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PubMed2001

Capsular attachment to the distal radius for extracapsular placement of pins.

The aim of this study was to evaluate the anatomy of the wrist joint capsule on the distal radius. As such the extent of the joint capsule and the limits of attachment in relation to the articular surface were determined. Furthermore, the study also determined whether there was any reflection of the capsule onto the distal radius. Fifty cadaveric specimens, preserved according to Thiel's method, were assessed. After careful dissection the distance between the chondral line of the carpal articular surface and three defined points on each of the palmar and dorsal aspects of the radius were measured. In none of the specimens was there any variation in the course and extent of the joint capsule. Using external fixators for managing fractures of the distal radius, pins and wires can be placed subchondrally close to the articular capsule. The risk of intraarticular infection, due to pin tract infection in intraarticularly positioned pins, is very low.

Adult↗

PubMed2005

Essential radiographic evaluation for distal radius fractures.

Fractures of the distal radius can be complex injuries, often generating multiple fragments with distortion of the normal anatomy in all three dimensions. Superficial assessment of the injury on the standard PA and lateral radiographs often can result in incomplete recognition of the injury pattern and a misdirected approach to treatment. In addition, failure to recognize subtle radiographic findings may result in the acceptance of a reduction that has significant residual incongruency and articular surface disruption. Standard radiographs of the distal radius can provide a wealth of information about the topography of the bone if the surgeon knows what to look for. The ability to recognize detailed landmarks and parameters on the radiographic images and convert this information into a three-dimensional visual image is a skill that requires education and training. As more aggressive treatments have emerged for anatomic restoration of the bony and articular anatomy, accurate identification of the pattern of injury has become essential. Parameters such as the tear drop angle, AP distance, and articular separation have been recognized only recently. Because these parameters reflect the congruency of the articular surface,it would be natural to assume that postreduction films in which these parameters are abnormal would compromise clinical outcome. Because nearly all historical studies do not include routine evaluation of these parameters, knowledge of radiographic correlation with clinical outcome is still incomplete. At the same time, previous studies to assess outcome of distal radius fractures may be compromised by the failure to recognize residual deformity and articular incongruency that would have been evident with measurement of these parameters. With careful understanding of the radiographic landmarks, radiographic parameters, and patterns of injury, the surgeon can visualize a more accurate picture of the fracture itself and the reduction. As a result, treatment decisions for distal radius fractures can be based on a more thorough understanding of the anatomy of the injury, and future grading of radiographic results may reflect more accurately the precision of the articular restoration.

Humans↗

PubMed2005

[Distal radius malunions in flexion].

AIMS: In this paper we will differentiate the clinical management of distal radial fractures with malunion in extension from those with malunion in flexion. Malunions in flexion are rare and radial shortening does not contribute significantly to the deformity. There is always a decrease in the range of motion, especially prono-supination. Besides the usual causes of these malunions, a new iatrogenic cause is becoming prevalent: malunion in flexion occurs when a fracture in extension is treated by posterior intrafocal pinning but the surgery is performed poorly or performed when it is contra-indicated because of volar comminution. PATIENT AND METHODS: We report a retrospective study of 20 cases of distal radius malunion in flexion. The series includes relatively young patients with a mean age of 39.3 of age (24-66). Three types of surgery are compared: 1) an isolated radius extension osteotomy (group 1); 2) an isolated procedure on the ulna (group 2); 3) combined procedures on radius and ulna (Group 3). RESULTS: Results of the three techniques on prono-supination are almost the same, resulting in an almost normal range of motion. Pain decreased from 2.1 (pain for significant strains) to 0.7 (no or climatic pain) in a five-scale classification from 0 to 4. Strength increased by 23% to reach 83.3% of the opposite side. Some differences with malunions in extension should be noted: 1) volar carpal subluxation relative to the radius is present in less than 1/3 of the cases (6/20); 2) adaptive carpus is very rare and independent of the volar displacement (2/20), 3) palmar flexion exists without significant shortening (bone graft rarely necessary); 4) Pronation of the distal fragment results in distal radioulnar joint incongruity. INDICATIONS: The best treatment for young patients is combined radial and ulnar osteotomy. Although a more radical procedure, it is worthwhile for the younger patient in order to recover normal anatomy. Isolated radial osteotomy may be sufficient if pronosupination and radioulnar joint congruity are regained. However, isolated procedures on the distal ulna are only indicated in the elderly, or in patients with little discomfort.

