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Abstract Objective The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1-10) and 3.50 (-6-10) in difference 1; 4.35 (-5-10) and 5.00 (-3-10) in difference 2; and 4.65 (1-10) and 3.80 (-3-10) in difference 3. Conclusion Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.
Resumo Objetivo O estudo compara a eficácia analgésica de duas técnicas para realizar redução incruenta: o bloqueio de hematoma da fratura e o bloqueio supracondilar de nervo radial. Métodos Quarenta pacientes com fraturas do terço distal do rádio, que necessitassem redução, foram selecionados em um ensaio clínico quasi-randomizado, para receber uma das técnicas anestésicas. Todos os pacientes assinaram o termo de consentimento ou assentimento, com exceção daqueles que não desejassem participar do estudo, tivessem lesão neurológica, com contraindicação ao procedimento na sala de emergências, ou com contraindicação ao uso da lidocaína. Para aferir a analgesia foi utilizada a escala numérica da dor em quatro momentos distintos: pré-bloqueio, pós-bloqueio, durante a redução e após a redução; em seguida, foram calculadas três diferenças: a primeira entre antes e após o bloqueio; a segunda entre durante a redução e após o bloqueio; e a terceira entre antes do bloqueio e após a redução. Resultados Os grupos do bloqueio de hematoma de fratura e bloqueio supracondilar apresentaram respectivamente os seguintes valores médios: 3.90 (1-10) e 3.50 (-6-10) na diferença 1; 4.35 (-5-10) e 5.00 (-3-10) na diferença 2; e 4.65 (1-10) e 3.80 (-3-10) na diferença 3. Conclusão As duas técnicas se provaram eficientes para analgesia, com discreta superioridade do bloqueio de hematoma, mas sem significância estatística.
Subject(s)
Humans , Radius Fractures , Pain Measurement , Closed Fracture Reduction , Anesthesia, Local , Nerve BlockABSTRACT
Objective:To investigate the common types of elbow joint injuries in skiing or snowboarding and their treatment.Methods:A retrospective study was conducted to analyze the data of 90 patients with elbow injury caused by skiing or snowboarding who had been admitted to Department of Upper Limbs, Sichuan Orthopaedic Hospital from February, 2015 to February, 2022. There were 53 males and 37 females with an age of (31.8±8.4) years. The types of elbow injury, visual analogue scale (VAS), range of motion (ROM) of the elbow and Mayo elbow performance score (MEPS) of the patients were recorded before treatment and at the last follow-up.Results:Of the patients, 18 were treated conservatively (3 simple Mason type I radial head fractures and 15 O'Driscoll type I coronal process fractures) and 72 surgically. Their follow-up time was (31.3±18.7) months. The fractures all healed by the time of the last follow-up. Simple elbow fracture was observed in 63 patients, simple elbow dislocation in 2 patients, fracture plus dislocation in 25 patients. The posterior dislocation was the most common (22 cases). Among the elbow fractures, radial head fracture occurred in 27 patients, ulnar coronoid process fracture in 41 patients, proximal ulnar fracture in 13 patients, and distal humeral fracture in 28 patients. Collateral ligament injuries were complicated in 65 cases. In the patients undergoing conservative treatment, their VAS, elbow ROM, and MEPS were all improved significantly from 4.7±1.4, 92.2°±14.4° and 63.9±6.5 before treatment to 0.4 (0,1.0), 110.6°±0.6°, and 92.2±3.9 at the last follow-up ( P<0.05); in the patients undergoing surgical treatment, their VAS, elbow ROM, and MEPS were also all improved significantly from 5.6±1.7, 24.3°±18.4°, and 26.9±12.2 before surgery to 0.6 (0,1.0), 97.4°±14.0° and 86.6±7.1 at the last follow-up ( P<0.05). After surgery, 8 patients presented with neurological symptoms and 7 patients developed heterotopic ossification. Conclusions:In skiing or snowboarding, the coronoid process of the ulna is the most vulnerable to fracture. In the elbow injuries due to skiing or snowboarding, posterior dislocation is the most common type which is often accompanied by injuries to the medial and lateral collateral ligaments. For simple Mason type Ⅰ radial head fractures and O'-Driscoll type Ⅰ coronoid process fractures in which the elbow is stable, conservative treatment can be adopted; surgical treatment is indicated for the other injuries.
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Objective:To compare the outcomes of isolated Mason type Ⅱ radial head fracture between operative and non-operative treatments.Methods:A retrospective study was conducted to analyze the data of patients who had been treated for isolated Mason type Ⅱ radial head fracture either operatively or nonoperatively at Department of Trauma and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University from January 2017 to October 2020. The patients were divided into a non-operative group and an operative group according to their treatment method. After 1:1 propensity score matching method was used to match the patients in the 2 groups, a total of 58 pairs of patients were successfully matched. In the operative group, there were 24 males and 34 females with a mean age of (40±14) years and a body mass index of (23.7±3.4) kg/m 2; in the non-operative group, there were 22 males and 36 females with a mean age of (42±13) years and a body mass index of (23.5±3.9) kg/m 2. Elbow flexion-extension, forearm rotation, Mayo elbow performance score (MEPS), Quick-disabilities of the arm, shoulder and hand (q-DASH) score and complications were compared between the 2 groups. Results:There was no significant difference in the baseline data between the 2 groups, indicating comparability ( P>0.05). All the patients were followed up for (24±9) months. At the last follow up in the operative and the non-operative groups, respectively, the elbow flexion-extension was 134° (132°, 136°) and 134°(131°, 136°), the forearm rotation 176° (174°, 179°) and 178° (175°, 179°), the MEPS 100 (100, 100) and 100 (100, 100), the q-DASH score 0 (0, 0) and 0 (0, 0), showing no significant differences between the 2 groups in the above items ( P>0.05). Elbow pain was reported respectively in 4 (6.9%) and 6 (10.3%) patients in the operative and non-operative groups, showing no significant difference between the 2 groups ( P>0.05). Conclusion:The outcomes of operative and non-operative treatments of isolated Mason type Ⅱ radial head fracture are comparable.
