Conservative Treatment of Distal Radius Fractures, Importance of Radial Height l

Transcription

1 e A þ t ý m Consevtive Tetment of Distl Rdius Fctues, Impotnce of Rdil Height l n i j i O O i g in Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi, Rdius Yüksekliğinin Önemi h c s Re l Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi / Consevtive Tetment of Distl Rdius Fctues Gökhn Keleş 1, Engin Een Desteli 2, Mut Edoğn 3, Bülent Köksl 4, Ebu Kelsk 5, Sbit Numn Kuyubşı 6 1 Deptment of Othopedics, Bf Stte Hospitl, Bf, 2 Deptment of Othopedics, Uskud Stte Hospitl, Istnbul, 3 Othopedics, Ondokuz Myıs Univesity, Smsun, 4 Deptment of Othopedics, Yuksek Ihtiss Hospitl, Kııkkle, 5 Anesthesiology, Ondokuz Myıs Univesity, Smsun, 6 Deptment of Othopedics, Ondokuz Myıs Univesity, Smsun, Tükiye Özet Rdius lt uç kııklının kplı vey cehi tedvi kı bzı tip kııkld dh zo olbili. Kliniğimizde kplı edüksiyon ve lçı ile tkip ettiğimiz hstlı klinik ve dyolojik olk değelendieek stbilite ve pognozu etkileyen bşlıc fktölei değelendimeyi mçldık. Çlışmd Ock 2007-Eylül 2010 tihlei sınd Klinik değelendimede Gtlnd ve Weley sistemi, DASH nketi ve dyolojik değelendimede; titik değişiklikle Knik ve Jupite tit değelendime sistemi ile ve çılnm Stewt dyolojik değelendime kitelei ile değelendiildi. Ondokuz Myıs Ünivesitesi Otopedi Bölümünde kplı edüksiyon ve lçı ile tkip edilmiş 51 hst dhil edildi (34 ekek,17 kdın ot. Yş 39.8 ± 11.3 ). Otlm tkip süesi 17.1 ydı (dğılım, 6-48 y). Gtlnd ve Weley klinik değelendime sistemine göe 23 hst (45.1%) 0-2 pun (mükemmel), 19 (37.3%) hst 3-8 pun (iyi) ve 9 (17.6%) hst 9-20 pun (ot) olk değelendiildi. Kötü sonuç yoktu. Rdil yükseklik kybı fonksiyonel sonuçlı olumsuz etkiledi, dil yükseklik tedvinin pognozun etki eden bşlıc fktöleden biisi olk tespit edildi, dil inklinsyon,dil kıslık, vey plm inklinsyon kybı pognoz olumsuz etki etmedi. Anht Kelimele Rdius Distl Kııklı; Kplı Redüksiyon; Rdius Yüksekliği Abstct Decision of consevtive tetment o sugey still emins debte fo some pticul types of dius distl fctues. We imed to evlute the clinicl nd diologicl esults of ptient goup teted in ou clinic with closed eduction nd plste cst fixtion nd tied to evlute the pime fctos ffecting stbility nd pognosis of consevtive tetment. The study compised 51 ptients (34 mles, 17 femles; men ge 39.8 ± 11.3 yes) teted with closed eduction nd plste cst fixtion fo dius distl end fctue t ou clinic duing the peiod Jnuy 2007 to Septembe Obtined clinicl esults wee scoed ccoding to the Gtlnd nd Weley clinicl evlution system12 nd the Disbility Am, Shoulde nd Hnd Sugey Questionnie (DASH), fo diologicl exmintion; thitic chnges wee evluted ccoding to the Knik nd Jupite thitis scoing system nd ngultion evlution ws mde ccoding to the Stewt s diologicl evlution citei. Men follow-up peiod time ws 17.1 months (nge, 6-48 months). Accoding to the Gtlnd nd Weley clinicl evlution system 23 ptients hd (45.1%) 0-2 points (excellent), 19 (37.3%) hd 3-8 points (good) nd 9 (17.6%) hd 9-20 points (modete). No poo esults wee detemined. Loss of dil height hd negtive effect on functionl outcome, dil height is one of the pime fctos ffecting the pognosis of the tetment. Impiment of the dil inclintion, dil shotening o loss of plm inclintion wee not obseved to negtively ffect the pognosis. Keywods Rdius Distl Fctues; Closed Reduction; Rdil Height DOI: /JCAM.2820 Received: Accepted: Published Online: Coesponding Autho: Engin Een Desteli, Uskud Devlet Hstnesi, Otopedi Bölümü, İstnbul, Tükiye. E-Mil: eendesteli@yhoo.co.uk Jounl of Clinicl nd Anlyticl Medicine 1

