Concomitant Distal Radius Fractures.

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Some studies have revealed that inappropriate treatment of distal ulna fractures with appropriately treated distal radius fractures resulted in distal radio ulnar joint instability and hence poor functional outcome at later years. There have been proponents for both operative and non-operative methods. Various studies are coming forth with various fixation techniques being described for distal ulna fractures with concomitant distal radius fractures. Good functional results were reported with either modality in low energy fractures in elderly but the ideal treatment for high energy injuries with associated distal ulna fractures is still being debated.

This prospective study consisted of 50 patients with complex, displaced and unstable distal radius fractures treated between July 2013 and August 2014 at the Department of Orthopaedics, and approved by Institutional Ethics committee for Human SSG Hospital, Vadodara, Gujarat, India. Patients < 18 years, medically unfit for surgery, with open fractures, with pathological fractures were excluded from our study. All fractures were classified using AO/OTA The study included 50) years age group, mean age was 42.2years with 40(80%) male & 10(20%) female. Majority 37(74%) were due to RTA & 13(26%) were due to fall. Wrist involvement was 35(70%) dominant & 15(30%) non dominant. njuries were in 13(26%) wrists. Age, occupation, functional demands & concomitant comorbid conditions were taken into consideration while selecting the patients. All fractures were reduced & splinted provisionally in emergency rther displacement & complications. Neurovascular status checked periodically. The mean surgical lag time was 4 days (range 1-6 days). All

This study was conducted in Government Hospital for Bone and Joint Surgery, Postgraduate Department of Orthopaedics, Government Medical College, Srinagar Kashmir from September 2013 to august 2016. The study was approved by the College Research Ethics Committee. This prospective randomized observational study consisted 30 cases who underwent ligmentotaxis with external fixation. Patients included in the study were adults (Age 20 – 60), patient with intra articular fractures of distal end of radius (AO Type B/C), all closed and Grade I (Gustillo and Anderson) compound fractures and presenting within 72 hours of injury. Patients with Grade II and III open fracture distal radius, pathological fractures, rheumatoid arthritis, concomitant injuries of same limb, bilateral distal end radius fractures and neurovascular injuries were excluded. The specific radiographic criterion for considering closed reduction as acceptable was more than a 2- mm step-off of the distal articular surface of the radius, The fractures were assessed preoperatively by wrist radiographs (PA and

theory: The distal radius has been conceptualized as a three column model. The wrist is divided into medial intermediate and lateral column. This theory emphasizes that the lateral or radial column is an osseous buttress for the carpus and is an attachment for the intra capsular ligaments. The primary function of the intermediate column is load transmission and the medial or the ulnar column serves as an axis for forearm and wrist rotation as well as a post for secondary load transmission. 2

External fixator was applied in the operation theatre under sterile conditions. The pins used for radius were 3.5 mm Schanz type and for that of metacarpal were 2.5 mm schanz type. After painting and draping with or without pneumatic tourniquet a small incision was made on dorsolateral aspect of forearm about 3-5 cm proximal to fracture site. Lateral cutaneous nerve of forearm was identified, 2.7 mm drill bit was used for predrilling. 3.5 mm Schanz pin (half pin) was inserted. Second pin site was selected beyond mid forearm proximally, asgreater the distance from first pin in distal end of radius 3-5 cm proximal to fracture site, more stable is the fixation.

surgical approach was through the sheath of the flexor carpi radialis tendon. The Synthes oblique 3.5 mm LCP T-plate was used for 17 patients and the 2.4 mm LCP distal radius plate (Synthes, Paoli, Pensylvania) was used for the remaining 4 patients. The plate was applied to the volar aspect of the distal radius under direct vision and fixed proximally using the oblong hole to allow fine adjustment, the fracture was reduced and temporary fixation was maintained with K-wires. The reduction and plate position were routinely checked under image intensification. Distal locking screws were subsequently sited so as to reach but not penetrate the dorsal cortex. A measurement of 2 millimetres was routinely sub- tracted from the distal screw length measurement in order to avoid penetration of the dorsal cortex and to minimise the potential for extensor tendon irritation. Distal locking screws were positioned aiming to site them 2 mm below the joint line in order to provide sub- chondral support [11]. A final check was made for plate and screw positions with image intensification using a standard postero-anterior view, two oblique views and a true lateral view of the wrist in order to ensure that the joint had not been penetrated [12].