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Objective:To evaluate a novel distraction reductor in the surgical treatment of unstable distal radius fractures with metaphyseal volar comminution.Methods:From January 2019 to December 2020, 27 patients with unstable distal radius fracture complicated with metaphyseal volar comminution were treated at Department of Orthopaedics, Zhoupu Hospital Affiliated to Shanghai University of Medicine & Health Sciences. They were 6 males and 21 females, with an age of (69.4±9.4) years. All fractures were unilateral and closed, involving the right side in 17 cases and the left side in 10 cases. All patients were treated by internal fixation with an anatomical locking plate through the volar approach and the novel distraction reductor was used to reduce the fracture ends. Regular imaging examinations were performed to evaluate the reduction, maintenance and union of fractures after surgery. One year after operation, the curative efficacy was assessed by evaluation of the range of wrist motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, Gartland-Werley score and Bartra radiology score.Results:All the operations went on successfully with a duration of (92.3±8.9) min. All the incisions healed primarily. The follow-up time was (15.9±2.9) months. The radial height, palmar tilt, ulnar inclination and articular surface step-off immediately after operation [(11.23±1.51) mm, 12.10°±3.44°, 20.54°±3.44°, and (0.95±0.42) mm] were not significantly lost compared with those one year after operation [(11.22±1.55) mm, 12.07°±3.44°, 20.51°±3.33°, and (0.93±0.40) mm] (all P>0.05). One year after operation, the range of wrist motion was good with dorsiflexion of 59.7°±5.5°, palm flexion of 63.0°±9.1°, pronation of 66.5°±5.5°, supination of 61.2°±5.6°, radial deviation of 22.7°±4.8°, and ulnar deviation of 30.3°±6.1°; DASH score was 13.5±5.5; Bartra radiology score was 88.6±6.5, giving an excellent and good rate of 88.9% (24/27);Gartland-Werley score was 2.7±2.1, giving an excellent and good rate of 92.6% (25/27). Follow-ups observed no poor fracture healing, internal fixation failure, tendon or nerve injury or traumatic arthritis. Conclusion:In the surgical treatment of unstable distal radius fractures with metaphyseal volar comminution, the novel distraction reductor can lead to ideal reduction of displaced fractures and effectively correct the shortening caused by volar cortex comminution to achieve satisfactory functional effects in clinic.
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Objective:To explore the diagnosis and treatment of humeral medial epicondyle fracture combined with radial neck fracture in children and adolescents.Methods:The clinical data were retro-spectively analyzed of the 12 pediatric patients with fractures of the humeral medial epicondyle plus the radial neck who had been admitted from February 2015 to August 2021 to Department of Pediatric Orthopedics, The Second Hospital of Fuzhou. There were 6 males and 6 females, with an age of (11.1 ± 2.5) years. According to the Papavasiliou classification, the humeral medial epicondyle fractures were type Ⅱ in 7 cases, type Ⅲ in 2 cases and type Ⅳ in 3 cases; according to the Judet classification, the radial neck fractures were type Ⅰ in 3 cases, type Ⅱ in 4 cases and type Ⅲ in 5 cases. Two Judet-Ⅰ radial neck fractures were missed by X-ray exam-ination but diagnosed by CT examination. Of the humeral medial epicondylar fractures, 9 were treated by open reduction and hollow screwing and 3 by closed reduction and Kirschner wiring. Of the radial neck fractures, 8 were treated by closed reduction and elastic intramedullary nailing and 4 conservatively. Fracture healing was followed up by postoperative radiographs. At the last follow-up, the carrying angles were measured, Kim Elbow Function Score (KEPS) was used to evaluate the functional recovery of the injured limb, and related complications were recorded.Results:All the 12 patients were followed up for (40.0±25.6) months. Fractures headed after (6.3±1.2) weeks. At the last follow-up, the carrying angle was 15.5°±2.6° on the injured side and 14.7°±2.0° on the healthy side, showing no significant difference ( P>0.05); KEPS was (96.3±5.3) points on the injured side and (98.8±2.3) points on the healthy side, showing no significant difference either ( P>0.05). No incision infection, bone nonunion, elbow valgus, joint stiffness or other complications were found; the postoperative elbow stability recovered well. Conclusions:As the fracture of the humeral medial epicondyle combined with the radial neck fracture is a special type of injury of straightened elbow during valgus stress in children and adolescents, it is likely to be missed in diagnosis. The goal of treatment is good functional recovery by restoring the articular match and elbow stability.
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Radiocarpal fracture-dislocation (RFD) is a rare injury normally associated with the destruction of bones, joints and ligaments. The improper diagnosis and treatment of RFD will cause severe complications and affect the long-term function of wrist joints. The difficulties of clinical diagnosis and treatment lie in the accurate diagnosis, identification and reconstruction of the structure of specific injury. As the foreign and domestic literatures are mainly case analyses or systemic case reports rather than large-scale reports, there still lacks a systemic knowledge of the standard diagnosis and treatment of RFD clinically, thus leading to problems such as missed diagnosed or misdiagnosed, improper application of treatment methods and incomplete reconstruction. Therefore, the authors reviewed relevant literatures about the features, diagnosis and treatment of RFD, in order to provide references for the clinical diagnosis and treatment of RFD.
