Distal metaphyseal radius fractures in children following closed reduction and casting: can loss of reduction be predicted?Pretell Mazzini J, Beck N, Brewer J, Baldwin K, Sankar W, Flynn J.Orthopaedic Surgery Department, Hospital 12 de Octubre, Madrid, Spain, email@example.com. • Abstract • PURPOSE: • The aim of this study was to identify factors which contribute to loss of reduction (LOR). • METHODS: • Outpatient records and initial, post-reduction (PR) and follow-up radiographs of patients with a distal radial metaphyseal fracture were reviewed to determine demographic factors; fracture characteristics (obliquity, comminution, intact ulna); three-point cast index (3PI); and initial, PR, and follow-up displacement (angulation and translation in the sagittal and coronal planes). Univariate and multivariate regression were used to identify significant risk factors for LOR. • RESULTS: • A total of 161 patients were included in our series (119 boys and 42 girls). Fifty-seven (35%) patients met the criteria for LOR. Multivariate logistic regression revealed that patients over 14 years old were 4.8 times more likely (p = 0.01) to lose reduction, and those with more than 10% PR translation in the sagittal plane were four times more likely (p = 0.03) to lose reduction. In younger patients, initial coronal translation and PR sagittal translation were independent risk factors. Patients with over 10% initial translation in the coronal plane were 2.4 times more likely (p = 0.01) to lose reduction, and those with over 10% PR translation in the sagittal plane were 2.7 times more likely (p = 0.03) to lose reduction. Three point cast index was not found to be a significant risk factor (1.64 vs. 1.57, p = 0.43). • CONCLUSION: • Our study, the largest dedicated series of distal radial metaphyseal fractures, indicates that loss of reduction is common. Our analysis suggests that an anatomical reduction, which minimises residual translation, is the most important variable in preventing a loss of reduction
Closed Treatment of Overriding Distal Radial Fractures without Reduction in Children.Crawford SN, Lee LS, Izuka BH.J Bone Joint Surg Am. 2012 Feb 1;94(3):246-52. • Abstract • BACKGROUND: • Traditionally, distal radial fractures with marked displacement and angulation have been treated with closed or open reduction techniques. Reduction maneuvers generally require analgesia and sedation, which increase hospital time, cost, patient risk, and the surgeon's time. In our study, a treatment protocol for pediatric distal radial fractures was used in which the fracture was left shortened in an overriding position and a cast was applied without an attempt at anatomic fracture reduction. • METHODS: • Consecutive patients three to ten years of age presenting between 2004 and 2009 with a closed overriding fracture of the distal radialmetaphysis were followed prospectively. Our protocol consisted of no analgesia, no sedation, and a short arm fiberglass cast gently molded to correct only angulation. Patients were followed for at least one year. All parents or guardians were given a questionnaire assessing their satisfaction with the treatment. Financial analysis was performed with use of Current Procedural Terminology codes and the average total cost of care. • RESULTS: • Fifty-one children with an average age of 6.9 years were included in the study. Initial radial shortening averaged 5.0 mm. Initial sagittal and coronal angulation averaged 4.0° and 3.2°, respectively. The average duration of casting was forty-two days. Residual sagittal and coronal angulation at the time of final follow-up averaged 2.2° and 0.8°, respectively. All fifty-one patients achieved clinical and radiographic union with a full range of wrist motion. All parents and guardians answered the questionnaire and were satisfied with the treatment. Cost analysis demonstrated that closed reduction with the patient under conscious sedation or general anesthesia is nearly five to six times more expensive than the treatment used in this study. Adding percutaneous pin fixation increases costs nearly ninefold. • CONCLUSIONS: • This treatment protocol presents an alternative approach to overriding distal radial fractures in children and provides the orthopaedic surgeon a simple, effective, and cost and time-efficient method of treatment. • LEVEL OF EVIDENCE: • Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Long-Term Outcome of Isolated Diaphyseal Radius Fractures With and Without Dislocation of the Distal Radioulnar Joint.van Duijvenbode DC, Guitton TG, Raaymakers EL, Kloen P, Ring D. • Abstract • PURPOSE: • We tested the hypothesis that there are no differences between apparently isolated fractures of the radial diaphysis and isolated fracturesof the radial diaphysis with concomitant dislocation of the distal radioulnar joint (DRUJ) in function, disability, and DRUJ stability more than 13 years after near-anatomic open reduction with plate and screw fixation. • METHODS: • We evaluated 17 adult patients with a diaphyseal fracture of the radius without a fracture of the ulna an average of 19 years after surgery (range, 13-33 y). Of these patients, 7 had concomitant dislocation of the DRUJ (Galeazzi fracture). At the long-term follow-up, we evaluated function with several composite scores, stability of the DRUJ, and arm-specific disability by using the Disabilities of Arm, Shoulder, and Hand questionnaire. • RESULTS: • The average scores were 96 (range, 85-100) on the Mayo Modified Wrist Score, 95 (range, 80-100) on the Mayo Elbow Performance Index, and 5 (range, 0-33) on the Disabilities of Arm, Shoulder, and Hand questionnaire. There were no significant differences between patients with and without DRUJ dislocation. No patients had greater laxity of the DRUJ than the opposite uninjured side. • CONCLUSIONS: • Near-anatomic open reduction and internal fixation of diaphyseal radius fractures with and without associated DRUJ dislocation have comparable long-term results. • TYPE OF STUDY/LEVEL OF EVIDENCE: • Therapeutic IV.
