University of Groningen Fracture of the distal radius Oskam, Jacob IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 1999 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Oskam, J. (1999). Fracture of the distal radius: selected issues of epidemiology, classification and treatment Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 10-12-2017
64 CHAPTER 6 FRACTURES OF THE DISTAL RADIUS AND SCAPHOID J Oskam, J S de Graaf, H J Klasen. Department of Surgery, University Hospital Groningen Groningen, the Netherlands Journal of Hand Surgery, 1996; 21B: 772-774
65 The usual conservative treatment for isolated distal radial fractures is to apply ligamentotaxis across the radiocarpal joint by traction with immobilization of the wrist in a neutral position. However, it is generally believed that tractional forces should be avoided in scaphoid fractures, while the wrist is best positioned in radial deviation with immobilization of the thumb. In the case of a combination of fractures of the distal radius and scaphoid, each immobilization technique may have opposite effects on fracture healing. Therefore, one might expect either an increased rate of scaphoid nonunion or malunion of the distal radius. We have treated 23 patients with simultaneous fractures of the distal radius and scaphoid over a period of 14 years. A below elbow cast including the thumb was used as standard treatment, because we feared more scaphoid than distal radius complications. In the present study, we have evaluated the results of our treatment policy. PATIENTS AND METHODS During the period 1980 to 1993, a fracture of the distal radius and the scaphoid was diagnosed in 23 patients. There were 10 women and 13 men, with a median age of 39 years (range 18-74). The dominant hand was involved in 9 patients. The injury resulted from an accidental fall in 17, sports in 3 and traffic accidents in 3 cases. X-ray assessment The scaphoid and distal radial fracture were classified separately. The scaphoid fracture was assessed for site and displacement. Displacement of the scaphoid fracture was defined as displacement of at least 1 mm. The scaphoid was divided in 3 parts to describe the fracture localization (2). The distal radial fracture was classified by type, and involvement of the radiocarpal joint surface was also assessed (3). During follow up, X-rays of the distal radius and scaphoid were used to investigate signs of disturbed bone healing. To assess malunion of the distal radius, the radiocarpal angle and radial shortening were measured (7). The scaphoid was
66 assessed for pseudarthrosis, avascular necrosis, or cysts. Finally, signs of posttraumatic osteoarthritis and carpal instability were noted. Treatment A below elbow cast including the thumb with the wrist immobilized in radial deviation and flexion was applied in 18 patients treated conservatively. The mean immobilization period was 9 weeks, and depended on healing of the scaphoid bone. Closed reduction of the distal radial fracture was performed in 9 of 18 conservatively treated wrists. Primary operative treatment was undertaken in 3 patients. A secondary operation was performed in 2 patients in whom redisplacement of the distal radius occurred during conservative treatment. An unstable distal radial fracture was the indication for surgery in all cases. Screw fixation of the radius was performed in a palmar Barton s fracture. An external fixator was applied in 2 other cases with a comminuted intra-articular distal radial fracture. Closed re-reduction and K-wire pinning was performed in the 2 patients with radial redislocation. Concomitant fixation of the scaphoid fracture with a cannulated cancellous bone screw was performed in 4 patients. Follow-up The follow-up study comprised both clinical and X-ray examination. Healing of the fractures was radiologically monitored in all patients a 5 day, 2, 6, 9, and 12 weeks intervals. In total, 21 patients were eligible for examination, because 2 patients were deceased at the time of study. Pain, range of wrist motion, and grip strength were assessed. The functional end results were judged as good when no pain occurred with use, and fair if pain and moderate discomfort was present with use, provided that the patients had completely returned to normal activities. The functional end result was considered to be poor in all other circumstances. RESULTS The mean follow up period was 7 years (range 1-13). The most serious complication of fracture healing was redisplacement in 3 of 9 initially dorsally-
67 displaced distal radial fractures. An extra-articular Colles type fracture with severe comminution of the dorsal cortex was present in these 3 patients. Closed reduction and trans-styloid Kirschner-wire fixation was performed to prevent malunion of the distal radius in these patients. Post-traumatic carpal instability was not observed in any wrist. Healing of the scaphoid fracture was uncomplicated in all 23 wrists. It appeared that all serious complications occurred on the side of the distal radial fracture. Fracture type It can be seen in Table 1, that all scaphoid fractures were localized in the middle or distal third. Displacement greater than 1 mm of the scaphoid fracture existed in 4 of 23 patients. Rotational subluxation or carpal instability was not present. An extra-articular fracture of the distal radius was found in 15 patients, and in 7 dorsal displacement (Colles fracture) was observed. An intra-articular distal radial fracture was observed in 8 of 23 wrists. Distal radius Scaphoid Middle third Waist Distal third Extra-articular Undisplaced 1 6 1 Colles 4 2 1 Intra-articular 2 4 Chauffeur s 1 Barton 1 Table 1. Radiological classification of 23 simultaneous fractures of the distal radius and the scaphoid. Wrist function Overall, 21 patients were satisfied with the functional end result and had resumed normal daily activities. Operative treatment had been undertaken in 4 of them.