2 Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi / Consevtive Tetment of Distl Rdius Fctues Intoduction Rdius distl end fctues e the most fequently seen of ll bone fctues nd compise 8-15% of ll fctues [1] % of dius distl end fctues e ext-ticul stble fctues nd cn be teted consevtively in the Emegency Deptment2 [2]. Howeve, ppoximtely 20% of these fctues e unstble nd sugicl tetment is equied nd decision on consevtive tetment o sugey still emins debte fo some pticul types of fctues [1,2]. In the choice of tetment methods, fctos such s the type of fctue, the ptient s ge, lifestyle, ccompnying helth poblems, complincy to tetment, physicl nd mentl cpcity must be consideed [3,4]. Depending on the physicin s expeience nd the fcilities vilble, sevel methods including simple plste cst o pecutneous niling, vious extenl nd intenl fixtion nd gfting techniques cn be used. The bsic pinciples of tetment e to obtin the most ppopite eduction nd the fixtion of this eduction [5]. This etospective study imed to evlute the functionl nd diologicl esults of ptient goup teted in ou clinic with closed eduction nd plste cst fixtion fo distl dius fctue nd to evlute the pime fctos ffecting stbility nd pognosis of consevtive tetment. Mteil nd Method Locl ethics committee ppovl fom Ondokuz Myıs Univesity nd witten infomed consent ws obtined fo the study. This etospective study compised 51 ptients (34 mles, 17 femles; men ge 39.8 ± 11.3 yes) teted with closed eduction nd plste cst fixtion fo dius distl end fctue t ou clinic duing the peiod Jnuy 2007 to Septembe Ptient selection citei wee, i) to hve been teted nd followed up t ou clinic, ii) ged ove 18 yes, iii) pe nd posttetment diogphs vilble, iv) to hve hd finl clinicl evlution fte t lest 6 months polyclinic follow-up, v) to hve been dignosed with distl dius fctue which ws teted with closed eduction nd plste csting. Duing the eduction mneuve mde to ptients pesenting with dius distl end fctue, nlgesi ws dministeed to ptients who could not tolete the pin (those with cdiovscul diseses, hypetension o those who stted tht they would not be ble to tolete pin). A singul dose of intmuscul Diclofenc N o Metmizol N ws dministeed s nlgesi nd intmuscul Dizepm (10mg) s sedtive. With the ptient in supine position nd the ffected m in bduction with the elbow t 90 flexion, one ssistnt pplied tction bove the elbow (opposite tction) nd nothe peson pplied tction holding the thumb in one hnd nd the 4 finges in the othe. Afte 2-3 minutes of continuous tction, the eduction mnoeuve ws mde ccoding to the fctue type nd estimted mechnism of the fctue. An bove-the-elbow bce which llowed movement of the metcpophlngel joint ws pplied to ll ptients. At this stge, the stndd position fo the wist ws not used but ce ws tken to pply the bce in the position in which eduction ws mde. Tht the eduction ws within cceptble mesuements ws checked by post-eduction diogphs. The ptients wee clled to follow-up one dy lte to infom them bout bce complictions nd comptment syndome. Fo ptients whee the oedem hd educed, diogphs wee epeted within the bce nd if the eduction ws potected, n bove-the-elbow plste cst ws pplied nd diogphs wee epeted fte the plste csting. Fo ptients with continuing oedem, elevtion ws explined gin nd they wee clled fo fequent follow-ups until the oedem hd ecoveed nd the bove-mentioned pocedue fo cicul plste cst ws pplied. Afte the ppliction of cicul plste cst, cicultion follow-up nd elevtion wee explined nd they wee