Abstract
Introduction:Comminuted fractures of
Lower end of radius most often bring out unsatisfactory outcome
if treated by conservative means of closed reduction and
casting. This study is to emphasize the far better functional
results obtained by treating these fractures by Ligamentotaxis.
Materials and Methods:This is a prospective Study
Conducted in a Government Medical College, and we analyzed the
functional outcome of 58 patients with comminuted fracture lower
end of radius treated by Ligamentotaxis during the period
January 2003 to 2006.Average follow up time was 2 years.
Patients with open epiphyseal plate, those with vascular insult
and open injuries were excluded from the study. Reduction of the
fragments was achieved by the principle of Ligamentotaxis.
Results:Patients underwent Ligamentotaxis had 88%
Excellent or Good results whereas 52% of patients on
Conservative care had similar results. When the Conservative
methods gave poor results for Severely Comminuted fractures,
Ligamentotaxis could bring out excellent re-orientation of
fragments back to near normal alignment.
Conclusion:Ligamentotaxis using a Distracter is a better
method to treat Comminuted fractures of lower end of radius.
Even though the initial reductions were excellent in a plaster
cast, re-displacement rates are very high in a plaster cast.
Fractures without intra articular extension always yielded far
better results than intra articular fractures. However, badly
comminuted and unstable fractures needed either supplementation
of bone grafting, or focal pinning to prevent collapse after
removal of external fixator.
J.Orthopaedics 2007;4(1)e8
Introduction:
Distal radial fractures are associated with a
colorful history since their first description by Ponteau in
1783 and Abraham Colles in 1814.4 Still they continue to be one
of the most common orthopedic injuries treated by Orthopedic
Surgeons1. Among these fractures, the challenging type is
comminuted distal radial fractures because, they tend to
displace within a plaster cast2. It is now clear that
preservation of articular congruity is the principal pre
requisite for successful recovery following Distal Radial
fractures. Wide arrays of techniques from closed manipulation
reduction followed by short arm cast, percutaneous pins, pin and
plaster, open reduction and internal fixation to complex
external fixators were evolved.3, 6,7,10,14,21,23.
Closed manipulative reduction and cast
immobilization invariably leads to poor functional outcome due
to re-displacement of fracture within the cast15. The purpose of
the study is to evaluate the results of ligamentotaxis in
comminuted fractures of the distal end of radius and to compare
it with the results of closed manipulative reduction and plaster
cast immobilization . The study evaluates complications and
their management. The study also intends to assess the final
outcome of this technique.
Material and Methods :
A prospective study was conducted on
ligamentotaxis for comminuted fracture lower end of radius from
2003 to 2006. 50 patients were taken for the study. 25 of these
patients were treated by conservative line of management (group
ll), and25 by external fixator (group l). Dr. Joshys external
stabilization system distractor (20 cm) and AO fixator were used
for external fixation. The mechanism of injury in 30 cases was
fall from height and in the rest 20 was due to road traffic
accident.
Case was selected based on comminution. In 21
of the group l patients, fixator was applied on the first day,
and in the rest of the 4 cases, within 3 days as a secondary
procedure. In groupll there were 6 males and 19 females, where
as in groupl there were 18 males and 7 females.
The fractures were classified according to
the Frykman classification.11
|
GROUP ll |
GROUPl |
Dorsal angulation |
21 degrees |
28 degree |
Radial shortening |
5mm |
7mm |
Radial deviation |
7 degree |
13 degree |
20 cm JESS distractor was used in groupl.
Post operative check x-rays were taken. If reduction was found
to be unsatisfactory, distraction was adjusted to get a perfect
alignment. The extremity was kept elevated in a sling and
antibiotics were prescribed for one week.
In groupll, after giving an intravenous
sedation, a closed manipulative reduction and short arm slab was
given. Re-manipulation was done if the reduction was not
satisfactory on check x-rays. If there were no associated
injuries, patients were discharged on the next day with a course
of oral analgesics and advice regarding active finger movements.