Outcome evaluation in patients with distal radius fracture.Kasapinova K, Kamiloski V.Prilozi. 2011 Dec;32(2):231-46. • Abstract • (Full text is available at http://www.manu.edu.mk/prilozi). Introduction: There are not enough scientific papers on the outcome of distal radius fracturesevaluated by the patients themselves. There is disagreement over the degree of correlation between the radiological and functional outcome and the disability of the patients. Aim: To analyse the correlation between the patient-rated outcome (disability) and radiological parameters of distal radiusfractures, as well as the objective parameters of the wrist function (range of motion and grip strength) Material and methods: This is a prospective randomized study of 64 patients with a distal radius fracture. To evaluate the disability a patient-rated wrist evaluation (PRWE) questionnaire was used. For radiographic assessment radial length, radial angle and dorsal angle were measured and graded according the Lidstrom method as modified by Sarmiento. The objective clinical parameters evaluated in this study are grip strength and range of movements. For a description of the association between these three outcome parameters a statistical correlation with the Spearman rank correlation was performed. Results: The results of this study showed no significant correlation between the radiological outcome or the range of motion in the injured wrist with the PRWE pain and disability. Only the grip strength was a significant pain and disability predictor three and six months after injury. Conclusion: Post-fracture rehabilitation and outcome assessment should extend beyond physical impairment and radiography to insure comprehensive treatment to individuals with a distal radius fracture. Key words: distal radius fracture, disability, patient-rated outcome.
[A case control study on the treatment of unstable distal radius fractures with internal and external fixation].Zhao Y, Cui XR, Guan JC, Zhang XP, Yan A, Zhang K, Sang ZC, He JC, Xie CC.ZhongguoGu Shang.2011 Nov;24(11):894-7. • Abstract • OBJECTIVE: • To explore the clinical effects of diaplastic external fixator on the treatment of unstable fractures of distal radius. • METHODS: • A clinical data of 60 patients with unstable fractures of distal radius admitted to Wangjing Hospital from August 2005 to September 2009 were retrospectively analyzed with the paired design. According to the paired design, 60 patients were equally divided into two groups (internal fixation group and external fixation group), which were respectively treated with open reduction and steel plate internal fixation (internal fixation group) or closed reduction and external fixation (external fixation group), including 8 males and 52 females, with an average age of 60.27 years ranging from 34 to 85 years. Left side was in 33 cases and right side was in 27 cases. All fractures were closed and caused by hand supporting when falling down. According to AO classification, type A3 was in 22 cases, type B2 was in 4 cases, type B3 was in 2 cases, type C1 was in 20 cases, type C2 was in 8 cases, type C3 was in 4 cases. Palmar flexion, dorsiflexion, radial deviation, ulnar deviation, pronation, supination, grip strength, radial angle, radiallength, volar tilt were observed before and after operation. • RESULTS: • All the patients were followed up from 12 to 18 months with an average of 15.4 months. The radial length was (4.85 +/- 2.75) mm,volar tilt (14.66 +/- 10.77) degrees, radial angle (7.90 +/- 4.70) degrees in the external fixation group,while those were (4.29 +/- 1.53) mm, (14.39 +/- 5.01) degrees, (6.19 +/- 3.15) degrees in the internal fixation group, but with no statistical significance (P>0.05). Function comparison of internal and external fixation group, P-value of every function is more than 0.05 or equal to 0.05, with no statistical significance except for supination and radialdeviation. The functions of wrist joints were evaluated according to Batra scoring system at 1 year after operation. The average radiological scores of external fixation group was 86.27,in which 15 cases were excellent, 11 good, 1 fair,3 poor,while the average functional scores was 94.93, and all the cases were excellent. The average radiological scores of internal fixation group was 91.27, 16 cases were excellent, 12 good, 2 fair, while the average functional scores was 94.23, in which all the cases were excellent. • CONCLUSION: • Compared with the open reduction and steel plate fixation, the unstable fractures of distal radius treating by diaplastic external fixator can be achieved a similar result, with no statistical significance.