Adult↗

PubMed2000

Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius.

We retrospectively reviewed the result from 50 children (5 to 14 years; mean age 11 years) with unstable diaphyseal forearm fractures involving both the radius and ulna, for which closed reduction has been unsuccessful, and so were treated with open reduction and internal fixation of the radius only. The rationale of this treatment is to stabilize the radius as it is this bone which has the more complicated function of the two forearm bones. After anatomical reduction and fixation of the radius the ulnar fracture had a better alignment. In this series the functional and the anatomical results in all children at a mean follow up of 4 years (range 1 to 10 years) were excellent.

Adolescent↗

PubMedDate not supplied

Remodeling of Salter-Harris type II epiphyseal plate injury of the distal radius.

The authors studied the relation between residual angulation at the time of healing and final orientation of the distal radius as well as the clinical outcome in patients after Salter-Harris type II epiphyseal plate injury of the distal radius. Eighty-five patients were reviewed with a median follow-up of 8.5 years. Anteroposterior and lateral radiographs were taken at follow-up. The mobility of both wrists and forearms was examined, together with grip strength. Pain with activities and sports was evaluated. At follow-up, 73 patients (86%) were anatomically normal on radiographs; the remaining 12 patients had an incomplete remodeling of the volar and/or radial inclination of the distal radius. Premature closure of the growth plate in the distal radius or ulna did not occur in any of these children. Complete remodeling was seen in children aged up to 10 years in all but one patient. Remodeling after Salter-Harris type II epiphyseal plate injury occurs in all age groups, but the potential is greater in children up to 10 years of age. The incomplete remodeling does not seem to have any substantial long-term negative effect on mobility of the wrist and grip strength.

Adolescent↗

PubMed2001

The development of metaphyseal cortex--implications for distal radius fractures during growth.

Fractures of the distal radial metaphysis are very common in otherwise healthy children. The reasons for this high fracture incidence are not entirely clear. To address this problem, we undertook a detailed analysis of distal radius development using peripheral quantitative computed tomography (pQCT) at a site 4% proximal to the radial articular surface. The study population comprised 337 healthy children and adolescents (aged 6-18 years; 171 girls) and 107 adults (aged 29-40 years; 88 women). Total volumetric bone mineral density (vBMD) remained stable at about 70% of the adult value between the ages of 6-7 years and 14-15 years in both genders. Cortical thickness increased little between 6-7 years and 12-13 years in girls and 14-15 years in boys. Strength-Strain Index (SSI; a parameter combining geometry and density) was still at only 20% of the adult value in girls aged 10-11 years and at 21% of the adult level in boys aged 12-13 years. At these ages, factors that contribute to the mechanical challenge to the distal radius in case of a fall (forearm length and body weight) had already reached 49% and 36% of the adult value in girls and boys, respectively. The shaping of the distal radius cortex (metaphyseal inwaisting) was assessed by analyzing the decrease in cross-sectional bone size between adjacent bone slices in a separate population of 44 children (aged 8-19 years; 26 girls). The rates of periosteal resorption and endocortical apposition were estimated to average 8 microm/day and 10 microm/day, respectively, during the growth period. In conclusion, during growth the increase in distal radius strength lags behind the increase in mechanical challenges caused by a fall, because metaphyseal cortical thickness does not increase sufficiently. The endocortical apposition rate is already very high at that site and apparently cannot be further increased to levels that would be necessary to keep bone strength adapted to the mechanical requirements.

Adolescent↗

PubMed2000

The role of osteoporosis in distal radius fractures.

Our study was designed to establish whether the degree of osteoporosis of the distal forearm affects the outcome of distal radius fractures in elderly women. We assessed the Gartland and Werley score, wrist mobility, grip strength, ulnar variance, radial inclination and palmar tilt of both wrists in 27 postmenopausal women who had sustained a unilateral distal radius fracture following a simple fall. Bone mineral density of the contralateral uninjured wrist and mid-tibial ultrasound velocity were measured. The Gartland and Werley score, wrist mobility, loss of grip strength and the radiological results of the fractured wrist did not correlate with bone mineral density of the uninjured distal radius or with mid-tibial ultrasound velocity. These results may indicate that the influence of osteoporosis on the radiological and clinical outcome in distal radius fractures is not very important.

Aged↗

PubMed1986

Midcarpal instability following malunion of a fracture of the distal radius. A case report.

