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Reflex sympathetic dystrophy may lead to rapid articular destruction with the end-stage of synostoses. Pre-existent osteoarthritis seems to have a localizing influence.
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A series of 56 consecutive patients with 59 fractures of the distal end of the radius, treated with an unilateral external fixator of Hoffmann between 1980 and 1988, is presented, 47 of these patients were examined clinically at home in the last months of 1989. We can distinguish two different groups of patients: the older females with an average of 59.2 years and the younger males with an average of 40.1 years. The fractures of the females were caused by a lower energy trauma than those of the males (p less than 0.05). The males had significantly more complex fractures (Frykman type VII or VIII) than the females (p less than 0.05). The indication for an external fixation was significantly different for males and females (p less than 0.01). The external fixator remained attached for an average time of 5.7 weeks. The traumatized wrist had an average power of 71% of the heterolateral side. 87% of the patients had no complaints in performing their daily activities. In 70% there was an anatomical reduction on the X-ray, in 64% an excellent cosmetic result and in 68% the functional end results were excellent or good. Functional end results can be ameliorated by paying more attention to the anatomical reconstruction of the wrist joint. Therefore, it can be necessary to complete the external fixation with an open reconstruction of the wrist joint and/or with a transplantation of cancellous bone. In some cases, a changing of procedure to a plate osteosynthesis could be the treatment of choice.
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The fracture management principles of anatomic or near anatomic reduction, fracture stabilization, minimal operative trauma, and early joint motion are paramount in man-aging unstable distal radial fractures. The operative approach and plate selection should correlate with the fracture configuration. Plates have the advantages of providing secure fixation throughout the entire healing process without protruding wires or pins and allowing early and intensive forearm, wrist, and digital exercises. Disadvantages include additional operative trauma, including fragment devascularization; some additional risk of wrist stiffness; occasional tendon rupture; and at times, the need for plate removal. New developments in plate and screw design and operative strategies, fragment specific fixation, and plate strength have improved results with plate fixation. Fixed angle blades and locking screws and pegs enhance overall plate stability, support the articular surface of the distal radius, and are effective in fractures occurring in osteopenic bone.
40 distal radial fractures were treated using either and external fixator alone or in combination with other osteosynthetic methods. 31 fractures were available for review with an average follow up 30.3 months. They were assessed according to Pfeiffer's criteria. The functional result was very good or good in 19, moderate in 5 and poor in 7 of these fractures. The functional outcome was related to the degree of articular damage, quality of joint reconstruction and the presence of algodystrophy.
The safe conservative treatment of distal radial fractures, aiming at excellent results, is based on a differentiating classification of fracture types. The main crucial implication is that there are instabile fractures that per se are not suit for conservative treatment. The timing of radiologic follow ups as well as of reposition maneuvers, if late dislocation should occur, the classical techniques (R. Jones, J. Charnley, L. Böhler) and A. Sarmiento's functional approach are furthermore presented.
We investigated the effect of pneumatic pressure applied to the proximal musculature of the sheep foreleg on load at the site of a transverse osteotomy of the distal radius. The distal radii of 10 fresh sheep foreleg specimens were osteotomized and a pressure sensor was inserted between the two bone fragments. An inflatable cuff, connected to a second pressure sensor, was positioned around the proximal forelimb musculature and the leg then was immobilized in a plaster cast. The inflatable cuff was inflated and deflated repeatedly to various pressures. Measurements of the cuff pressure and corresponding change in pressure at the osteotomy site were recorded. The results indicated that application of pneumatic pressure to the proximal foreleg musculature produced a corresponding increase in load at the osteotomy site. For the cuff pressures tested (109.8-238.4 mm Hg), there was a linear correlation with the load at the osteotomy site with a gradient of 12 mm Hg/N. It is conceivable, based on the results of this study, that a technique could be developed to provide dynamic loading to accelerate fracture healing in the upper limb of humans.
An avulsion of the ulnar styloid apex led--because of a simultaneous rupture of the ulnar collateral ligament and a rupture of the disc's insertion in the fovea ulnaris--to a displacement of the triangular fibrocartilage. During movements in the frontal plane, the latter underwent a deformation, was displaced, compressed and blocked ulnar abduction. This pathology and the ulnar impingement could be observed in a "MRI-movie".
Hyperdistraction with external fixation in the treatment of distal intraarticular fractures (Frykman types VII/VIII) in elderly patients results in a higher risk of secondary shortening and loss of the radius length with functional impairment. Using the modified K-wire technique of Kapandjii, a more sufficient restoration of articular congruency can be achieved. The overall score showed 87.5% excellent and good results in the Kapandjii group, compared to 76.5% in the external-fixation group.
Despite the best of treatments, problems and complications may be inherent in the fracture, depending on the nature of its severity. For that reason, patients should be followed for a minimum of 2 years after injury and treatment to assess the result and rule out a degenerative processes. A careful, thoughtful analysis at the time of presentation using a descriptive classification system that provides guidance for therapeutic intervention followed by meticulous execution of the mode of treatment employed, regular follow-up care, and rehabilitation will provide the surgeon with a means to treat these common yet vexing problems in an effective way while minimizing complications.