68 Wrist pain was reported by 5 patients. Diminished dorsal flexion with disturbed forearm rotation was observed in 4 patients, of whom 3 were treated surgically. Subjective loss of grip strength was found in 2 patients with fair and poor functional results. After healing of the distal radius, shortening (2-7 mm) was observed in 6 wrists. Diminished wrist motion was found in 4 patients. Wrist pain and serious limitation in daily life was found in only 2 patients. One patient could not resume his job and complained of pain with severe loss of wrist motion due to radiocarpal osteoarthritis (a poor result), while another patient suffered from malunion of the distal radius. A good functional result was eventually observed in 18 patients. DISCUSSION This study confirms that in most simultaneous fractures of the distal radius and scaphoid good results can be obtained with conservative treatment (4,6). However, the finding that nearly all problems with fracture healing occurred in the distal radius has not been reported before. The redisplacement of three distal radial fractures might well have been caused by the position of the wrist in the below elbow cast. In this series the wrist was immobilized in radial deviation, a position which can provoke radial displacement because it allows the brachioradial muscle to act on the distal radius. Although we cannot be certain, we think that radial deviation of the wrist might have contributed to redisplacement of the distal radius. Primary surgery was necessary in a minority of cases. The indication for surgery in the three primarily operated patients was an unstable, intra-articular distal radial fracture, in which the risk of malunion with conservative treatment was thought to be unacceptable. We would also have operated on these wrists had the fracture been isolated, so the presence of the scaphoid fracture did not influence the decision. In our opinion, standard indications for operation cannot be given, and surgical treatment should be tailored to the individual patient. Generally, the decision whether to operate on the simultaneous fractures should be based on the
69 same criteria as isolated fractures, e.g. an unstable, displaced scaphoid fracture (2,5), an unstable, displaced distal radial fracture (3), and carpal instability. All scaphoid fractures healed normally, and avascular necrosis was not observed. The explanation for this observation is most likely the fact that 19 out of 23 scaphoid fractures were undisplaced and localized to the waist. It has been described previously that healing of fractures near or at the waist of the scaphoid is complicated in only 5% of cases (2). However, we initially thought that the scaphoid fracture would produce the more serious complications, so a below elbow cast including the thumb instead of a dorsal splint was used. It appears that the outcome of the combined fractures is determined more by the distal radial fracture. It has been reported that the type of cast used to immobilize stable scaphoid fractures does not affect the incidence of non-union or other complications of fracture healing (1), and that good results could be achieved by applying a dorsal splint with the wrist in neutral position. Immobilization of the thumb is not necessary and reduction of the scaphoid fracture was not lost with tractional forces across the wrist. Consequently, there is strong evidence that treating a scaphoid fracture with the wrist in neutral position is not detrimential. As a result of this study we shall apply a dorsal splint with the wrist in neutral position for 6 weeks for non-operative treatment in future cases, because there is more likelihood of redisplacement of the distal radial fracture than non-union of the scaphoid. REFERENCES 1. Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. Journal of Bone and Joint Surgery 1991; 73B: 828-32. 2. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to mangement. Clinical Orthopaedics and Related Research 1980; 149: 90-7. 3. Jupiter JB. Current concepts. Review fractures of the distal end of the radius. Journal of Bone and Joint Surgery 1991; 73A: 461-9. 4. Smith JT, Keeve JP, Bertin KC, Mann RJ. Simultaneous fractures of the distal radius and scaphoid. Journal of Trauma 1988; 28: 676-9.
70 5. Szabo RM, Manske D. Displaced fractures of the scaphoid. Clinical Orthopaedics and Related Research 1988; 230: 31-8. 6. Tountas AA, Wadell JP. Simultaneous fractures of the distal radius and scaphoid. Journal of Orthopaedic Trauma 1988; 1: 312-7. 7. Warwick D, Prothero D, Field J, Bannister G. Radiological measurement of radial shortening in Colles fracture. Journal of Hand Surgery 1993; 18B: 50-2.
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