The authors report a case of midcarpal instability following a malunited fracture of the distal radius. After corrective osteotomy of the radius the wrist became stable and the symptoms were completely relieved. The instability in such cases is due to subluxation of the capitate on the lunate with the wrist in radial abduction. This in turn is due to a reversal of the normal palmar tilt of the articular surface of the radius. In the mechanics of the normal wrist this palmar tilt allows the lunate to slide forwards during radial abduction, so enabling the capitate to maintain collinearity with the vertical axis of the radius. This situation can be restored by corrective osteotomy, as in the present case, with complete relief of symptoms.

Adult↗

PubMed1993

Congenital pseudoarthrosis of the radius. A case report and review of the literature.

Congenital pseudoarthrosis of the radius (CPR) is rare. Only ten cases seem to have been found in the literature. Congenital pseudoarthrosis of the radius usually is associated with neurofibromatosis or fibrous dysplasia. This is a report of a congenital pseudoarthrosis of the left radius associated with congenital dislocation of the left hip in a five-month-old girl. Apart from the pseudoarthrosis, there were no visible abnormalities. This patient was treated successfully with excision of the pseudoarthrosis, shortening osteotomy of the ulna, grafting, and intramedullary fixation of both the radius and the ulna. Review of the literature disclosed the extreme difficulties in treating this condition. It was also found that vascularized fibular graft has been used successfully.

Female↗

PubMed1988

Bone density of the radius, spine, and proximal femur in osteoporosis.

Bone mineral density (BMD) was measured in 140 normal young women (aged 20 to 39 years) and in 423 consecutive women over age 40 referred for evaluation of osteoporosis. Lumbar spine and proximal femur BMD was measured using dual-photon absorptiometry (153Gd), whereas the radius shaft measurement used single-photon absorptiometry (125I). There were 324 older women with no fractures, of which 278 aged 60 to 80 years served as age-matched controls. There were 99 women with fractures including 32 with vertebral and 22 with hip fractures. Subsequently, another 25 women with hip fractures had BMD measured in another laboratory; their mean BMD was within 2% of that of the original series. The mean age in both the nonfracture and fracture groups was 70 +/- 5 years. The BMD in the age-matched controls was 20% to 25% below that of normal young women for the radius, spine, and femur, but the Ward's triangle region of the femur showed even greater loss (35%). The mean BMD at all sites in the crush fracture cases was about 10% to 15% below that of age-matched controls. Spinal abnormality was best discriminated by spine and femoral measurements (Z score about 0.9). In women with hip fractures, the BMD was 10% below that of age-matched controls for the radius and the spine, and the BMD for the femoral sites was about 25% to 30% below that of age-matched control (Z score about 1.6). Femoral densities gave the best discrimination of hip fracture cases and even reflected spinal osteopenia. In contrast, neither the spine nor the radius reflected the full extent of femoral osteopenia in hip fracture.

Adult↗

PubMed1996

Bone structure and turnover in the distal radius and iliac crest: a histomorphometric study.

In bone grafting procedures of the wrist, the distal radius would be a more convenient graft donor site than the conventionally used iliac crest. We compared tetracycline-labeled bone biopsies from these two sites in 18 white patients (12 males, 6 females, aged 26-66 years) undergoing bone grafting procedures of the wrist. Fourteen had had previous trauma, 1 osteonecrosis of the lunate, 2 mild rheumatoid arthritis, and 1 a brachial plexus palsy. The specimens were processed undecalcified and examined by routine histomorphometry for bone structure, static and dynamic bone turnover variables, and marrow cellularity. We found that bone from the distal radius had thinner cortices (p = 0.0001), lower bone volume (p = 0.01), thinner trabeculae (p = 0.029), greater trabecular separation (p = 0.015), and lower wall thickness (p = 0.0001), marrow cellularity (p = 0.0001), osteoid volume (p = 0.01), osteoid surface (p = 0.02), osteoid thickness (p = 0.0002), osteoblast surface (p = 0.001), eroded surface (p = 0.01), osteoclast surface (p = 0.012), mineral apposition rate (p = 0.0002), double-labeled surface (p = 0.0005), single-labeled surface (p = 0.006), bone formation rate (p = 0.0005), adjusted apposition rate (p = 0.0001), longer mineralization lag time (p = 0.012), and greater activation frequency (p = 0.003). Prolonged mineralization lag time in the radius was associated with thin osteoid seams and low adjusted apposition rates and was therefore attributable to a low level of osteoblast activity rather than to osteomalacia. We conclude that bone from the distal radius was structurally inferior to and had lower turnover than the iliac crest bone. We suggest that where a graft has to provide immediate structural integrity, the iliac crest is the preferred donor site. However, where bone graft is to be compacted into a small cavitary defect, distal radial bone may be an adequate alternative. A clinical study is needed to confirm this assumption.