Reliability and Clinical Importance of Teardrop Angle Measurement in Intra-articular Distal Radius Fracture.Fujitani R, Omokawa S, Iida A, Santo S, Tanaka Y.J Hand Surg Am. 2012 Jan 25 • Abstract • PURPOSE: • The teardrop angle (TDA) is a newly characterized radiographic parameter that some authors propose as an indicator of articular incongruity of the lunate facet. The purposes of this study were to investigate intra-observer and interobserver reliability of the measurements of the TDA and to determine whether the TDA is a reliable indicator of articular step and gap formation after distal radius fracture. • METHODS: • We studied radiographs of 24 uninjured wrists and 24 wrists with intra-articular distal radius fractures. On standard and 10° tilt views of lateral wrist radiographs, the teardrop represents the volar rim of the lunate facet, and the TDA is defined as the angle between the central axis of the teardrop and the radial shaft. We examined interobserver and intra-observer reliability for 3 observers using the intraclass correlation coefficient (ICC) for measurements of the uninjured and fractured wrists. For subjects with fractures, we determined correlation of the TDA-volar tilt with the articular step and gap measured by computed tomography using simple linear regression. • RESULTS: • There was almost perfect intra-observer (ICC = 0.95) and interobserver (ICC = 0.93) reliability in the fractured wrists. We observed substantial intra-observer (ICC = 0.64) and fair interobserver (ICC = 0.28) reliability in the uninjured wrists on the standard lateral radiographs. On the 10° tilt views, intra-observer and interobserver reliability in the uninjured wrists increased to substantial levels (ICC = 0.76 and 0.61, respectively). The TDA-volar tilt was significantly associated with articular step and gap on computed tomography. • CONCLUSIONS: • The TDA, measured on the lateral radiograph of the wrist, exhibits higher intra-observer and interobserver reliability in fractured wrists compared with uninjured wrists. On the 10° tilt views, the reliability increased in the uninjured wrists. Measurement of the TDA in plain radiographs may allow direct estimation of articular incongruity as seen on sagittal computed tomography reconstruction images. • TYPE OF STUDY/LEVEL OF EVIDENCE: • Diagnostic II.
The Cobra External Fixation System In The Treatment Of Distal Radius FracturesM.J.L. Bertol, A.A. Rivera and R.B. Gustilo • Abstract • Introduction: The balance between achieving stable fixation and maintaining hand and wrist function during the treatment of distal radius fractures has continuously plagued the orthopaedic surgeon. A radio-radial external fixation system was developed by Dr. Guillermo Bruchmann to address these concerns. This study was designed to evaluate the immediate functional and anatomical results of the fixation system on intra-articular and extra-articular fractures. This is the first study documenting the use of this technique in Asia. • Materials and methods: Fifty-four consecutive patients, 18 male and 36 female, with 56 distal radius fractures were treated with closed reduction and application of the COBRA radio-radial external fixator. The operative procedure is described in detail. Immediate use of the affected hand for activities of daily living (ADL’s) was encouraged. Each patient was evaluated regarding functional and anatomical recovery at 2, 4 and 6 weeks postoperatively. Using the modified system of Green and O’Brien, functional recovery was based on the presence of pain, ability to do ADL’s, and range of motion. The grading system of Sarmiento was used to evaluate the overall maintenance of anatomic reduction by comparing the post-operative radiographs with those taken at 2, 4 and 6 weeks and on removal of the fixator. • Results: Assessment of functional status showed that patients had occasional to no pain at the pin sites at 2 weeks; improving on biweekly follow-up. Those with extra-articular fractures were able to do restricted ADL’s wearing the device within the 1st 2 weeks; with wrist motion arc between 50–75°. Patients with intra-articular fractures were functionally delayed by 2 weeks but with a dramatic improvement at 3–4 weeks, doing light ADL’s with wrist motion between 20–60°; progressively improving on follow-up. Biweekly radiographic evaluation showed good to excellent maintenance of reduction for both intra- and extra-articular fractures up to time of fixator removal. Average time of fixation was 7 weeks (range, 6 – 9 weeks) with removal depending on radiographic evidence of fracture union. • Summary: The COBRA external fixator is a versatile tool in the treatment of intra-articular and extra-articular fractures that any general orthopaedic surgeon can use. The overall functional and anatomical outcome is good to excellent during the time of fixation up to the time of fixator removal. Hand and wrist function is initiated immediately markedly limiting the usual complications of stiffness and disability commonly associated with these fractures. As the Smallest external wrist fixation system on the market, the Cobra has the advantage of allowing Immediate Postoperative Hand & Wrist range of motion. Unlike other wrist fixation systems, the Cobra's Radius to Radius design does not restrict the hand's and wrist's motion at all, while still fully stablizing distal radius fractures.