Load relaxation and forces with activity in Hoffman external fixators: a clinical study in patients with Colles' fractures.

A small-frame Hoffman external fixation bar instrumented with strain gauges to quantify bending and torsional forces was applied to 4 patients with a displaced metaphyseal fracture of the distal radius. Measurements were taken during surgery as well as at 1, 3, and 6 weeks after surgery during activities of daily living and hand therapy mobilization. Radiographs also were taken before and after reduction and at each subsequent visit. Force decay occurred after reduction of the fracture, averaging only 26% of the initial distraction forces by 5 minutes. These forces plateaued and did not significantly change over the subsequent 40-minute observation period. There was no correlation between carpal height index and the forces measured in the external fixator. Significant changes in external fixator forces were measured during activities of daily living and hand therapy mobilization, but these returned to baseline after the activities were performed. The most provocative activities studied were twisting a doorknob and lifting heavy objects. These activities should be performed with caution by patients with unstable distal radial fractures.

Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures.

The management of unstable phalangeal fractures has been associated with significant morbidity. Percutaneous transmetacarpal intramedullary Kirschner wire fixation of proximal phalangeal fractures has been described as a useful technique. We present a retrospective review of 35 digits in 24 patients with unstable fractures of the proximal phalanx treated using this technique between 1985 and 1995. Outcome measures, including radiological adequacy of reduction, total active range of motion, development of joint contracture, grip strength, and digital grip strength, were assessed. Good or excellent results were obtained in 76% of fractures (19 of 25) that were treated and followed. Thirty-two percent of digits (8 of 25) treated developed a proximal interphalangeal joint flexion contracture. Flexion contracture averaged 18.1 deg at the involved joints. Seven secondary procedures were required in 6 patients. Major complications noted during the study included loss of reduction with rotational deformity in four digits, and one nonunion. The use of skeletal traction devices was associated with three of the major complications observed. These devices should not be used concurrently on or adjacent to any digit treated by intramedullary pinning. We conclude that transmetacarpal axial Kirschner wire fixation is a technically simple method of treating unstable proximal phalangeal fractures, and good or excellent results can be obtained in the majority of appropriately selected patients.

Reliability of range-of-motion measurement in the elbow and forearm.

The purpose of this study was to examine intratester, intertester, and interdevice reliability of range of motion measurements of the elbow and forearm. Elbow flexion and extension and forearm pronation and supination were measured on 38 subjects with elbow, forearm, or wrist disease by 5 testers. Standardized test methods and a randomized order of testing were used to test groups of patients with universal standard goniometers, a computerized goniometer, and a mechanical rotation measuring device. Intratester reliability was high for all 3 measuring devices. Meaningful changes in intratester range of motion measurements taken with a universal goniometer occur with 95% confidence if they are greater than 6 degrees for flexion, 7 degrees for extension, 8 degrees for pronation, and 8 degrees for supination. Intertester reliability was high for flexion and extension measurements with the computerized goniometer and moderate for flexion and extension measurements with the universal goniometer. Meaningful change in interobserver range of motion measurements was expected if the change was greater than 4 degrees for flexion and 6 degrees for extension with the computerized goniometer compared with 10 degrees and 10 degrees, respectively, if the universal goniometer was used. Intertester reliability was high for pronation and supination with all 3 devices. Meaningful change in forearm rotation is characterized by a minimum of 10 degrees for pronation and 11 degrees for supination with the universal goniometer. Reliable measurements of elbow and forearm arm movement are obtainable regardless of the level of experience when standardized methods are used. Measurement error was least for repeated measurements taken by the same tester with the same instrument and most when different instruments were used.