On the first review after 1 week in the
groupl patients, check x-ray was taken. The pin track dressings
were changed and movements of the extremity assessed. In groupll,
check x-ray was taken and cast conversion done. Then every 2
weeks patients were reviewed. On the 6th week cast were removed,
x-ray taken and mobilization started. In groupl patients fixator
was removed in the 4th week. Dressings were applied over pin
tract and a below elbow cast is applied which was removed after
2 weeks.
The patients were evaluated on 3rd, 6th, 12th
and 18th months after surgery for analyzing results. Vander
Linden’s radiological criteria were used to asses the Anatomical
results.24. Functional results were assessed by Gartlands point
score system12.
Results :
Out of 25 patients in group 1, 6 were male
and 19 were females. Of the 6 male patients, 5 got excellent
results and 1 unsatisfactory result. Of the 19 females, 16 got
excellent results, and 3 unsatisfactory results. In group ll, of
the 18 males, 10 had excellent results and 8 had unsatisfactory
results. Of the 7 females, 4 had excellent and 3 had poor
results. This shows that sex has got no significance in the
final result.(p value=0.4321).
12 patients in Gr.l had Rt wrist injured
where as 13 had left wrist. Among the 12 10 had good result and
2 had unsatisfactory results. Among the 13 with left sided
injury, 10 had good results and 3 had bad results. In Gr.ll, 14
had Rt and 11 had Left wrists affected. Among the 14 Rt.siders,
8 had good and 6 had un satisfactory results. Among the 11 Lft.
Siders, 7 had excellent results and 4 had poor results. There
was no statistical correlatrion between side and end results. (p
value=0.7832)
Of the 25 patients in Gr.l, 22 had excellent
results regarding residual deformity where as in the Gr.ll,
only 14 had, good or excellent results, which is statistically
significant( P value=0.0054).In Gr.l, out of the 25 patients, 18
had good grip strength, where as, only 11 had good or excellent
grip strength in Gr.ll, which is statistically significant.( p
value=0.0046)
Dorsal Angle:
Table shows the dorsal angle in each patient.
Angle
|
Group Il
|
Group I
|
Post Red
|
6wks
|
12 wks
|
Post Red
|
6 wks
|
12 wks
|
No.
|
%
|
No.
|
%
|
No. %
|
No.
|
%
|
No,
|
%
|
No. %
|
-6 to -10
|
5
|
20
|
|
|
|
|
|
|
|
|
0 to -5
|
5
|
20
|
1
|
4
|
|
2
|
8
|
1
|
4
|
|
1 to 5
|
8
|
32
|
4
|
16
|
no
|
6
|
24
|
6
|
24
|
no
|
6 to 10
|
6
|
24
|
9
|
36
|
marked
|
12
|
48
|
1 1
|
44
|
marked
|
10 to 14
|
1
|
4
|
8
|
32
|
change
|
5
|
20
|
6
|
24
|
change
|
>15
|
-
|
-
|
3
|
12
|
- •.
|
-
|
-
|
1
|
4
|
|
From this table it is clear that though
initial correction was better in group Il displacement in the
cast was marked. The average dorsal angle in group lI is 2.66
and in group I 8.32.
Radial angle: The values in two groups
are given in table.
|
Group Il
|
Group I
|
Angle
|
Post Red
|
6wks
|
12 wks
|
Post Red
|
^K.
6 wks
|
12 wks
|
in degrees
|
No.
|
%
|
No.
|
%
|
No. %
|
No.
|
%
|
No.
|
%
|
No. %
|
> 20
|
10
|
40
|
1
|
4
|
no
|
12
|
48
|
10
|
40
|
no
|
15-19
|
11
|
44
|
4
|
16
|
change
|
10
|
40
|
10
|
40
|
change
|
10-40
|
3
|
12
|
14
|
56
|
> 5°
|
2
|
8
|
3
|
12
|
> 5°
|
5-9
|
1
|
4
|
6
|
24
|
|
1
|
4
|
2
|
8
|
|
Intra articular was seen in 16 cases (64%) in
group I and 10 cases (40%) in group lI. They were again sub
classified by Melones classifications. Of the 16 cases in Gr.l,
14 had excellent or good results. Of the 10 cases in Gr.ll, only
6 had good or excellent results. (p value=0.0062)
Movements of Joints : In group I 88%
of patients showed good or excellent movements of wrist and
forearm. In group II 48 % of the patients showed good or
excellent movement of wrist and forearm. Palmer flexion is most
affected followed by limitations of dorsiflexion and supination.