Problems reported with forced and prolonged immobi- lization of the hand in flexion are avoided because HEF restricts all fixation to the radius. The hand is left free, and early active motion of the wrist is possible in uncompli- cated cases. There is general consent that early hand function is beneficial for bone and articular cartilage healing, as well as advantageous for the surrounding soft tissues [3, 26, 28–30, 32, 50]. The aforementioned advan- tage was the reason for the invention of other nonbridging (radio-radial) constructions. Their use might be associated with mechanical problems (most require the distal frag- ment to be broad enough to accommodate two threaded pins—about 2 cm) or, like the device invented by Gradl, initial bridging external fixation, thus excluding inveterate cases [3, 5, 13, 14, 20, 26, 28]. The use of hinged, bridging fixators to mobilize the hand early was found to be tech- nically difficult and is associated with a redislocation rate that reaches 28%, even if dorsiflexion is limited [49, 50]. Thus, the hybrid construction used in this study appears a reasonable answer to these problems.

The studies from Oslo and Bergen were conducted sev- eral decades ago. More recent studies show a considerably lower incidence and are closer to our findings [1, 8, 15]. The present study might therefore indicate a true decline in incidence in DRFs. The study population, criteria of in- clusion, and study design differ however between the vari- ous studies, making comparison challenging. The studies from Bergen and Oslo started their inclusion in patients above the age of 20 years. The incidence of distal radius fractures among children is high, but decreases towards the age of 15 – 16 years in both genders [16]. In our study, the incidence among women aged 16–19 years is relatively low compared to the other age groups. This will give a low total incidence among women compared to studies not including this group. The incidence in males of the same age group is the second highest, which will increase the total incidence among men.

Methods: Forty patients (16 males, 24 females) with different types of fractures of distal radius were treated. K-wire fixation was performed under axillary bolock or general anaesthesia. Anatomical restoration was evaluated by postero-anterior and lateral radiographs obtained preoperatively and at 09 months of follow up to evaluate Radial Height (RH), Radial Inclination (RI) and Volar Tilt (VT). Functional outcome was evaluated using Mayo scoring system.

Background: Intermediate column fractures of the distal radius (ICF) are fractures only or mainly limited to the lunate fossa of the distal radius. There are no classification systems and its value evaluation for ICF in the literature. Methods: According to the characteristics of ICF, ICF were divided into the volar, dorsal, split, collapse, and collapse with split types. Inter- and intra-observer agreements were analyzed with kappa statistics. Seventy-four patients with ICF were retrospectively studied from January 2008 to June 2016. Surgical approach and reduction-fixation method were taken under the guidelines of the classification in 54 patients with displaced fractures, while conservative treatment was taken in 16 patients with non-obvious displaced fractures and 4 patients with displaced fractures who declined surgery.

Fixed-angle volar plates can adequately stabilize artic- ular fragments and both volar and dorsal comminution, even in osteoporotic bone [8, 9]. Optimal positioning of the plate, with screws and pins placed in the subchondral position, restores radial length and radial and palmar tilt, acting as an internal fixator; indirect reduction of the dorsal aspect of the radius avoids damaging bone vascularity in comminuted fractures, reducing or avoiding the need for bone grafting. Using long plates, the metaphyseal and distal diaphyseal fracture is bypassed and the plate fixed proximally with at least three screws in the healthy diaphyseal bone. In multifragmented and highly commi- nuted fractures, multiple wire loops or single cortical screws can be used to improve stability and the reduction of the metadiaphyseal part of the radius. The rationale behind this technique is to obtain optimal stability of the fracture, restoring radial length and correct radioulnar and radiocarpal relationships, avoiding interference with soft tissues, and allowing an early functional recovery. As the plate is positioned deep and covered by muscles, interfer- ence with tendons is rare; elsewhere, there is no need to remove the hardware. Associated ulnar head fractures are treated with percutaneous pin fixation or ORIF depending on the stability of the fracture [10, 11]. In our cases, this technique led to the consolidation of all fractures except one that needed a secondary bone grafting. Optimal reduction was achieved in most cases (16 out of 21); in particular, restoration of radial length was obtained in all cases with average ulnar variance of 0°. Two patients healed with an articular step; clinical results were graded as good and fair. No case showed loss of reduction during the treatment. Imperfect reduction was found to be associated with higher DASH scores (P = 0.0006). A clinical evalu- ation revealed satisfactory results in 19 cases out of 21. Two cases had poor results—one associated with articular incongruity and one due to radioulnar synosthosis. The latter case was operated on 12 months from the first intervention with almost complete recovery of forearm rotation. Extra-articular A3 fractures showed better results than articular C2 and C3 fractures, but no significant dif- ferences were noted among these two groups (P = 0.2). Associated ulnar fractures are generally the consequence of a high-energy trauma; despite that, they did not produce significant effects on the outcome (P = 0.4). Even though the fractures appeared extremely comminuted in some cases, bone grafts or substitutes were never used. In C3 fractures with multiple small articular fragments, adequate fixation with periarticular plates may be difficult and, in