clled fo follow-up 2 dys lte fo cicultion monitoing. Ptients with good cicultion hd follow-up diogphs tken fte 4 weeks nd the plste cst ws emoved to below the elbow. They wee followed up in this wy fo 2 weeks. At this stge, elbow execises wee ecommended to the ptients. At the end of 6 weeks, the plste cst ws emoved nd diologicl nd clinicl exmintions wee mde. Fo ehbilittion, isotonic nd isometic wist, finge nd elbow execises wee tught to the ptients. At the finl follow-up, the ptients wee questioned bout ny complints. The wist shpe, foem ottion nd wist movements wee exmined in the clinicl exmintion. Gip stength ws mesued comptively with dynmomete (Jm, Bseline hydulic hnd dynomomete, Ivington, NY, USA) with the elbow t 90 nd the foem nd wist in neutl position. In this mesuement, the gipping m is held tight nd gipping foce is pplied t single time by the ptient using mximum stength. The test ws pplied by mking two mesuements fo ech hnd ltentely. Ech foce ws ecoded. Thee my be 5-10% diffeence between the dominnt nd non-dominnt hnd. The obtined clinicl esults wee scoed ccoding to the Gtlnd nd Weley clinicl evlution system12. Fo the finl evlution the ptients wee questioned using the Disbility Am, Shoulde nd Hnd Sugey Questionnie (DASH), which consists of 30 questions. Of these 30 questions, 21 evlute dily ctivities of the ptients, 5 e elted to symptoms nd 1 to sleep. In this system, no complint o pefoming the specified ctivity without ny difficulty is scoed s 1 nd excessive complints o inbility to pefom the ctivity s 5 [6]. At the sme time, nteio-posteio nd ltel diogphs of the wist wee tken. In the diologicl exmintion, thitic chnges wee evluted ccoding to the Knik nd Jupite thitis scoing system [4]. nd ngultion evlution ws mde ccoding to the Stewt et l diologicl evlution citei [7]. In ddition, the ptients wee evluted by diect diogphs tken fte plste csting using the bove-mentioned scoing systems. Results The men follow-up peiod of the 51 ptients in the study ws 17.1 months (nge, 6-48 months). Distibution of the ptients ccoding to the Fykmn nd AO Clssifictions is shown in Tble 1. Accoding to the Gtlnd nd Weley clinicl evlution system the ptients wee evluted s 23 (45.1%) t 0-2 points (excellent), 19 (37.3%) t 3-8 points (good) nd 9 (17.6%) t 9-20 points (modete). No poo esults wee detemined. The men DASH scoe ws 35.9 ± 4.2. When muscle stength 2

3 Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi / Consevtive Tetment of Distl Rdius Fctues Tble 1. Distibution ccoding to Fykmn nd AO Clssifictions Fykmn clssifiction No of ptients % AO clssifiction No of ptients I A II A III B IV C V C VI VII VIII TOTAL TOTAL ws comped with the helthy side, the helthy side ws found to be men 34.1 ± 10.0 kg, nd the fctued side, 27.9 ± 9.6 kg. Peopetive men dil height ws 12 mm. Postopetive men dil length ws mesued to be 11.8 mm. Totl of 6 ptients hd decesed dil heights nd men muscle stengths of these 6 ptients ws found to be 22.5 this vlue ws found to be sttisticlly significntly lowe thn ptients who hd post-tetment noml dıl heights. (p<0.05). When the ptients wee exmined ccoding to the Stewt et l diologicl citei, esults wee obtined of 18 (35.3%) excellent, 28 (54.9%) good nd 9 (17.6%) modete. No poo esults wee obtined. Osteothitis ws detemined diologiclly in 14 (27.4%) ptients ccoding to the Knik nd Jupite thitis scoing system. Of 11 ptients detemined with Gde 1 thitis, 4 (36.3%) fctues wee Fykmn Type 7, 5 (45.4%) Fykmn Type 8, 1 (9%) Fykmn Type 3 nd 1 (9%) Fykmn Type 4. Of the 3 ptients