Adult↗

PubMed1998

Distal radius fractures: mechanisms of injury and strength prediction by bone mineral assessment.

The strength of the radius depends on the mechanical properties of cancellous and cortical bone. By assessing both compartments quantitatively with bone densitometry, we tried to identify the specificity of each in predicting the load at which the distal radius will fracture. Twenty human cadaver forearms were scanned for bone mineral and geometric properties with quantitative computed tomography and dual x-ray absorptiometry. In both a neutral loading situation and one in which the wrist was extended 45 degrees, the load distribution was determined with pressure-sensitive films, and a fracture simulating a fall on the hand was produced with a material testing machine. Fractures that occur with the wrist in extension were produced by a central impact of the scaphoid onto the radiocarpal joint, and those that occur under neutral loading conditions were produced by a more commonly distributed loading pattern. The load at fracture was most specifically predicted (r2=0.74) by bone mineral and geometric measures of the cortex at the shaft of the radius. Bone mineral density measures of trabecular (r2=0.64) and total (r2=0.66) bone were less successful in predicting the fracture load. After adjustment for bone size, the geometric and density measures revealed similar specificity. Cortical bone, therefore, contributes significantly to the strength of the distal radius and may play an important role in the prediction of osteoporotic wrist fractures.

Absorptiometry, Photon↗

PubMed1993

Aneurysmal cyst of the proximal radius: resection and free vascularized fibular bone graft.

We present the case of a 22-year-old woman with an aneurysmal cyst of the right proximal radius, treated by resection and a free bone graft (microvascular fibular transfer), without recurrence after 4 years. Over a 4 month period, there was a rapidly expanding and lytic lesion found in the radius. There were symptoms of elbow and wrist pain and early radially innervated muscle weakness. Radiological examination showed a localized tumour of the proximal radius, type 2, grade C, according to the classification of Campanacci. Biopsy led to the diagnosis of an aneurysmal bone cyst. Complete tumour resection was followed by a free vascularized fibular bone graft, resulting in good functional improvement, without local recurrence. Aneurysmal bone cysts are a rare condition, and the location in the radius has not previously been described. Vascularized bone grafts are mechanically and biologically superior in this type of case.

Adult↗

PubMed1980

[Surgical treatment results in radius head fractures (author's transl)].

The operative treatment of radius head fractures represents only one method. Indication for surgical treatment and the method (resection or reconstruction of the radius head) is elucidated based on 30 surgically treated radius head fractures. Postsurgical examinations show better results for the reconstruction method in the limitation of movement and post-traumatic arthrosis than the resection, even though the difference between them shows no significance regarding the small number of cases. Cubitus valgus or changes on the distal radioulnar joint after resection were not found. If there is indication for surgical treatment of a radius head fracture, one should consider using the reconstruction method first.

Adolescent↗

PubMed2000

Corrective osteotomy for malunion of the distal radius.

Forty-five patients were reviewed on average 5.7 years after corrective osteotomy for symptomatic distal radius malunion. Restoration of anatomy and function was assessed compared with the contralateral wrist. It was found that osteotomy of the distal radius alone did not completely restore normal anatomy and relieve symptoms, and in several cases a second operation was needed. Osteoarthritic changes in the radiocarpal and radioulnar joints were common, and they correlated with restriction in range of motion, but not with pain. Range of motion and grip power were reduced compared to the unaffected hand, but only loss of supination and ulnar deviation correlated with an unsatisfactory subjective result. The result was good or satisfactory in 33 of the 45 patients. We conclude that reconstructive procedures in patients with distal radius malunion may not completely restore normal function, and every effort should therefore be made to prevent malunion in the treatment of distal radius fractures.

Adult↗

PubMed2005

Dorsal double-plate fixation of the distal radius.