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Objective:To investigate the effects of metacarpal inclination angle and ulnar deviation angle on radius length shortening after internal fixation of distal radius fracture combined with ulnar styloid fracture.Methods:A retrospective case-control study was conducted to analyze the clinical data of 84 patients with distal radius fracture complicated with ulnar styloid fracture treated by Beijing Daxing District People′s Hospital from February 2018 to January 2022. According to whether the ulnar styloid fracture was fixed or not, the patients were divided into two groups: 18 patients with ulnar styloid fractures who were surgically fixed were in the fixation group, and 66 patients with ulnar styloid fractures who were not surgically fixed were in the non-fixation group. The perioperative indexes (operation time, intraoperative blood loss, surgical incision length), wrist joint function indexes [Gartland-Werley score, disability of the arm, shoulder, and hand (DASH) score, forearm rotation, ulnar deviation, metacarpal flexion, radial deviation, dorsal extension, grip strength] and complications (bone nonunion, osteolysis, ulnar pain, internal fixation failure, lower ulnar and radial instability, postoperative infection) were compared between the two groups. The changes of metacarpal inclination angle, ulnar deviation angle and distal radius distance of the two groups were analyzed by generalized estimation equation (GEE). The patients were followed up for 12 months, they were divided into two groups: non-shortening group (radius shortening distance < 4 mm, n=61) and radius shortening group (radius shortening distance ≥ 4 mm, n=23) according to whether the radius shortening distance was ≥ 4 mm at the last follow-up. The influencing factors of postoperative radius shortening were evaluated by Logistic regression analysis. Results:Compared with the non-fixation group, the Gartland-Werley score(1.79±0.62 vs 4.65±0.97), DASH score (16.43±4.71 vs 28.72±6.06) and the incidence of complications (11.11% vs 39.40%) in the fixation group were significantly lower, and the forearm rotation angle [(81.29±6.60)° vs (70.79+ 5.15)°], ulnar deviation angle [(21.36±2.35)° vs (16.77±2.11)°], metacarpal flexion angle [(45.84±2.80)° vs (37.55±2.45)°] and dorsal extension angle [(50.23±5.16)° vs (40.65±3.580°] were significantly larger in the fixation group, all the differences were statistically significant ( P<0.05). GEE analysis and evaluation showed that treatment time, treatment plan and their interaction had significant effects on metacarpal inclination, ulnar deviation and distal radius ( P<0.05). The change of metacarpal inclination angle and ulnar deviation angle were independent influencing factors of radius shortening after internal fixation ( P<0.05). Conclusions:In the treatment of distal radius fracture combined with ulnar styloid fracture, internal fixation of distal radius combined with ulnar styloid process can improve wrist joint function, reduce the incidence of complications, and improve metacarpal inclination angle and ulnar deviation angle. A certain degree of radius shortening will occur after internal fixation. The changes of metacarpal inclination angle and ulnar deviation angle are the independent influencing factors of radius shortening after internal fixation.
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PURPOSE@#The aim of this study was to analyze if any difference exists on the type of immobilisation (above elbow vs. below elbow) in the conservative treatment of distal end radius fractures in adults.@*METHODS@#The study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses. An electronic literature search was performed up to 1st October 2021 in Medline, Embase, Ovid and Cochrane database using the search terms, "distal end radius fractures OR fracture of distal radius", "conservative treatment OR non-surgical treatment", "above elbow immobilisation" and "below elbow immobilisation". Randomized clinical trials written in English, describing outcome of distal end radius fractures in adults by conservative or non-surgical means using above elbow immobilisation or below elbow immobilisation were included and assessed according to the risk of bias assessment (RoB2) tool by Cochrane collaboration. Non-randomized clinical trials, observational studies, retrospective studies, review articles, commentaries, editorials, conference presentations, operative techniques and articles without availability of full text were excluded from this review. The meta-analysis was performed using Review Manager version 5.4.1 (The Cochrane Collaboration, Copenhagen, Denmark).@*RESULTS@#Six randomized clinical trials were included for quantitative review. High heterogeneity (I2 > 75%) was noted among all the studies. The standard mean difference (MD) between the disability of the arm, shoulder and hand scores in both the groups was 0.52 (95% CI: -0.28 to 1.32) which was statistically non-significant. There was no statistical difference in the radial height (MD = 0.10, 95% CI: -0.91 to 1.12), radial inclination (MD = 0.5, 95% CI: -1.88 to 2.87, palmar tilt (MD =1.06, 95% CI: -0.31 to 2.43) and ulnar variance (MD = 0.05, 95% CI: -0.74 to 0.64). It was observed that shoulder pain occurred more commonly as a complication in above elbow immobilisation and the values were statistically significant (above elbow: 38/92, 41.3%; below elbow: 19/94, 20.2%).@*CONCLUSION@#This two-armed systematic review on the above elbow or below elbow immobilisation to be used for conservative treatment of the distal end radius fracture in adults resulted in non-significant differences in terms of functional and radiological scores among the 2 groups but significant increase in the complication rates in the above elbow group.
Subject(s)
Humans , Adult , Elbow , Fracture Fixation/methods , Conservative Treatment , Retrospective Studies , Randomized Controlled Trials as Topic , Wrist Fractures , Radius Fractures/surgeryABSTRACT
ABSTRACT Objectives: This study aimed to compare the functional and radiological results of patients who had intra-articular comminuted distal radius fractures and were operated on with external fixation percutaneous pinning or the volar-dorsal combined plate osteosynthesis. Methods: In this study, 49 patients operated on and followed up for the comminuted distal radius fractures between May 2015 and January 2019 were retrospectively evaluated. The surgical outcomes of the patients, who were operated on with combined dorsal-volar plate osteosynthesis or external fixation percutaneous pinning, were compared in this study. Functional and radiological scores were evaluated and analyzed statistically. Results: There was no statistical difference between external fixation and volar-dorsal combined plate groups regarding the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Visual Analog Scale (VAS), the Mayo scoring system, range of motion, and grip strength values. Discussion: Although the combined volar-dorsal plate osteosynthesis technique had a longer operation time and a more complicated surgical procedure, the combined volar-dorsal plate osteosynthesis had lower complication rates and permitted early mobilization. The combined volar-dorsal plate osteosynthesis could be an alternative to external fixation percutaneous pinning. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.