Pin loosening: In group II three
patients had pin each loosened but the fixator was stable it was
noticed on removal.
Pin tract infection: In group I seven
patients had mild pin tract infection which was completely
controlled by short course oral Cefuroxime and proper pin tract
care.
Malunion / Nonunion: No nonunion was
observed. In four cases of group I and six Cases of group II had
some tenderness over the fracture site they were treated by
additional two weeks of cast.
Sudeks osteodystrophy : No case of
Sudeks osteodystrophy was noticed in either group in this
study.
Neuro vascular complications: In group
I two cases had median nerve affection and two patients had
numbness over the radial nerve superficial branch distribution.
In group II no median nerve affection was seen but three
patients had numbness along the radial nerve distribution and
two had neuralgia along the radial nerve distribution.
Post traumatic osteoarthritis : No
severe cases of osteoarthritis was noticed in the group I
patients and two patients in group Il had moderate
osteoarthritic changes. But mild moderate articular incongruity
was noticed in six of group I and fifteen of group II patients.
Result based on treatment: When both
group I and group II are compared group I had 52% good or
excellent results and group ll had 88% of good or excellent
results. From this it is clear that group II patients received a
better treatment than group I. When the statistical formula is
used t=2.02 which shows that P value is 0.0053 and hence it is
statistically significant.
Complications: Finger stiffness,
inferior-radio ulnar instability, pin loosening, pin tact
infections, mal union/ non union, Sudeks osteodystrophy,
neurovascular complications (median nerve involvement) and post
traumatic osteoarthrosis were the complications seen with this
study.
Discussion :
In the study, most of the cases were in the
younger age group. As stated by Melone, there is an increased
frequency for the comminuted fractures of lower end of radius in
younger age groups in recent years due to increased incidence of
Road Traffic Accidents22. Almost all authors got a female
preponderance. In the study, Group I had high incidence in young
Males since the females were reluctant to Surgery. There is a
Right sided predominance in this study. It is observed that the
right hand is affected in almost all series because it is the
dominant hand20. In this study, 96% of patients in Group I had
no or mild deformity at the end of follow up, whereas only 52%
in GrouplI had no or mild deformity. The treatment with external
fixator is better to maintain the reduction and to prevent the
recurrence of deformity. It reduces the rate of malunion, which
is evident by radiological analysis. Other than fracture of
lower end of ulna no other skeletal injuries were noted in the
same upper limb in the present series, but according to Belcorn
and other authors, fracture Scaphoid is a common association11.
48% of GrouplI patients got good or excellent grip strength,
whereas it was 60% in Group I. Stiffness of joints was more in
conservatively treated patients. Intra articular fractures
carried poorer results. Post traumatic Osteo Arthrosis was
assessed according to Kirk Jupiter Scale16. In Group lI, 32% and
in GroupI 4% of Osteoarthrosis was noted. Pin track infection
was noted in 7 patients (28%), which responded to a short course
of oral antibiotics. Pin loosening was found in 3 patients
(12%). Frame pin junction loosening was noted in 4(16%).
Difficulties met with during these procedures
were:
-
patient motivation is essential
-
non-threaded wire had less purchase than
threaded
-
readjustment was difficult with a static
fixator
Conclusion:
Comminuted fracture lower end of radius is
seen in middle aged, commonly with slight female preponderance.
The common causes are fall from height and road traffic
accidents. Conservative management with a plaster slab after
closed manipulative reduction often gives unsatisfactory results
due to re-displacements, whereas, Ligamentotaxis using a
distractor is a better treatment option. Anatomical restoration
of the joint is a must for the excellent functional result.
Commonest complication is Malunion which in later age may lead
to arthritic change. Intraarticular fractures give poorer
results compared to non articular fractures. Chance of collapse
after removal of external fixator is there. So additional bone
grafting or focal pinning may be needed. Early active exercise
can avoid stiffness of joints.
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