OBJECTIVE: Restoration of the intra- and extraarticular anatomy of the distal radius. Stable internal fixation of fragments, with the possibility of early functional rehabilitation. INDICATIONS: Distal intraarticular radius fractures with impacted articular fragments and displaced dorsoulnar fragment. Distal intraarticular radius fractures with bony or ligamentous injury of the proximal carpal row. CONTRAINDICATIONS: General medical contraindications for surgical intervention. Distal radius fractures with palmar tilt of the distal fragment. SURGICAL TECHNIQUE: Dorsal longitudinal incision. Approach to the intermediate column via the third extensor compartment by detaching the extensor pollicis longus (EPL) tendon. Arthrotomy and revision of the proximal carpal row. Reconstruction of the radiocarpal articular surface and support with a plate applied to the dorsoulnar aspect. Approach to the radial column by subcutaneous preparation between skin flaps (cave: superficial branch of the radial nerve) and retinaculum, incision of the first extensor compartment and support of the radial column with a preshaped plate, which is pushed through under the tendons of the first compartment. Cancellous bone grafting is usually not necessary. Subcutaneous displacement of the EPL tendon with the aid of a small retinacular flap. MANAGEMENT RESULTS: Application of a removable velcro cuff. Immediate functional postoperative physiotherapy, without the cuff. No straining or forcing until first radiographic examination at 6 weeks after the operation. RESULTS: 25 consecutive patients were monitored following a double-plate fixation, with a minimum follow-up of 12 months. In all cases the reduction, in accordance with the Stewart Score, was very good, a loss of reduction was not observed. The range of motion was between 100 degrees and 160 degrees for flexion/extension and between 160 degrees und 180 degrees for pronation/supination. The average DASH Score was 7.2 points, the PRWE Score 8.0 points. No relevant loss of strength (JAMAR dynamometer) was found in any of the patients in comparison with the healthy side. Complications noted were a muscle adhesion in the region of the first extensor compartment as well as a mild reflex sympathetic dystrophy, which healed without consequences. Implants were removed from six of the patients.

Adolescent↗

PubMed2005

[Frequency of acute and chronic scapholunate dissociation in distal radius fractures. Different treatment plans].

BACKGROUND: Early diagnosis and appropriate treatment of acute scapholunate dissociation (SLD) is crucial for obtaining a favorable result in fractures of the distal radius. The aim of this study was to determine the incidence of acute SLD in a prospective study and to differentiate this entity from chronic SLD. PATIENTS AND METHODS: A total of 120 patients with unilateral distal radius fractures were prospectively evaluated for SLD. Stress radiographs were obtained for all patients on the injured side after fixation of the distal radius fractures. In cases of SLD the unaffected side was examined to rule out chronic, bilateral SLD. RESULTS: Acute SLD was detected in 13 patients (11%), 11 (9.1%) of whom had stage 3 injury. Chronic SLD with bilateral asymptomatic instability was seen in three patients (2.5%). CONCLUSION: When treating fractures of the distal radius, acute SLD has to be ruled out and to be discriminated from chronic SLD. While acute SLD requires appropriate treatment, immediate treatment of chronic SLD is not indicated.

Acute Disease↗

PubMed2006

[Functional outcome after corrective osteotomy of the distal radius].

BACKGROUND: Malunited fractures of the distal radius frequently show disabling and painful reductions in active range of motion (AROM) of the wrist and forearm with reduced grip strength. Shortening and three-dimensional torsion of the distal radius occur with relative ulnar lengthening. Corrective osteotomy of the distal radius is indicated in these conditions. METHODS: We examined 24 of 30 patients after corrective osteotomy with respect to AROM, grip strength, DASH, and pain perception (visual analogue scale). The mean age of the population was 49 years (18-69 years), and the mean follow-up period was 22 months (6-63 months). RESULTS: Preoperative extension/flexion was 65 degrees , postoperative 92 degrees (p<0.05). Forearm rotation improved from 129 degrees preoperative to 160 degrees postoperative (p<0.01). The DASH score could be reduced from 40 (n=9) to 18 (n=24). Grip strength increased from 17 kg to 27 kg postoperative (p<0.01). Radioulnar inclination increased from 15 degrees preoperative to 24 degrees postoperative (p<0.05). Relative ulnar lengthening could be minimized from 4.3 mm to 0.7 mm (p<0.05). CONCLUSION: Data show that reconstruction of the distal radius improves grip strength and range of motion significantly with simultaneous reduction of pain perception and DASH scores.

Adolescent↗