RESUMO Objetivo: O objetivo deste estudo foi comparar os resultados funcionais e radiológicos de pacientes portadores de fraturas intra-articulares cominutivas do rádio distal, operados com fixação externa percutânea ou com osteossíntese volar-dorsal de placa combinada. Método: Foram avaliados 49 pacientes operados e acompanhados por fraturas cominutivas distais do rádio entre maio de 2015 e janeiro de 2019 retrospectivamente. Os resultados cirúrgicos dos pacientes operados com osteossíntese de placa volar-dorsal combinada ou fixação externa percutânea foram comparados. Os escores funcionais e radiológicos foram avaliados e analisados estatisticamente. Resultados: Não houve diferença estatística entre os grupos de fixação externa e placa combinada volar-dorsal em relação ao questionário Deficiências do braço, ombro e mão (DASH), à Escala Visual Analógica (VAS), ao sistema de pontuação Mayo, à amplitude de movimento ou à avaliação de força de preensão. Conclusão: Embora a técnica combinada de osteossíntese da placa volar-dorsal tenha um tempo cirúrgico mais longo e procedimento mais complicado, a osteossíntese combinada da placa volar-dorsal apresentou menores taxas de complicações, permitindo a mobilização precoce. A osteossíntese combinada da placa volar-dorsal pode ser uma alternativa à fixação externa percutânea. Nível de Evidência III, Estudos terapêuticos - Investigação dos resultados do tratamento.
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ABSTRACT Objectives: Describe the frequency and types of outcomes in randomized clinical trials (RCT) of intervention for distal radius fractures, analyze how confusing outcome presentations can lead to misinterpretations, and suggest strategies to improve the reader's understanding of the decision-making process. Methods: A retrospective study was conducted through a systematized search on the PubMed® database in the last 10 years, in which only intervention RCT was included for distal radius fractures, and outcomes were analyzed. Results: Of the primary outcomes analyzed in the 75 selected articles, 46.6% were classified as clinical outcomes, 20% as surrogate, 30.6% as composite, 1.3% as complex scales, and 1.3% as safety outcomes. 34.7% of the articles did not report adverse events. Conclusion: The presentation of outcomes with little clinical relevance represented more than half of the sample (53.4%) - such studies can harm the reader since they confuse the interpretation of scientific evidence; the Core Outcome Measures in Effectiveness Trials (COMET) initiative could help health professionals in understanding and selecting the most appropriate therapeutic interventions for patients. Level of Evidence III; Retrospective comparative study .
RESUMO Objetivos: Descrever a frequência e os tipos de desfechos em ensaios clínicos randomizados (RCT) de intervenção para fraturas distais do rádio, analisar como apresentações confusas de desfechos podem levar a interpretações equivocadas e sugerir estratégias para melhorar a compreensão do leitor sobre o processo de tomada de decisão. Métodos: Foi realizado estudo retrospectivo mediante busca sistematizada na base de dados PubMed® nos últimos 10 anos, na qual foram incluídos apenas RCT de intervenção para fraturas do segmento distal do rádio, cujos desfechos foram analisados. Resultados: Dos desfechos primários analisados nos 75 artigos selecionados, 46,6% foram classificados como desfechos clínicos, 20% como substitutos, 30,6% como compostos, 1,3% como escalas complexas e em 1,3% como desfechos de segurança. 34,7% dos artigos não reportaram eventos adversos. Conclusão: A apresentação de desfechos com pouca relevância clínica representou mais da metade da amostra (53,4%) - tais estudos podem prejudicar o leitor, uma vez que confundem a interpretação das evidências científicas; a iniciativa Core Outcome Measures in Effectiveness Trials (COMET) auxilia os profissionais de saúde na compreensão e seleção das intervenções terapêuticas mais adequadas para os pacientes. Nível de Evidência III; Estudo retrospectivo comparativo .
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Objective:To investigate the operation efficacy of anterior radius head fracture combined with lateral ligament complex injury.Methods:The patients with radial head fracture admitted from September 2017 to August 2021 were retrospectively analyzed, 51 males and 54 females, average age of 38.84±13.63 years (range of 16-70 years). Based on the radial head fractures of Mason classification of type II, the cases involving the anterior radius head fracture were divided into three subtypes according to the number of fracture blocks and the type of displacement: type A (53 cases): one part of the anterior radius head collapse fracture; type B (50 cases): two or more parts of the anterior radial head collapse fracture; type C (2 cases): anterior radius head dissociated and displaced fracture. All fractures were treated with open reduction and internal fixation. Among them, the lateral ligament complex of type B were elongated due to the injury but the continuity existed. Therefore, the lateral ligament complex in 21 cases were not repaired in the early period (unrepaired group); in recent years, 29 cases repaired the lateral ligament complex (repair group). The postoperative efficacy was evaluated by elbow range of motion, table-top relocation test, Mayo score, and Broberg Morrey score. the patients were evaluated at final follow-up, except table-top relocation test was recorded according to the actual completion time.Results:All operations were successfully completed. The mean follow-up was 14.08±1.52 months (range of 12-18 months). Type A: the flexion and extension range was 115.70°±6.35°; the completion time of the table-top relocation test was 75.68±11.90 days; the Mayo score was 93.72±2.40 point, and the Broberg Morrey score was 92.89±2.28 point. Type B: lateral ligament repair group (repaired group) 29 cases and unrepaired lateral ligament group (unrepaired group) 21 cases. The flexion and extension range of elbow in repaired group was 112.1°±4.4°, which was better than that in unrepaired group 105.8°±3.7° ( t=5.31, P<0.001). The completion time of table-top relocation test was 77.72±6.51 days in repaired group and 104.29±18.45 days in unrepaired group ( t=6.32, P<0.001). The Mayo score of the repaired group was 90.21±5.88 points and that of the unrepaired group was 87.14±5.26 points ( t=1.90, P=0.063), and there was no significant difference between the two groups. Broberg Morrey score of 90.93±6.43 points in the repaired group was better than 86.95±6.37 points in the unrepaired group ( t=2.17, P=0.035). Type C for 2 patients, the flexion and extension range of elbow were 107°and 106°; the completion time of table-top relocation test were 82 days and 98 days; the Mayo scores were 91 point and 87 point; Broberg Morrey scores were 93 point and 85 point. There was a patient developed myositis ossificans in unrepair group of tybe B. Conclusion:The elbow joint is stable when one part of the anterior radius head collapse fracture; there is a degree of instability in the elbow when two or more parts of the anterior radial head collapse fractures suggest to repair the lateral ligament complex. The elbow joint is extremely unstable when anterior radius head dissociated and displaced fractures, the lateral ligament complex should be repaired in time.