From January 2007 to March 2012, 80 patients with a mean age of 37 years (range -21 to 71 years) with closed DRFs were treated in our institution within 3 weeks of their injuries. We excluded the skeletally immature patients or those patients with congenital anomalies of the wrist, radio-carpal arthritis, open fractures, neuro- vascular injuries, associated injuries of the ipsilateral upper limb, bilateral wrist injury, mental incompetence and other systemic injuries. Also, all those patients with incomplete data and those patients who had lost to follow up were excluded from our study. Our research protocols and procedures were approved by the ethical committee of our hospital. 52 of our patients were right handed and 28 were left handed. There were 48 males and 32 females. The injuries were sustained as a result of high velocity road traffic accidents (20 cases), moderate velocity fall and pedestrian injuries (35 cases) and low velocity fall (25 cases). Thirty had the AO type A, 12 had the AO type B, and the remaining 38 had the AO type C fractures. Fifty eight fractures were dorsally displaced and 22 were volarly displaced. The following treatment was employed: fingertrap traction; manipulation to obtain as near an anatomic reduction as possible; application of an above-the-elbow plaster cast for 18 patients, closed reduction and multiple pinning for 32, closed reduction and external fixation for another 20 and open reduction and internal fixation by using a plate and screws for the remaining 10.

was performed through the malunion site using a 5-mm osteotome, and transfixed provisionally with Kirschner wires after manual reduction under C-arm fluoroscopic assistance. A second 1-cm incision was made over the radial styloid, followed by blunt soft-tissue dissection and meticulous protection of the superficial radial sensory nerve. Dissection through the interval of the first and second dorsal extensor compartments was made using a starter awl in order to create a cortical bone window. This was followed by tapping sequential broaches into the intramedullary canal until the proper fit was achieved (Fig. 2). After sizing and trialing, a Micronail Ò of the measured size was gently inserted through the pre-taped track into the medullary canal of the distal radius. Three distal fixed-angle locking screws and two proximal interlocking screws were then applied through the guiding system. After satisfactory realignment and secure fixation were confirmed by fluoroscopy, all provisionally trans- fixed Kirschner wires were removed and the guide system was disassembled from the intramedullary nail. Local callus from the nascent malunion was morselized to serve as a bone graft for the osteotomy site in 14 patients (87.5 %). Two patients (12.5 %) needed additional arti- ficial bone graft substitutes due to insufficient local bone graft. The wound was closed layer by layer. A volar short arm splint was applied for protection after dressing the wound.

Operative fixation with a volar locking plate has becoming increasingly popular in the treatment of distal radius fractures [1, 2]. Many studies have indicated the advantages of the tech- nique, and have shown good outcomes [3-5]. However, volar locking plate fixation is expen- sive and it can cause tendon problems and neurolysis, and a second implant-removal oper- ation may be required [6-8]. It is not clear whether volar locking plate fixation is superior to other treatment methods. Recently, a few randomized controlled trials (RCTs) compared the effectiveness of volar locking plate versus minimally invasive and less expensive implants, such as percutaneous Kirschner wires, for the treatment of distal radial fractures. However,