detemined with Gde 2 thitis, 1 fctue ws Fykmn Type 7 nd 2 fctues wee Fykmn Type 6. In ddition, it ws detemined tht s the Fykmn degee incesed so thee ws n incese in clinicl scoe, DASH nd the diologicl ntomic scoe. 32-ye old mle with left side dius distl end complex fctue, Fykmn Type 6, AO A3, AP nd Ltel Roentgenogmbefoe closed eduction (Figue 1), fte closed eduction (Figue 2) nd fte follow-up peiod of 10 months (Figue 3). Figue ye old mle with left side dius distl end complex fctue, Fykmn Type 6, AO A3, AP nd Ltel Roentgenogmbefoe closed eduction. Figue 2. Afte closed eduction % Figue 3. Afte follow-up peiod of 10 months Discussion Rdius distl end fctues e fctues which e ntomiclly in the distl of the distl dius metphysis. Although these e the most fequently encounteed fctues duing n othopedic cee, thee is still no consensus on clssifiction, tetment nd the evlution of tetment esults. To obtin good functionl esults in dius distl end fctues it is necessy to coect dil shotness, dil inclintion, dosl cuve nd distl diouln joint inconguity. In study by Klezli et l, ntomic esults of 40.7% excellent, 44.4% good, 9.9% fi nd 5% poo wee obtined ccoding to the Stewt scoe system, clinicl esults of 30.8% excellent, 47% good, 17.2% fi nd 5.0% poo nd it ws dvocted tht to chieve good functionl esult, it is necessy to obtin good ntomic esult [8]. In the cuent study, when the esults obtined wee evluted, it ws detemined tht s the ntomic esult wosened so the clinicl esult lso wosened. In ddition, ptients who did not hve good functionl nd ntomic esults hd high DASH scoe. In the tetment of dius distl fctues, it is still mtte of debte s to which is the most impotnt citei defining pognosis of the esult of eduction. Accoding to Plme, it is the estotion of dil length, while Gtlnd nd Weley epoted it to be the pesence of esidul dosl tilt [9,10]. Fenndez et l stted tht dosl ngultion >25 will negtively ffect the pognosis nd Pogue et l climed tht moe thn 20 will led to poo esults [11,12]. Fykmn nd de Plm epoted tht it is necessy to povide dil length to be ble to obtin good functionl esults [10,13]. In the cuent study, tht loss of dil height hd negtive effect on both gip stength nd clinicl esults, suppots the view tht dil height is the most impotnt citei defining the pognosis of the tetment. Impiment of the dil inclintion, dil shotening o loss of plm inclintion wee not obseved to negtively ffect the pognosis. In study by Vul et l whee compison ws mde of the Kpndji technique with plste csting, thee ws no diffeence between the goups in espect of dil length nd dil inclintion but plm inclintion ws detemined to hve been bette estoed in the Kpndji technique [14]. In the cuent study, when evlution ws mde of the finl follow-up mesuements of ll the ptients, the men dil cuve ngle ws found to be 19.4 ± 4.4, the men plm cuve ngle 0.3 ± 8.5 nd dil height 8.5 ± 2.6 mm. Accoding to these esults fom the cuent study, it ws concluded tht the plm inclintion ngle ws moe difficult to coect thn the othe ngles, lthough s the most obvious limittion of this study is tht thee ws no contol goup, we e in suppot of futhe studies to be mde on the subject of by which method the plm inclintion 3