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Abstract Objective Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications. Methods A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life-5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate). Results We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH (p= 0.18) and PRWE (p= 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes. Conclusion In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique. Level of EvidenceLevel I
Resumo Objetivo Nas últimas décadas, a placa volar bloqueada (PVB) tem sido o tratamento principal para fraturas do rádio distal (FRDs). Com o crescente conjunto de evidências, revisamos sistematicamente estudos sobre modificações recentes na PVB. Métodos Uma pesquisa sistemática foi realizada utilizando o banco de dados PubMed/MEDLINE por estudos publicados em inglês nos últimos cinco anos. Os critérios de inclusão foram ensaios clínicos controlados e randomizados (ECCRs) sobre o tratamento cirúrgico de FRDs. Excluímos ensaios e estudos em andamento que não abordavam diretamente a FRD. Os desfechos primários avaliados foram desfechos clínicos subjetivos (como as pontuações no questionário de Deficiências do Braço, Ombro e Mão [Disabilities of the Arm, Shoulder and Hand, DASH, em inglês], na Avaliação do Punho Classificada pelo Paciente [Patient-rated Wrist Evaluation, PRWE, em inglês], no questionário Qualidade de Vida Europeia - 5 Dimensões [European Quality of Life-5 Dimensions, EQ-5D, em inglês], na Pesquisa de Saúde por Formulário Curto de 36 Itens [36-item Short Form Health Survey, SF-36, em inglês], e na Escala Visual Analógica [EVA]) e objetivos (taxa de complicações). Resultados Identificamos 29 artigos publicados entre 2016 e 2020 com alta qualidade de evidência, exceto por um, de qualidade moderada. Ao todo, foram analisadas 3.079 FRDs neste estudo, Todos os estudos analisados, exceto por um, tinham maior proporção de participantes do gênero feminino, e somente em 1 estudo a idade média da amostra foi < 40 anos. Não houve diferença significativa entre a PVB e fixação externa (FE) em termos das pontuações no DASH (p= 0,18) e na PRWE (p= 0,77). Os resultados da PVB isolada, sem qualquer reparo do pronador quadrado (PQ), foram significativamente melhores. Conclusão Em fraturas instáveis, a PVB e a FE produziram resultados comparáveis no longo prazo. Não há um benefício claro em se adicionar reparo do PQ à técnica cirúrgica atual da PVB. Nível de EvidênciaNível I
Subject(s)
Radius Fractures/surgery , Wrist Injuries/surgery , Bone Plates , External FixatorsABSTRACT
Abstract Objective To evaluate the prevalence of persistent pain in the postoperative period of fractures of the distal extremity of the radius, as well as to detect early signs of neuropathic pain to develop protocols for the prevention of chronic postoperative pain. Methods Prospective study, carried out with 56 patients who underwent open reduction and internal fixation of fractures of the distal extremity of the radius with a volar locking plate from March to September 2020. The patients were submitted to assessment of neuropathic pain and functional capacity through the Douleur Neuropathique 4 questionnaire (DN4) and Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaires. Qualitative variables were compared using the Mann-Whitney U test and their correlation was analyzed using the Spearman Correlation and Equality of Two Proportions tests. Results A total of 43 patients aged between 18 and 66 years old were included in the present study; 39.5% of the participants scored ≥ 4 on the DN4 questionnaire. In relation to Quick-DASH, the average was 38.6. There was no statistically significant difference between the gender of the patient and the DN4 value (p= 0.921). There was also no statistical correlation between the quantitative variables DN4 and Quick-DASH (p= 0.061). Conclusions The prevalence of neuropathic pain in analyzed postoperative patients was significant, and the presence of signs and symptoms of neuropathic pain was a positive predictive factor for pain persistence beyond 2 months in 100% of cases. Thus, with early diagnosis of the neuropathic component of pain, associated with the nociceptive component, adequate pain control can be achieved, preventing its chronicity, and ensuring better rehabilitation.