corresponding to adolescent growth spurt with a high level of activity (Rodrı´guez-Mercha, 2005; Hove and Brudvik, 2008). Remodeling capacity in children around 10 years of age is found to be less than that in younger children, with a higher probability for residual deformity and limitation of function due to improper reduction and molding of thecast (Hove and Brudvik, 2008). Parameters of acceptance of the reduced fracture vary according to the age of the patient and site of the fracture, which can be slightly confusing (angles of acceptance ranging from 15 degree at ages below 9 years to 10 degrees at ages above 9 years, with attention to malrotation and remaining years of growth) (Noonan and Price, 1998). Many parameters are used to predict the outcome of reduced fractures; this can be confusing as it includes mathematical calculations and shows interobserver variability (Alemdarog ˇ lu, 2008; Chess et al., 1994; Choi et al., 1995; Daruwalla, 1979; Davis and Green, 1976; Dicke and Nunley, 1993; Edmonds et al., 2009). Problems originate from the use of extreme positions of reduction to hold the fractured parts (compartment syndrome, compression neuropathy) with an above-elbow cast and anxiety related to the loss of reduction or development of problems (Zamzam and Khoshhal, 2005). The most common complication of this fracture is the high rate of redisplacement, which occurred in 29–48% of patients and can occur 24 days after reduction and casting alone (Zamzam and Khoshhal, 2005; Voto et al., 1990; Van Leemput and De Ridder, 2009). Operative treatment plays a role in treating unstable or irreducible fractures, open fractures, floating elbow injuries, and neurovascular or soft-tissue injuries that prevent cast immobilization (Bae, 2008); however, because of the high rate of redisplacement, indications for operative management were extended to include complete fractures of the distal radius with variable degrees of displacement, with satisfactory results in most patients (Van Leemput and De Ridder, 2009; Mostafa et al., 2009). Complications such as transient neuropraxia, hypertrophic scarring, and pin-tract infection have been reported after percutaneous pinning (Choi et al., 1995; Gibbons et al., 1994); many complications were also reported after casting in an above-elbow plaster to immobilize fractures using the conservative method including loss of reduction, elbow stiffness, neuropraxia that required bivalving of the cast (Miller et al., 2005), extreme positions of immobilization with traction of nerves, or compression ischemia with risk of compartment syndrome (Zamzam and Khoshhal, 2005).

Recently surgical management has been widely recommended and performed to prevent disability. Several studies have shown convincingly that functional outcome is good when the anatomy is restored by obtaining good reduction of fracture fragments maintaining the angulations of the articular surface of radius and radial length, and to minimize those related complications as well. This study evaluates the surgical and functional outcomes of intra- articular fractures of distal end radius in a comparative study between closed reduction using external fixation and distraction osteosynthesis to align fragments versus open reduction internal fixation (ORIF) with buttress plating.

Postoperative care: Each patient was immediately shifted to recovery ward and distal neurovascular status was assessed. On 1st postoperative day pin site dressing was checked besides a check radiograph. Patients were discharged on 3 rd postoperative day with advice about pin site care and finer range of motion exercises. Pin site infection and pin site loosening were assessed continuously. Each patient was asked to report outpatient department weekly for initial 3 weeks for check radiograph to look for any loss of reduction and articular incongruency. After 6 weeks, the external fixator was removed in outpatient department after checking with radiograph for union. Patients were started on intensive physiotherapy after removal of fixator .Clinical parameters evaluated were pain, swelling, tenderness, deformity any obvious nerve palsy, compression of the level of radial and ulnar styloid process on normal and abnormal side and any complication thereof recorded. Patients were assessed for range of motion of wrist, finger and elbow (for range of motion Goniometer was used). Radiological assessment was done for radial inclination, radial length, palmar tilt and ulnar variance..

Some authors have studied whether factors such as age and sex would affect the final outcomes, as these factors play a major role in determining the bone mineral density (BMD) [12] [15]. Hollevoet et al. studied the correlation of clin- ical parameters with the bone mineral density to a greater extent compared to the radiological parameters. They suggested that osteoporosis may be one of the factors affecting the outcome of comminuted intra-articular distal radial frac- tures. In contrast, Dhainaut et al. did not observe any significant association between the reduced BMD of the cortical bone of the hand analyzed by digital radiography (DXR) and the risk of having an intra-articular or extra-articular fragility fracture in the distal radius. They concluded that the use of glucocorti- coids may be responsible for the increase in the risk of having an intra-articular fracture, more than BMD, which can cause more severe fractures [16].

Background: Pulmonary thromboembolism after upper extremity operation is rare. We report a patient with thromboembolism after debridement open reduction and internal fixation for bilateral open distal radius fractures. Case presentation: The Japanese patient was an 80-year-old previously healthy female who was able to walk on her own. She fell down and was taken to our hospital. She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day. Although she could not walk and was depressed, she was discharged on the ninth postoperative day. However, on the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μ g/dl, troponin T was positive, and urgent contrast computed tomography scan of her thorax revealed thrombosis in the bilateral main pulmonary artery. She was diagnosed with pulmonary thromboembolism and admitted to our hospital again. On the second admission, although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants. On the seventh day after being diagnosed with embolism, thrombosis in the bilateral main pulmonary arteries had disappeared.

Fracture of the distal radius being a common fracture and closed in most cases, has long been treated by closed reduction and cast application. Although cast does provide support, it will not completely maintain a reduction. Hence, in a majority of cases, satisfactory reduction will reangle or redisplace in an immobilizing cast resulting in a poor functional outcome.