate bone cement, with external fixation in the treatment of redisplaced distal radial fractures by a prospective randomized study in 40 patients (women 50-80 years or men 60-80 years). After rereduction, the fracture was either stabilized by injection of SRS and immobilized with a cast for 2 weeks, or externally fixed with Hoffman's bar for 5 weeks. Each patient was evaluated at 2, 5, 7 weeks and at 3, 6 and 12 months. Functional parameters were grip strength, range of motion and pain. Radiographic parameters were radial angle, ulnar variance and dorsal tilt. The chosen primary effect variable was grip strength at 7 weeks. Patients treated by injection of SRS apatite had better grip strength, wrist extension and forearm supination at 7 weeks. There was no difference in functional parameters at 3 months or later. None of the methods could fully stabilize the fracture: radiographs showed a progressive redislocation over time. The results indicate that SRS can be used in the treatment of unstable distal radial fractures. The more rapid recovery of grip strength and wrist mobility in the SRS group appears to be due to the shorter immobilization time.

Manipulative management of post-Colles' fracture weakness and diminished active range of motion

OBJECTIVE

To discuss the management of a patient with wrist weakness and a diminution in active range of motion resulting from Colles' fracture.

CLINICAL FEATURES

A 58-year-old woman complained of persistent loss of grip strength and mobility in her right wrist. These complaints were from Colles' fracture occurring 19 months before initiation of care. Dynamometer and goniometric testing revealed significant loss of grip strength and range of motion compared with the uninvolved, nondominant wrist.

INTERVENTION AND OUTCOME

Specific joint manipulation for improvement in mobility and grip strength of the wrist was performed. The patient's right wrist was evaluated for grip strength and active range of motion over a 3-week period, providing a baseline of function before treatment. After 4 visits of baseline measurements, a series of 4 treatments and 4 reevaluations was performed. The patient exhibited a significant increase in grip strength and active range of motion.

CONCLUSION

Appropriate intervention of chiropractic manipulation and examination procedures culminated in a successful resolution of this case. When such cases are recognized, appropriate management may occur conservatively with judicious application of joint manipulation and reevaluation procedures.

The clinical importance of carpal instabilities following distal radial fractures

A prospective study was undertaken to determine the clinical importance of the different carpal instabilities following dorsally displaced distal radial fractures (Colles' type). All patients were followed for 1 year and a Cooney score and X-ray evaluation were done. Nine different carpal instabilities were evaluated. Only dissociative DISI and ulnar translocation showed significant clinical differences at 1 year follow-up. It is therefore recommended that a dissociative DISI, usually caused by scapholunate dissociation, should be treated by percutaneous pinning at the time of the initial treatment.

Osteoporosis in Colles fracture

Previous studies of bone density in patients with Colles fracture have been inconclusive. We measured bone density at the second metacarpal in 36 postmenopausal women with Colles fracture. The patients were found to have highly significant (P < 0.01) or significant (P < 0.05) differences in the parameters of bone density compared with controls matched for age. The results suggest that osteoporosis is of definite relevance to the etiology of Colles fracture in postmenopausal women.

AO and Frykman's classifications of Colles' fracture. No prognostic value in 652 patients evaluated after 5 years

We retrospectively assessed hand and forearm symptoms of 652 patients with a Colles' fracture, 5 years after the fracture, using a questionnaire. The contralateral forearm, which was free of major injuries or illnesses, was used as control. Forearm and hand symptoms were common and only one quarter of the fractured forearms were completely free of symptoms at the time of review, whereas four fifths of the control forearms had no symptoms. Nearly half of the patients complained of impairment in various activities and 8% had had to give up leisure activities or make special arrangements at work. Demographic, and most of the fracture-related factors, were not associated with the symptoms. Neither AO nor Frykman's radiographic classifications of the primary fracture were of any use for predicting the clinical outcome.

Attritional flexor tendon ruptures after a malunited intra-articular fracture of the distal radius

Rupture of the flexor tendon following Colles fracture is uncommon. In all reported cases it occurred as a complication of an extra-articular, displaced fracture of the distal radius. We report a case in which flexor tendon rupture occurred 30 years after a comminuted intra-articular fracture of the distal end of the radius. There have been no reports of delayed flexor tendon rupture after an intra-articular fracture of the distal radius in young adults.

Pouteau-Colles fracture: double-closed "basket-like" pinning according to Kapandji. Apropos of a homogeneous series of 70 cases

First described by Kapandji, the double closed "basket-like" pinning is a new and quite attractive treatment of the Colles' fracture. With or without XR TV, following closed reduction the epiphysis is fixed steady with two Kirschner wires, sliding along its lateral and its posterior aspects, entering the radius at the fracture site and transfixing the bone cortex above. Plaster cast is unnecessary, and wrist reeducation begins on the first day post-op. Technical "know-how" is specified, and seventy-two patients followed up. Present findings indicate that the complication rate is very low, excellent and good results are 83%. Rehabilitation is quicker, socio-economically gratifying. We believe that the method significantly improves the conservative treatment of Colles' fracture and decide to use it extensively from now on.

[Close injury of the tendon at wrist]

Because of the complicated causes and variable clinical signs, closed injury of tendons at wrist is difficult to diagnosis and treat. Twenty-six cases of tendon ruptur were reported. Among them, 11 cases were caused by bone fracture or dislocation, 8 cases were caused by rheumatoid synovitis, 5 cases were caused by synovial tuberculosis, and 2 cases caused by other. The pathogenesis and clinical signs were analyzed. Twenty-three cases were treated by tendon transfer and 3 cases were treated by tendon transplantation. By average follow-up of 16 months (ranged 6 months to 4 years), the results were as follows: the clip strength and both active and positive motion of fingers were restored in 19 caese, 75% of those were restored in 7 cases and 50% of those were restored in 2 cases. It was suggested that diagnosis, treatment and function rehabilitation should be carried out early, and tendon transfer or tendon transplatation were the method on priority.