The aim of the present retrospective study was to evaluate the performance of bone graft substitutes currently in use. After exclusion of those with inadequate data for comparison, 70 out of the 101 operated fractures remained available for statistical analysis. Grafts were used in 38 cases: 23 were bone substitutes and 15 autogenous grafts. Distal radial inclination and lateral angles showed no significant difference. Analysis of ulnar variance showed the relative inability of intramedullary pinning to maintain radial length in the absence of graft. In contrast external fixators preserved radial length both with and without bone grafts, and with all types of graft material. TCH (hydroxyapatite and calcium phosphate) or autogenous bone grafts allowed intramedullary pinning to maintain radial length; whereas collagen matrix material was ineffective. We conclude that TCH and autogenous bone grafts have equivalent effectiveness despite potential bias in this study.
In an experimental study, the biomechanical qualities of the combined Kirschner wire osteosynthesis (KWO) in the unstable Colles' fracture were analyzed. This type of pin fixation is our preferred osteosynthesis in the treatment of unstable Colles' fracture because it allows immediate functional therapy. It represents a modification of Kapandji's dynamic KWO, compensating for the insufficient volar stability by means of the conventional static KWO. Clinical experience according to the anatomical and functional results, was very encouraging suggesting that a clinical concept based on the biomechanical principles of combined KWO and its single components should be constituted. Simulation of the unstable Colles' fracture was realized by dorsal wedge osteotomy of the distal end of the radius using cadaveric material. This fracture model was subsequently pinned using the different KWO types and tested by a standardized vector energy testing device regarding its stability in the four main loading directions. The combined KWO unifies the advantage of volar stability of the conventional KWO with the high dorsal stability of dynamic KWO. The main functional principle of dynamic KWO with regard to its axial stability consists in the repositioning of the dorsal bone fragmentation zone and hence the reconstitution of cortical load transmission. Besides its good stabilization, dynamic KWO also leads to optimal alignment of the distal metaphyseal fragment. Furthermore, the experiments yielded important information about technical aspects of the surgical procedure, which helps us to avoid anatomical and functional deficiencies. Based on these experimental findings, the surgical technique of combined KWO was standardized.
OBJECTIVES/HYPOTHESES: (a) To determine the radiographic correlation between an artificially created dorsal comminution (via a wedge osteotomy) and dorsal tilt (clinical instability) and (b) to determine the efficacy of cast immobilization in maintaining reduction of the simulated fracture pattern as a predictor of successful treatment in the clinical setting. STUDY DESIGN: Biomechanical cadaveric study. SETTING: Level I trauma center. METHODS: In ten fresh cadaveric upper extremities, sequential dorsal wedge osteotomies (25, 50, and 75 percent of the distal radial diameter) were performed, each followed by measurement of tilt and radial inclination on posteroanterior and lateral radiographs before and after applying a load simulating the physiologic static forces of the forearm. In the last five specimens, the osteotomies were reduced and casted after the load application for each osteotomy, and radiographic measurements were again taken under loaded and unloaded conditions. RESULTS: In the uncasted loaded group (n = 10), average tilt changed from an initial 9 degrees palmar to 3 degrees palmar after the first osteotomy and became dorsally angulated (11 and 30 degrees) after the second and third osteotomies, respectively. Casting and loading resulted in a palmar tilt of 10, 6, and 3 degrees for the 25, 50, and 75 percent osteotomies, respectively. CONCLUSION: Increasing wedge osteotomies across the midline axis of the radius resulted in dorsal tilt and radial inclination changes representative of clinically unstable fractures that require more aggressive treatment protocols. However, in our experimental setting, casting maintained reduction of stable and unstable osteotomy patterns.
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AIM: The purpose of the study was to verify test criteria of the upper-limb DASH questionnaire in patients with Colles' fractures. METHODS: 107 of 139 patients with Colles' fractures treated operatively were examined and asked to complete the questionnaire. To establish reliability, the item answers of all questionnaires were analysed by using Cronbach's Alpha correlation coefficient and corrected item total correlation. Construct validity was evaluated by comparing the DASH points with clinical measures according to Gartland/Werley and Castaing (Spearman correlation coefficient). Discriminant validity was assessed by comparing the DASH points of patients with AO-type A/B fractures and AO-type C fractures (Mann-Whitney U-Test). RESULTS: 2.7 percent of all questionnaires were unusuable. The time to fill out the questionnaire was on average 12 minutes. Cronbach's alpha values were high in all scales (alpha > 0.8). No items were found unsuitable (corrected item total correlation > 0.5 in 28 of 30 questions). DASH scores were correlated with ROM deficits and clinical measures of wrist function (r = 0.53; r = 0.59; r = 0.52, p < 0.01). The questionnaire could discriminate patients with different fracture types (p < 0.05). CONCLUSIONS: DASH is a workable, reliable and valid instrument for patients with Colles' fractures.
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