Resumo Objetivo Avaliar a prevalência de dor persistente no pós-operatório de fratura da extremidade distal do rádio, assim como detectar precocemente sinais de dor neuropática com o intuito de desenvolver protocolos de prevenção da dor crônica pós-operatória. Métodos Estudo prospectivo, realizado com 56 pacientes submetidos a redução aberta e fixação interna de fratura da extremidade distal do rádio com placa volar bloqueada no período de março a setembro de 2020. Os pacientes foram submetidos a avaliação de dor neuropática e capacidade funcional através dos questionários Douleur Neuropathique 4 questionnaire (DN4) e Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH, na sigla em inglês). As variáveis qualitativas foram comparadas pelo teste de Mann-Whitney e sua correlação foi analisada pelos testes de correlação de Spearman e de Igualdade de Duas Proporções. Resultados Foram incluídos no presente estudo 43 pacientes, com idades entre 18 e 66 anos; 39,5% dos participantes apresentaram pontuação ≥ 4 no questionário Douleur neuropathique 4 questionnaire (DN4). Em relação ao Quick-DASH, a média foi de 38,6. Não houve diferença estatística significante entre o sexo do paciente e o valor do DN4 (p= 0,921). Também não foi encontrada correlação estatística entre as variáveis quantitativas DN4 e Quick-DASH (p= 0,061). Conclusões A prevalência de dor neuropática nos pacientes pós-operatórios analisados foi significativa e a presença de sinais e sintomas de dor neuropática foi fator preditivo positivo para a persistência da dor além de 2 meses em 100% dos casos. Assim, com diagnóstico precoce do componente neuropático de dor, associado ao componente nociceptivo, é possível obter o controle adequado da dor, impedindo sua cronificação e garantindo uma melhor reabilitação.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Pain, Postoperative/prevention & control , Pain Measurement , Surveys and Questionnaires , Radial Head and Neck Fractures/surgery , Radial Head and Neck Fractures/rehabilitationABSTRACT
Abstract Objective To evaluate the inter- and intraobserver reliability and reproducibility of the new AO/OTA 2018 classification for distal radius fractures and to compare it with the Fernandez classification system. Method A questionnaire was applied in the Qualtrics software on 10 specialists in hand surgery who classified 50 radiographs of distal radius fractures according to the Fernandez and AO/OTA 2018 classifications and, subsequently, indicated their treatment. The questionnaire was applied in time T0 and repeated after 4 weeks (t1). The mean agreement between the answers, and the reliability and inter- and intraobserver reproducibility were analyzed using kappa indexes. Results The mean interobserver agreement in the Fernandez classification was 76.4, and it was 59.2% in the AO/OTA 2018 classification. The intraobserver agreements were 77.3 and 56.6%, respectively. The inter- and intraobserver kappa indexes for the Fernandez classification were 0.57 and 0.55, respectively, and, in the AO/OTA 2018 classification, they were 0.34 and 0.31, respectively. Conclusion The AO/OTA 2018 classification showed a low intra- and interobserver reproducibility when compared with the Fernandez classification. However, both classifications have low intra- and interobserver indexes. Although the Fernandez classification did not obtain excellent results, it remains with better agreement for routine use.
Resumo Objetivo Avaliar a confiabilidade e a reprodutibilidade inter- e intraobservadores da nova classificação AO/OTA 2018 para fraturas distais do rádio e compará-la com o sistema classificatório de Fernandez. Métodos Foi aplicado um questionário no software Qualtrics em 10 especialistas em cirurgia da mão que classificaram 50 radiografias de fraturas distais de rádio de acordo com as classificações de Fernandez e AO/OTA 2018 e, posteriormente, indicaram seu tratamento. Esse questionário foi aplicado em tempo T0 e repetido após 4 semanas (t1). Analisou-se a média de concordância entre as respostas e confiabilidade e reprodutibilidade inter- e intraobservadores utilizando os índices kappa. Resultados A concordância média interobservador para a classificação de Fernandez foi de 76,4, e de 59,2% para a AO/OTA 2018. A concordância intraobservador foi de 77,3 e 56,6%, respectivamente. O índice de kappa inter- e intraobservador para a classificação de Fernandez foram de 0,57 e de 0,55, respectivamente, e a classificação AO/OTA 2018 obteve 0,34 e 0,31, respectivamente. Conclusão A classificação AO/OTA 2018 mostrou uma reprodutibilidade intra- e interobservadores baixa quando comparada à classificação de Fernandez. Porém, ambas as classificações apresentam índices intra- e interobservadores baixos. Embora a classificação de Fernandez não tenha obtido resultados excelentes, ela permanece com melhor concordância para o uso rotineiro.
Subject(s)
Humans , Radius Fractures/classification , Wrist Injuries/classification , Surveys and Questionnaires , Reproducibility of Results , Wrist Fractures/diagnostic imagingABSTRACT
Background: Distal radius fractures are the third most common osteoporotic fractures and are frequently treated in emergency department. They have a trimodal peak of occurrence and there has been a significant increase in incidence of involvement in elderly females and young males. Management of these fractures comes with lots of treatment options and challenges to provide good functional outcome. This prospective study was done for the management of communited intra/juxta articular fractures of distal end radius using a bridging external fixator on 25 patients. The principle of ligamentotaxis was used for alignment of fracture fragments and wrist spanning external fixator was used to maintain the fracture reduction.Methods:25 patients of either sex with age group 16 to 80 years were taken from the orthopedic department. After proper primary care, cases were classified using Fernandez classification, and posted for surgery as soon as investigations and fitness were taken.Results:Patients involved in the study were in range of 16 to 78 years with 16 patients having dominant side with road traffic accident as leading cause.Radiological union was seen at an average of 7.3 weeks, 4 patients had superficial pin tract infection, 3 patients had stiffnes and a single case had malunion. Conclusions:Modified clinical scoring system of Green and O払rien was used to evaluate the overall functional results which showed excellent to good results in 84% of cases. Hence, properly planned and executed bridging external fixator is an easy, cost-effective and reliable treatment modality through the 揚rinciple of Ligamentotaxis�.