4 Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi / Consevtive Tetment of Distl Rdius Fctues cn be coected. It is known tht when the tetment of dius distl fctues esults in insufficient ntomic estotion, this cetes loss of gip stength. McQueen found moe thn 2mm shotening in the dius to be n indicto of gip stength loss [15]. In study by Özdemi et l, while it ws obseved tht s ngultion incesed doslly, gip stength decesed, no eltionship ws found between the dil ngle nd gip stength [16]. In the cuent study, in the coeltion between gip stength nd dius distl end ntomy, the conclusion ws eched tht s dil length decesed, so gip stength lso decesed. No significnce ws found between gip stength nd dil nd plm inclintion. One of the most fequently encounteed poblems in consevtive follow-up of dius distl end fctues is tht the eduction is not potected inside the plste cst. This poblem is moe evident pticully in unstble fctues [17]. It hs become known tht even if thee is successful eduction initilly in dius distl end fctues with metphysel fgmenttion, loss of eduction develops inside the plste cst in ppoximtely 60% of these cses [18]. In this espect, these fctues equie ceful monitoing in consevtive follow-up with plste cst. Jenkins et l epoted tht eduction loss of 5% ws obseved s esult of consevtive tetment in unstble int-ticul fctues nd this equied coection with new eduction [19]. In study by Wwick with 10-ye follow-up peiod, it ws epoted tht plste csting tetment could not povide sufficient dil length nd thus extenl fixtos should be pefeed [20]. In the cuent study, ntomic ngles wee mesued following plste csting nd t the finl follow-up. In the light of these vlues, the dil inclintion ngle nd dil height within the plste cst wee found to be sttisticlly significntly highe thn the vlues mesued t the finl follow-up. Howeve, no significnt diffeence ws found between the vlue of the plm tilt ngle in the plste cst nd tht t the follow-up following bone union. In ddition, while the dil height nd dil inclintion vlues in the plste cst of eldely ptients nd those with metphysel fgmenttion wee found to be significntly highe thn the follow-up vlues, no sttisticlly significnt diffeence ws detemined in the plm tilt. Tht no diffeence ws detemined between the plm tilt ngles in the plste cst nd t follow-up is thought to be ssocited with the povision of sufficient suppot fom the dosl of the plste cst which ws pplied fte oedem hd ecoveed. Howeve, osteopenic fctues in eldely ptients hve tendency to displcement pticully in the lte peiod nd this cn be consideed to confom with the view of Wwick tht plste csting tetment cnnot povide sufficient dil length [20,21]. Anothe subject fo debte in dius distl fctues is the effect on pognosis of n uln styloid fctue togethe with dius fctue. Accoding to Knik et l, non-union of the styloid ffects the pognosis negtively [4]. Smill et l epoted tht n uln styloid fctue my cuse esticted wist movement [22]. Howeve, in study by Bdwy et l, it ws stted tht non-union of n uln styloid fctue did not ffect functionl esults. [23]. In the cuent study, 21 (41.1%) ptients hd n uln styloid fctue s well s the dius distl fctue. At the finl follow-up, union of the uln styloid ws detemined in 6 (28.5%) ptients nd non-union in 15 (71.5%) ptients. Although the numbe of ptients ws low in the cuent study, s thee ws no sttisticlly significnt diffeence in the follow-up men clinicl evlution scoe nd DASH scoe between the ptients with union of the uln styloid nd those with non-union, the pesence of styloid fctue ws not thought to ffect the functionl esults. Conclusion The cuently ccepted view of dius distl end fctues is tht they e complex fctues nd pognosis vies depending on the type of fctue nd the tetment pplied. Tetment with closed eduction nd plste cst fixtion is extemely chep nd is n esy method to pply in shot time. In the cuent