1 University of Khartoum Faculty of Medicine Postgraduate Medical Studies Board
Colles’ Fracture Clinical, Radiological Features and Outcome of Conservative Treatment
By: Dr. Osman Idris Osman
M.B.B.S (Unversity Of Gezira)
A thesis Submitted In Partial fulfillment Of The Requirement For The Degree Of M.D In Orthopaedics & Traumatology
Supervisor Dr. Geili Karrar Associate prof. of Orthopaedics and Truamatology Faculty of Medicine U of K November 2003
2
ﻦ اﻟ َﺮﺣِﻴﻢ ﺣ َﻤ ِ ﺴ ِﻢ اﻟﻠّﻪ اﻟ َﺮ ْ ِﺑ ْ
ﻗﺎل ﺗﻌﺎﻟﻰ:
)وﻗﻞ رب زدﻧﻲ ﻋﻠﻤ َﺎ( ﺻﺪق اﷲ اﻟﻌﻈﻴﻢ ﺁﻳﺔ رﻗﻢ ) (114ﺳﻮة ﻃﻪ
3
To
My Parents… My Wife… My Brothers and Sisters… My Teachers… And My Friends… With Wishes Of Healthy and Happy Future…
Osman
4
Acknowledgement
I would like to express my indebtedness to my supervisor Dr Geili Karrar, for his continuous encouragement and criticism. It is also a privilege to express my deep gratitude to his unique patience during the whole period, which made this work possible. I am also grateful to all my teachers through out my training period for their kind support and guidance. Finally I would like to express my thanks to all my patients who are involved in this thesis for allowing me to do this study. I wish them all the best.
5
Abstract A total of 211 patients with Colles’ fracture were included in this study for a period of one year from 1st of March 2002 to 1st of March 2003. All of them have been seen and managed in Khartoum Teaching Hospital. Only 102 of these were available for final assessment. The data was collected after completing a questionnaire containing a detailed history, thorough physical examination and X-rays in posteroanterior and lateral planes.
The aim was to establish a scientific basis
for clinical presentation, radiological features and outcome of conservative management of these patients. Of 211 patients; males were 39.2% and females were 60.8%. Of these females 62.5% were middle aged. The fracture followed a fall on the outstretched hand in 49.3% of all patients and 68.0% of females. 86.6% of these patients were otherwise healthy subjects; with no previous medical disease. 78.2% of them presented with wrist pain and swelling with mild or no deformity. Only in few cases the deformity was marked. The fracture was an isolated injury in 84.3%. In lateral X-rays; 69.6% of the fractures were undisplaced or the disturbance of the volar angles at the distal articular surface of the radius was acceptable. In the postero-anterior projections; 85.5% of the radial angles were undisturbed or acceptable, 72.1% of radial heights were not
6
reduced or acceptable. 71% of these patients were manipulated to improve the anatomy. All patients were treated by closed manipulation and cast immobilization for 6 weeks. 71.9% of the patients had excellent to good objective functional results and 89% of these patients had excellent to good subjective functional results.
7
ﺧﻼﺻﺔ اﻷﻃﺮوﺣﺔ ﻟﻘﺪ ﻓﻤﺖ ﺑﺈﺟﺮاء هﺬﻩ اﻟﺪراﺳﺔ ﻋﻠﻰ 211ﻣﻦ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﻴﻦ ﺑﻜﺴﻮر ﻋﻈﻤﺔ اﻟﻜﻌﺒﺮة ﻗﺮب اﻟﻤﻌﺼﻢ و اﻟﻤﺴﻤﻰ آﺴﺮ "آﻮﻟﺲ" ﻋﻠﻰ ﻣﺪى ﻋﺎم آﺎﻣﻞ ﺧﻼل اﻟﻔﺘﺮة ﻣﻦ أول ﻣﺎرس ﻋﺎم أﻟﻔﻴﻦ و إﺛﻨﻴﻦ إﻟﻰ أول ﻣﺎرس ﻋﺎم أﻟﻔﻴﻦ وﺛﻼﺛﺔ ﺣﻴﺚ ﺗﻤﺖ دراﺳﺔ و ﻣﻌﺎﻟﺠﺔ ﺟﻤﻴﻊ اﻟﺤﺎﻻت ﻓﻰ ﻣﺴﺘﺸﻔﻰ اﻟﺨﺮﻃﻮم اﻟﺘﻌﻠﻴﻤﻰ .ﻣﻦ هﺬا اﻟﻌﺪد اﻟﻜﻠﻰ ﺑﻘﻰ 102ﻣﺮﻳﻀًﺎ ﻣﺘﺎﺑﻌًﺎ إﻟﻰ ﻧﻬﺎﻳﺔ ﻣﺪة اﻟﺒﺤﺚ ﺣﻴﺚ ﺗﻢ اﻟﺘﺤﻠﻴﻞ اﻟﻨﻬﺎﺋﻰ. ﻟﻘﺪ ﻗﻤﺖ ﺑﺘﺠﻤﻴﻊ اﻟﻤﻌﻠﻮﻣﺎت ﻣﻦ إﺳﺘﻤﺎرات ﺗﻢ ﺗﻌﺒﺌﺘﻬﺎ ﺑﺎﻟﻤﻌﻠﻮﻣﺎت ﺧﻼل ﺗﺎرﻳﺦ ﻣﺮﺿﻰ ﻣﺪﻗﻖ ،آﺸﻒ ﺟﺴﻤﺎﻧﻰ ﻣﻄﻮل و دراﺳﺔ ﺻﻮر أﺷﻌﺔ ﻟﻠﻤﻌﺼﻢ اﻟﻤﺼﺎب ﻓﻰ ﻣﺴﺘﻮى ﺧﻠﻔﻰ-أﻣﺎﻣﻰ و ﻣﺴﺘﻮى ﺟﺎﻧﺒﻰ .آﺎن اﻟﻬﺪف ﻣﻦ إﺟﺮاء هﺬﻩ اﻟﺪراﺳﺔ هﻮ إﻧﺸﺎء ﻗﺎﻋﺪة ﻋﻠﻰ أﺳﺎس ﻋﻠﻤﻰ ﺑﻤﺎ ﻳﺨﺺ آﻴﻔﻴﺔ ﺣﻀﻮر هﺆﻻء اﻟﻤﺮﺿﻰ ،و ﺳﻤﺎت هﺬا اﻟﻜﺴﺮ ﻋﻠﻰ ﺻﻮر اﻷﺷﻌﺔ و ﺗﻘﻮﻳﻢ ﻧﺎﺗﺞ ﻣﻌﺎﻟﺠﺔ هﺆﻻء اﻟﻤﺮﺿﻰ ﻣﻌﺎﻟﺠﺔ ﺗﺤﻔﻈﻴﺔ. ﻣﻦ ﻣﺠﻤﻮع 211ﻣﺮﻳﺾ 39.2% ،هﻢ ﻣﻦ اﻟﺮﺟﺎل و 60.8%هﻢ ﻣﻦ اﻟﻨﺴﺎء .