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Objective:To investigate the application of combined distractor in the treatment of refractory distal radius fractures.Methods:From March 2018 to February 2020, the data of 32 patients with refractory distal radius fractures treated with combined distractor-assisted reduction were retrospectively analyzed. The propensity score matching method was used to establish a non-distractor group according to 1∶1 matching, with a total of 32 patients. In the distractor group, there were 15 males and 17 females, age 54.9 ±15.8 years (range, 18-77). According to AO classification, 3 cases were A3, 3 cases were B3, 16 cases were C2, 10 cases were C3. In the non-distractor group, there were 12 males and 20 females, age 59.7±14.8 years, 4 cases were A3, 5 cases were B3, 12 cases were C2 and 11 cases were C3. Main measures: surgical time, radial height, palm inclination, ulnar deviation, range of motion of the wrist, visual analogue scale (VAS), and functional assessment using disability of arm, shoulder and hand (DASH) and modified Mayo wrist score (MMWS).Results:A total of 64 patients were included in this study, and all patients successfully completed the operation and were followed up for 12-54 months, with an average of 17.8 months. The operative time of the distractor group was 91.2±14.6 min, which was significantly lower than that of the non-distractor group 137.6±27.3 min, and the difference was statistically significant ( t=8.48, P<0.001); the radial height in the distractor group 11.5±1.4 mm was significantly higher than that in the non-distractor group 10.6±1.3 mm, and the difference was statistically significant ( t=2.59, P=0.012). At the last follow-up, there were no statistically significant differences in the palm inclination 7.9°±4.4° vs. 7.5°±3.5°, ulnar deviation 23.3°±5.7° vs. 22.3°±4.5°, wrist flexion 63.2°±15.3° vs. 62.6°±11.1°, dorsiflexion 63.5°±10.7° vs. 62.4°±15.2°, pronation 69.2°±11.8° vs. 67.0°±11.0°, supination 73.1°±10.4° vs. 72.0°±8.7°, VAS 0.8±0.5 points vs. 0.9±0.7 points, DASH score 12.9±6.6 points vs. 13.4±7.0 points amd MMWS 84.1±5.8 points vs. 83.5±6.2 points ( P>0.05). One patient in the distractor group had symptoms of extensor muscle irritation, and the symptoms disappeared after the internal fixation was removed; 2 patients in the non-spreader group developed carpal tunnel syndrome, which improved after incision and decompression treatment. Conclusion:For refractory distal radius fractures, the use of combined distractor can achieve better radius height recovery and shorten the operation time, and has a satisfactory postoperative effect.
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Objective:To investigate the importance of measuring and restoring distal radius tear drop angle in the treatment of distal radius middle column fracture with anterior collapse of lunate fossa joint.Methods:Thirty one cases of distal radius fractures in 29 patients was reported for 2 years from January 2018 to January 2020. Two patients with both distal radius fractures were included in this study. All cases in this group were treated by operation. Among the 29 patients, there were 20 males and 9 females. Their ages were 44.9±15.1 years (ranged from 20 to 78 years). Two patients with both distal radius fractures were included in this study, due to both teardrop angle (TDA) reduced. The time from injury to operation was 4-17 d, with an average of 6.9 d. Except for 2 cases of fracture with simple volar approach, the other cases were treated with combined volar and dorsal approach. All patients were treated with open reduction and internal fixation with plates and bone grafting. The teardrop angle was measured before and after operation, and the effect of surgical recovery of teardrop angle was compared. The wrist function was evaluated by Gartland-Werley scores.Results:The wounds of all patients healed in one stage without postoperative infection. The follow-up time of 29 patients were 15.1±5.2 months, ranged from 7 to 31 months. The healing time for all fractures was 10.3±2.9 weeks (from 8 to 16 weeks). No fracture nonunion or redisplacement. In 31 cases, the tear drop angle was 33.4°±5.83° (20°-45°) before operation, and 58.9°±9.89° (35°-70°) after operation. At the end of follow-up, Gartland-Werley scores was 4.7±4.6, ranged from 0 to 17. Among them, 10 cases were excellent, 16 were good, 5 cases were fair, and the excellent and good rate was 83.9%. The Gartland-Werley scores of the two subgroups with postoperative tear drop angle recovery ≥50° and <50° were compared, and the results were significantly different (the excellent and good rate for two subgroups were 96.2% and 20.0% respectively ( P=0.001). Conclusion:The distal radius fracture with significantly reduced tear drop angle should be actively treated. The measurement and recovery of tear drop angle is an important factor affecting the functional outcome of distal radius fracture with anterior edge collapse of lunate fossa joint, which should be highly concerned by clinical doctors. The recovery of teardrop angle mostly requires dorsal approach.
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Objective:To investigate the efficacy of intramedullary plus extramedullary fixation in the treatment of fractures of distal radial diametaphyseal transition zone in children.Methods:The data were retrospectively analyzed of the 49 children who had been admitted to Pediatric Orthopedic Hospital, Honghui Hospital Affiliated to Xi'an Jiaotong University from July 2018 to April 2020 for fractures of distal radial diametaphyseal transition zone. There were 30 males and 19 females; 21 left sides, 27 right sides, and one case of bilateral sides. In the operation, an elastic intramedullary nail or Kirschner wire was used for intramedullary fixation while another Kirschner wire was used to fix the cortex at the distal and proximal ends of the fracture. The ranges of wrist motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores at 1 and 9 months after operation were recorded and compared; the incidence of postoperative complications was also recorded.Results:The operation time for the 49 children averaged 45.0 min (from 39 to 51 min). The patients were followed up for 6 to 36 months (mean, 18.6 months). The fracture union time averaged 8.6 weeks (from 6.8 to 10.4 weeks). Needle tract infection developed in one case but the wound was healed after removal of the K-wire after callus formation and oral use of antibiotics for 3 days. Another case reported skin irritation the symptoms of which disappeared after the child reduced activities. The ranges of pronation, supination, flexion and extension of the wrist and DASH score were 47.9°±2.5°, 45.5°±3.0°, 51.2°±1.6°, 53.4°±1.7° and (36.7±4.5) points at one month after operation while they were 85.6°±3.1°, 87.6°±2.1°, 88.8°±2.0°, 88.0°±1.2° and (23.2±8.6) points at 9 months after operation. There were statistically significant differences in the above indexes between one and 9 months after operation ( P<0.05). Conclusion:In the treatment of fractures of distal radial diametaphyseal transition zone in children, intramedullary plus extramedullary fixation is simple in surgical techniques, easily repeatable, slightly invasive, and reliable in fixation.