study, tht loss of dil height hd negtive effect on both gip stength nd clinicl esults, suppots the view tht dil height is the most impotnt citei defining the pognosis of the tetment. Impiment of the dil inclintion, dil shotening o loss of plm inclintion wee not obseved to negtively ffect the pognosis. Competing inteests The uthos decle tht they hve no competing inteests. Refeences 1. Seitz WH, Foimson Al, Books DB, Potsk P, Polndo G, Geenwld AS. Extenl fixto pin insetion techniques. Biomechnicl nlysis nd clinicl elevnce. J Hnd Sug Am 1991;16(3): Rogge R, Adms BD, Goel VK. An nlysis of bone stesses nd fixtion stbility using finite element model of simulted distl dius fctues. J Hnd Sug (Am) 2002;27(1): Cooney WP, Linsheid RL, Dobyns JH. Extenl pin fixtion fo unstble Colles fctues. J Bone Joint Sug 1979;61: Knik JL, Jupite JB. Int-ticul fctues of the distl end of the dius in young dults. J Bone Joint Sug 1986:68: Censhw AH. Fctues of shoulde, m nd foem. In: Cnle ST (Ed.). Cmpbell s opetive othopedics. 10th ed. Phildelphi: Mosby Publ; 2003.p Atoshi I, Gummesson C, Andeson B, Dhlgeen E, Johnsson A. The disbilities of the m, shoulde nd hnd (DASH) outcome qestionnie. Relibility nd vlidity of the swedish vesion evluted in 176 ptients. Act Othop Scn 2000;71(6): Stewt HD, Innes AR, Buke FD. The hnd complictions of Colles fctues. J Hnd Sug 1985;10: Klezli K,Demi R, İlt S, Çkı A, Klezli N, Özei Z. Rdius distl uç kııklınd konsevtif tedvi sonuçlımız. Gülhne Tıp Degisi 2004;46(4): Gtlnd JJ J, Weley WC. Evlution of heled Colles fctues. J Bone Joint Sug 1951;33: DePlm, AF, Comminuted fctues of the distl end of the dius teted by uln pinning. J Bone Joint Sug 1952;34: Fenndez DL. Reconstuctive pocedues fo mlunion nd tumtic thitis. Oth Clin of Noth Ameic 1993;68: Pogue DJ, Viegs SF, Ptteson RM, Peteson PD, Jenkins DK, Sweo TD et l. Effects of distl dius fctue mlunion on wist joint mechnics. J Hnd Sug (Am) 1990;15(5): Fykmn G. Fctue of the distl dius including sequelqe Shoulde-hndfinge syndome distubnce in the distl diouln joint nd impiment of neve function. A clinicl nd expeimentl study. Act Othop Scnd 1967;108: Vul Ö, Okçu G, Özlp RT, Akky MG, Yecn HS. Kolles kıığı tedvisinde kplı edüksiyon lçılı tespit ile Kpndji yönteminin kşılştıılmsı. Joint Dis Rel Sug 2008;19(2): McQueen MM, Hjduck C, Cout-Bown C. Redisplced unstble fctues of the distl dius: ndomised, pospective study of bidging vesus non-bidging extenl fixtion. J Bone Joint Sug 1996;78(3): Özdemi H, Özenci M, GÜL S. Konsevtif yöntemle tedvi edilen distl dius kııklının eken ve geç dönem sonuçlının kşılştıılmsı. Act Othop Tumtol Tuc 2000;34: Pocto MT, Mooe DJ, Pteson JM. Redisplcement fte mnipulting of distl dil fctues in childen. Jounl of Bone Joint Sug 1975;93:

5 Rdius Alt Uç Kııklının Kplı Yöntemle Tedvisi / Consevtive Tetment of Distl Rdius Fctues 18. Diego L. Fenndez, Andew K. Plme. Fctues of the distl dius. In: Geen, Hotchkiss, Pedeson, editos. Geen s Opetive Hnd Sugey. Vol.1.Fouth edition. Phildelphi: Chuchill Livingstone co.; 1999.p Jenkins NH, Jones DG. Extenl fixtion of Colles fctues n ntomicl study. J Bone Joint Sug 1987;69(B): Wwick D, Potheo D: Rdiologicl mngement of the dil shotening in Colles fctues. J Hnd Sug 1993;18: Solgd S. Clssifiction of distl dius fctues. Act Othop Scnd 1984;56: Smill GB. Long tem follow up Colles fctue. J Bone Joint Sug (B) 1965;47: Bdwy JK, Amdio PC, Cooney WP. Open eduction nd intenl fixtion of displced, comminuted intticul fctues of the distl end of the dius. J Bone Joint Sug 1989;71: