A L G O D Y S T R O P H Y IS A N E A R L Y C O M P L I C A T I O N OF COLLES' FRACTURE W h a t are the implications? J. FIELD and R. M. ATKINS

From the UniversityDepartment of Orthopaedics, Bristol Royal Infirmary, Bristol, UK One hundred patients who had sustained a Cortes' fracture were observed for features of algodystrophy at 1, 5, 9 and 12 weeks following injury. The diagnosis of algodystrophy was possible as soon as 1 week after fracture. Early diagnosis has important clinical implications: the aetiological factors may become apparent and different treatment modafities be identified; furthermore, early treatment can be started, limiting the morbidity of the condition. It is proposed that patients with features of algodystrophy require physiotherapy after a Colles' fracture. Those without features may not. Journal of Hand Surgery (British and European Volume, 1997) 22B." 2:178-182 Algodystrophy (reflex sympathetic dystrophy or Sudeck's atrophy) is a syndrome consisting of excessive pain, loss of joint mobility, swelling and temperature, colour and sudomotor changes (collectively referred to as vasomotor instability (VMI)). Later, atrophy of the skin and soft tissues may occur with joint contractures and regional osteoporosis. The most common precipitating cause is trauma (Doury et al, 1981) and it has been shown that the incidence soon after Colles' fracture, when specifically sought, is between 25% and 30% (Atkins et al, 1989; Aubert, 1980, Bickerstaff, 1990; Hoffmann, 1953). The condition may be transient (Bickerstaff, 1990) and often not recognized (Stewart et al, 1985). Even after 2 years some patients still experience symptoms (Bickerstaff, 1990), and features have been found to be present 10 years after Colles' fracture (Field et al, 1992). Treatment of the condition is difficult, but as it is generally agreed that early treatment is very important (Cooper et al, 1989; Livingston, 1943), early diagnosis is essential. Before this study it was noted that patients developing algodystrophy appeared to get little relief of pain when immobilized in a plaster of Paris cast. It has been shown that the diagnosis can be made at 9 weeks following fracture (Atkins et al, 1989) and it was the object of this study to determine whether the diagnosis could be made earlier.

classifications (the latter including displacement of the fracture). The diagnostic criteria for algodystrophy previously reported by Atkins et al (1989) were used. In addition a sensitive and reproducible technique to examine finger stiffness was developed. A formal diagnosis of algodystrophy was made at 9 weeks (Atkins et al, 1990) and a comparison made of the features at that time with those seen at 1 and 5 weeks to determine how early the diagnosis could be made. The sensitivity and specificity of the dolorimetry ratio and finger stiffness measurement were then tested to determine whether there was a single diagnostic test that could pick up those patients with algodystrophy at either 1 or 5 weeks. Reproducibility studies For the purpose of establishing normal ranges, a group of 20 control patients of similar age and sex to the Colles' fracture patients was examined. Reproducibility of the measurements was assessed by examining the patients on two separate occasions. A group of eight of the original 100 patients were examined 1 week after their Colles' fracture on two separate occasions to assess reproducibility of the measurements with the arm in the plaster of Paris cast. Diagnostic measurements of algodystrophy

PATIENTS AND METHODS

Finger tenderness

To assess the incidence of features of algodystrophy soon after Colles' fracture, 100 consecutive patients with this injury were examined 1, 5 and 9 weeks after fracture. Assessment of the patients 1 week after fracture involved examination within the plaster of Paris cast. There were 80 women and 20 men. All patients were given advice about finger exercises at the 1 week assessment. All patients were aged 50 years or more (mean age 65 years 6 months). The severity of the injury was classified using both the Frykman (1967) and Lidstr6m (1959) fracture

This was measured using a dolorimeter, which gives a dolorimetry ratio of abnormal to normal hands (McCarty et al, 1965). This method has been shown previously to be reproducible (Atkins et al, 1989) and the lower 95% reference limit for the expected dolorimetry ratio in normal subjects of this age was 0.9l. While the patient was still in a plaster of Paris cast, dolorimetry was performed excluding the metacarpophalangeal joints (MCPJ). The lower 95% reference limit (i.e. the lower limit of normal) of this measurement was 0.90. 178

ALGODYSTROPHYAFTERCOLLES'FRACTURE The variation measurement (within the plaster cast) was 2.3%.

179 Table 1--Features of algodystrophy in each group

Group

Swelling Digit circumference was measured using an arthrocircameter (Willkens et al, 1973). Hand swelling was measured using water displacement. The normal range for the arthrocircameter measurement was minus 25 mm to plus 25 mm, and 0.97 to 1.03 for the hand swelling ratio.

Range offinger movement Finger stiffness was quantified by measuring the range of movement of each joint of each finger of each hand using a goniometer. A total range of movement for each hand was obtained by addition of each joint value. The value for joint stiffness was found by subtracting one hand total from the other. The variation measurement was 1.2% (normal range minus 63 ° to plus 63°). Reproducibility within the plaster cast was 1.8%.

Vasomotor instability ( VMI) Vasomotor instability was assessed by a questionnaire (Atkins et al, 1989). Each feature was scored as 0 (absent) or 1 (present); the sum of these scores was used to give a semiquantitative assessment of VMI. In addition to these criteria used for the diagnosis of algodystrophy, grip strength was measured using a Jamar dynamometer (Bechtol, 1954). All studies had local ethical committee approval. All patients gave informed consent to participation in the study. No change in the clinical management was caused by their participation.

Number in group

Number of features

Algodystrophy Borderline

24 28

Normal

48

4 3 (n=4) 2 (n= 13) 1 (n=ll) 0

The differences between the measurements of each component of the syndrome at 9 weeks were significantly different between the algodystrophy, borderline and normal groups (by definition as this was when the diagnosis was made). There was no difference in the fracture types of those patients who had developed algodystrophy, those who were borderline and those who had developed no features of the syndrome at 9 weeks. The differences between features in the three diagnostic groups are illustrated using dolorimetry ratio and goniometry difference (Figs 1, 2). Both dolorimetry and goniometry measurements were significantly different at each measurement time in each of the three diagnostic groups. The rise seen in goniometry difference at 5 1.2

1 Dolorimetry Ratio

Statistical analysis

Comparison of values between the three groups was performed using the ANOVA analysis of variance and then Student's paired t-test as appropriate. Correlation of data was performed using the Spearman Rank test. The significance of difference between proportions was assessed using the Z2 test with Yates' correction. Variation of measurements was determined using reproducibility percentages. "

0.8

0.6

RESULTS Algodystrophy was diagnosed at 9 weeks by the presence of all four features of finger tenderness, swelling, joint stiffness and vasomotor instability. Of the 100 patients studied three groups were identified: 24 had developed algodystrophy with all four features at 9 weeks after their fracture; 28 patients were classified as borderline, showing one, two or three features of algodystrophy (Table 1); and 48 patients showed none of the features at 9 weeks and were regarded as normal.

0.4 1

5

9

12

Weeks After Injury

Fig 1

The dolorimetry ratios of each diagnostic group at each assessment time. Algodystrophy (n=24) (complete line) (bold), borderline (n=28) (dotted line), normal (n=48) (dashed line).

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THE JOURNAL OF HAND S URGER Y VOL. 22B No. 2 APRIL 1997

300 I Goniometry Difference

three diagnostic groups in each parameter using analysis of variance the algodystrophy group was significantly different from the normal group in all parameters tested and at each testing time except for finger swelling at 1 and 5 weeks (Table 3). Dolorimetry and goniometry were the only two distinguishing features that consistently distinguished between the two diagnostic groups at each assessment time at the P