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Objective:To explore the risk factors that may affect the stabilization of dorsal intra-articular fragment in distal radius fracture after volar internal fixation.Methods:A retrospective analysis was performed of the patients with distal radius fracture who had been treated by volar internal fixation at Department of Traumatic Orthopedics, Tongji Hospital Affiliated to Tongji University from July 2016 to July 2020. After 3D reconstruction of their preoperative CT scans by software Mimics 20.0, 66 patients with a dorsal intra-articular fragment were screened out. They were 31 males and 35 females, aged from 23 to 78 years (average, 53.4 years). By the AO classification, there were 17 case of type C1, 22 cases of type C2, and 27 cases of type C3. The displacement of dorsal intra-articular fragment was judged by X-ray observation on postoperative day 2 and X-ray follow-up at the outpatient department. The 13 patients with displacement of dorsal intra-articular fragment>2 mm were assigned into a displacement group while the other 53 ones into a displacement-free group. The 2 groups were compared in terms of preoperative general data and anatomical data of the dorsal intra-articular fragment (total preoperative displacement, radius-ulnar length, dorsal-volar length, aspect ratio, proximal-distal length and volume) to analyze the correlations between them and displacement.Results:There was no significant difference in preoperative general data (age, gender, affected side, cause of injury or AO classification) between the 2 groups, showing comparability between groups ( P>0.05). All patients were followed up for 6 to 24 months (mean, 14 months) after surgery. There were no postoperative complications like neurovascular lesion or infection. None of the patients in the displacement group underwent revision surgery, and the fractures healed successfully during the postoperative follow-up. The total preoperative displacement in the displacement group was(10.0±1.3) mm, significantly larger than that in the displacement-free group [(7.8±1.5) mm]; the radius-ulnar length in the displacement group was (8.2±1.3) mm, significantly shorter than that in the displacement-free group [(10.8±2.3) mm]; the aspect ratio of the fragment in the displacement group was 1.2±0.2, significantly lower than that in the displacement-free group (1.4±0.2); the fragment volume in the displacement group was (690.5± 201.4) mm 3, significantly smaller than that in the displacement-free group [(995.8±295.0) mm 3]. There were significant differences in the above items between the 2 groups ( P<0.05). Conclusion:The total preoperative displacement, radius-ulnar length, aspect ratio and volume of a dorsal intra-articular fragment are important factors which may affect the displacement of the dorsal fragment after volar internal fixation.
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Objective:To investigate the effect of arthroscopically-assisted open reduction and internal fixation of intra-articular distal radius fracture.Methods:A retrospective cohort study was made on clinical data of 44 patients with distal radial intraarticular fracture admitted to Jing′an District Central Hospital, Fudan University between June 2017 and August 2020. There were 13 males and 31 females, at age of 35-85years [(62.5±12.9)years]. According to AO/OTA fracture classification system, there were 7 patients with type B and 37 with type C. Open reduction and internal fixation with volar plate was used in all patients, among which 22 were operated on using arthroscopy assistance (arthroscopy group) and 22 were operated on with traditional intraoperative fluoroscopy (fluoroscopy group). The operation time in both groups and triangular fibrocartilage complex (TFCC) injury and fracture displacement in arthroscopy group were recorded. Patient-rated wrist evaluation (PRWE) score, disabilities of the arm, shoulder and hand (DASH) questionnaire and range of wrist motion were compared between the two groups at 12 months after operation. The incidence of complications was observed.Results:All patients were followed up for 12-15 months [(13.3±1.1)months]. The operation time in arthroscopy group was (104.0±40.5)minutes, longer than (71.3±32.1)minutes in fluoroscopy group ( P<0.05). In arthroscopy group, 14 patients (64%) with TFCC injury were diagnosed intraoperatively, with the fracture displacement gap and step for 0.8 (0.3, 0.8)mm and 1.0 (0.3, 1.5)mm under arthroscopic vision, which were reduced to 0.3 (0.0, 0.5)mm and 0.5 (0.0, 0.5)mm after arthroscopically-assisted reduction (all P<0.05). The PRWE score in arthroscopy group was (9.8±4.9)points at 12 months after operation, lower than (13.4±5.8)points in fluoroscopy group ( P<0.05). The DASH questionnaire in arthroscopy group was (9.0±5.0)points at 12 months after operation, lower than (13.0±6.1)points in fluoroscopy group ( P<0.05). The dorsal extension and posterior rotation of the wrist in arthroscopy group were (73.8±8.9)° and (82.5±8.0)°, higher than (65.8±14.2)° and (76.3±10.4)° in fluoroscopy group (all P<0.05). There were no postoperative complications such as loosened or broken screws, vascular nerve damage, incision infection or traumatic arthritis in both groups. Conclusion:Arthroscopic-assisted open reduction and internal fixation of intra-articular distal radius fracture can increase the accuracy of joint surface reduction, improve postoperative wrist function and confirm the diagnosis of TFCC injury during operation.