Algodystrophy is an early complication of Colles' fracture. What are the implications?

One hundred patients who had sustained a Colles' fracture were observed for features of algodystrophy at 1, 5, 9 and 12 weeks following injury. The diagnosis of algodystrophy was possible as soon as 1 week after fracture. Early diagnosis has important clinical implications: the aetiological factors may become apparent and different treatment modalities be identified; furthermore, early treatment can be started, limiting the morbidity of the condition. It is proposed that patients with features of algodystrophy require physiotherapy after a Colles' fracture. Those without features may not.

Rupture of all finger flexor tendons 17 years after a colles fracture: a case report

A case with closed sequentional rupture of all flexor tendons of the fingers, 17 years after a Colles fracture is described. The repair with free tendon grafts resulted in a fair result.

Proximal neuropathy in Colles' fracture

BACKGROUND

Peripheral nerve injury at the wrist following Colles' fracture is rare and usually located in the region of the fracture. Mononeuropathies in the proximal forearm have not been reported.

METHOD

We present two patients with Colles' fracture with proximal forearm neuropathies.

RESULTS

Both cases were associated with mononeuropathies in the forearm as proximal as the elbow, involving the median, ulnar and radial nerves in one, and the median and ulnar nerves in the other.

CONCLUSION

Following Colles' fracture proximal nerve involvement may occur and, with increased awareness, this lesion may be identified more frequently.

Do we underestimate the predictive value of the ulnar styloid affection in Colles fractures?

Various radiographic factors have been suggested as predictively important when dealing with an unstable distal radius fracture. Accordingly, many classification systems have been established in order to give an accurate description of a fracture and to grade the seriousness of the injury. In this paper, we use the classification of Colles fractures introduced by Frykman to investigate the predictive value of a concomitant fracture of the ulnar styloid. We found styloid affection to be a better predictor of a poor outcome than intra-articularity, but the combination carries the worst prognosis. We therefore suggest that a fracture of the distal radius associated with those two types of injuries should be considered for surgical treatment.

Distal radioulnar joint injuries associated with fractures of the distal radius

The most common cause of residual wrist disability after fractures of the distal radius is the distal radioulnar joint. The 3 basic conditions that produce radioulnar pain and limitation of forearm rotation are instability, joint incongruency, and ulnocarpal abutment. The last 2 entities initiate irreversible cartilage damage that eventually leads to degenerative joint disease. Early recognition and management in the acute stage aim at the anatomic reconstruction of the distal radioulnar joint including bone, joint surfaces, and ligaments in an effort to reduce the incidence of painful sequelae and functional deficit. This article provides a description and the treatment options of the distal radioulnar joint lesions that occur in association with fractures of the distal radius, and the results obtained with open and arthroscopic techniques. Both acute and chronic disorders are analyzed, and a prognostic and treatment oriented classification is presented Furthermore, the pathoanatomy and management of chronic distal radioulnar joint derangement after fracture of the distal radius are reviewed briefly.

Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Rupture of the extensor pollicis longus tendon

Rupture of the extensor pollicis longus (EPL) tendon after nondisplaced fracture of the distal radius is a known complication, but can also occur in nonrheumatoid patients without a history of fracture. This study is a retrospective analysis of seven patients treated between 1985 and 1992. Five EPL ruptures occurred with nondisplaced Colles' fractures. Two involved a chronic tenosynovitis of the second dorsal extensor compartment of the wrist. The age of the patients ranged from 29 years to 68 years (mean, 42 years). Length of follow-up ranged from 6 weeks to 62 months (mean, 30 months). Rupture occurred at a median of 7 weeks (range, 2 weeks to 11 months) from the time of the distal radius fracture. Three extensor indicis proprius tendons and four free palmaris longus tendon grafts were performed. At final follow-up, six patients had an extensor lag < 10 degrees or normal thumb interphalangeal joint motion. One patient had a 25 degrees extensor lag. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Extensor indicis proprius transfer or free palmaris longus grafts yield good results after EPL rupture.

[Experimental study of Colles' fracture combined with dorsal radio-carpal subluxation]

By cutting different ligaments and the distal end of radius of 20 fresh specimens with radiophotographic records, the author explored the mechanism of formation and traumatic anatomy of Colles' fracture with dorsal radio-carpal subluxation (DRSA). The results of experimental studies indicate that under normal condition, the change of radiolunate angle has some influence on the displacement of central point of lunate (CPL) but does not lead to DRS. The first is the rupture of the dorsal and palmar ligaments of radiocarpal joint and the second is the fracture of distal end of radius with a reversed palmar tilting angle of articular surface of distal radius. To treat the patients of Colles' fracture with DRS the previous palmar tilting angle should be restored to the full, as well as the anatomic reduction. The fixatiion in neutral or light dorsal extension position should be recommended.

Reliability of different methods of determination of radial shortening. Influence of ulnar and palmar tilt

Assessment of the grade of deformity after fracture of the distal end of the radius demands and accurate method of determination of radial shortening. Radiographs of 50 patients with malunited Colles' fractures were analyzed in order to find the method which is least affected by changes in ulnar and palmar tilt. Two new landmarks, the centre-point in the distal articular surface of the radius and the capitate vertex, are introduced as possible new landmarks for radial shortening determination. Results derived from commonly used methods and the new method are compared and analyzed. These show that radial shortening measured according to the commonly used landmarks is greatly affected by changes in ulnar and palmar tilt, leading to errors. Shortening measured by the two new landmarks gives results that are less influenced by rotation of the distal fragment in the frontal and sagittal planes.