ﻣﻦ اﻟﻨﺴﺎء ﻧﺴﺒﺔ 62.5%هﻢ ﻣﺘﻮﺳﻄﻰ اﻷﻋﻤﺎر .ﻓﻰ 49.3%ﻣﻦ اﻟﻤﺮﺿﻰ ﺑﺼﻮرة ﻋﺎﻣﺔ و ﻓﻰ 68.0%ﻣﻦ اﻟﻨﺴﺎء ﺑﺼﻮرة ﺧﺎﺻﺔ ،آﺎن اﻟﻜﺴﺮ ﻧﺘﻴﺠﺔ ﻟﺴﻘﻮط اﻟﻤﺮﻳﺾ ﻣﺴﺘﻨﺪًا ﻋﻠﻰ ﻳﺪﻩ. 86.6%ﻣﻦ هﺆﻻء اﻟﻤﺮﺿﻰ ﻣﻌﺎﻓﻴﻴﻦ ﻣﻦ اﻷﻣﺮاض اﻷﺧﺮى ﺑﺨﻼف هﺬا اﻟﻜﺴﺮ 78.2% .ﻣﻦ اﻟﻤﺮﺿﻰ ﺣﻀﺮوا ﻟﻠﻤﺴﺘﺸﻔﻰ ﻳﺸﻜﻮن ﻣﻦ أﻟﻢ ﻓﻰ اﻟﻤﻌﺼﻢ و ﺗﻮرم ﺑﺪون ﺗﺸﻮﻩ أو ﻣﻊ ﺗﺸﻮﻩ ﺧﻔﻴﻒ. ﻗﻠﻴﻠﻮن هﻢ اﻟﺬﻳﻦ ﺣﻀﺮوا و ﻋﻨﺪهﻢ ﺗﺸﻮﻩ ﻣﻌﺘﺒﺮ 84.3%. .ﻣﻦ اﻟﻤﺮﺿﻰ ﻟﻢ ﻳﺼﺤﺐ اﻟﻜﺴﺮ أى إﺻﺎﺑﺔ أﺧﺮى. ﺑﺈﻋﺘﺒﺎر ﺻﻮرة اﻷﺷﻌﺔ اﻟﻤﺄﺧﻮذة ﻣﻦ اﻟﺨﻠﻒ إﻟﻰ اﻷﻣﺎم 69.6% ،آﺎﻧﺖ اﻟﺰاوﻳﺔ اﻷﻣﺎﻣﻴﺔ ﻓﻰ ﺳﻄﺢ اﻟﻤﻔﺼﻞ اﻟﻘﺎﺻﻰ ﻟﻠﻜﻌﺒﺮة ﻗﻠﻴﻠﺔ اﻟﺘﺰﺣﺰح أو ﻣﻘﺒﻮﻟﺔ .ﺑﺈﻋﺘﺒﺎر ﺻﻮرة اﻷﺷﻌﺔ اﻟﻤﺄﺧﻮذة ﻣﻦ
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ﻟﺠﺎﻧﺐ آﺎﻧﺖ اﻟﺰاوﻳﺔ اﻟﻜﻌﺒﺮﻳﺔ ﻓﻰ ﺳﻄﺢ اﻟﻤﻔﺼﻞ اﻟﻘﺎﺻﻰ ﻟﻠﻜﻌﺒﺮة ﻗﻠﻴﻠﺔ اﻟﺘﺰﺣﺰح أو ﻣﻘﺒﻮﻟﺔ ﻓﻰ 85.5% وآﺎن ﻃﻮل ﻧﺘﻮء ﻋﻈﻤﺔ اﻟﻜﻌﺒﺮة ﻃﺒﻴﻌﻰ أو ﻣﻘﺒﻮل ﻓﻰ 71% . 72.1%ﻣﻦ هﺆﻻء اﻟﻤﺮﺿﻰ ﺗﻢ ﻋﻤﻞ ﻣﺤﺎوﻟﺔ ﻟﺘﺼﺤﻴﺢ اﻟﻜﺴﺮ إﻟﻰ وﺿﻊ أﺣﺴﻦ ﻣﻤﺎ هﻮ ﻋﻠﻴﻪ. ﻟﻘﺪ ﺗﻤﺖ ﻣﻌﺎﻟﺠﺔ آﻞ هﺆﻻء اﻟﻤﺮﺿﻰ ﺗﺤﻔﻈﻴ ًﺎ ،ﻋﻦ ﻃﺮﻳﻖ ﻣﺤﺎوﻟﺔ إرﺟﺎع اﻟﻜﺴﺮ و ﺗﺜﺒﻴﺖ اﻟﻮﺿﻊ اﻟﺠﺪﻳﺪ ﻓﻰ ﺟﺒﺺ ﻟﻤﺪة 6أﺳﺎﺑﻴﻊ 71.9% .ﻣﻦ اﻟﻤﺮﺿﻰ آﺎﻧﺖ ﻧﺘﻴﺠﺔ اﻟﻤﺆﺷﺮات اﻟﻮﻇﻴﻔﻴﺔ اﻟﺘﻰ ﻳﻤﻜﻦ ﻗﻴﺎﺳﻬﺎ ﻣﻦ ﻣﻤﺘﺎزة إﻟﻰ ﺟﻴﺪة و 89%ﻣﻦ اﻟﻤﺮﺿﻰ آﺎﻧﺖ ﻧﺘﻴﺠﺔ اﻟﻤﺆﺷﺮات اﻟﻮﻇﻴﻔﻴﺔ اﻟﻌﻴﺮ ﻗﺎﺑﻠﺔ ﻟﻠﻘﻴﺎس ﻣﺎ ﺑﻴﻦ ﻣﻤﺘﺎز إﻟﻰ ﺟﻴﺪ.
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List of Tables Tables 1. Table (1): Evaluation of radiological anatomy.
Page 4 7
2. Table (2): Evaluation on subjective functional outcome.
4 7
3. Table (3): Evaluation of objective functional outcome.
4 8
4. Table (4): Sex distribution among patients with Colles’ fracture.
4 9
5. Table (5): Age distribution among patients with Colle’s fracture.
4 9
6. Table (6) Clinical presentation.
5 0
7. Table (7): Injuries associated with Colle’s fracture.
5 1
8. Table (8): Past medical history.
5 2
9. Table (9): Volar angle before and after reduction.
5 3
10. Table (10): Radial angle before and after reduction.
5
10
4 11. Table (11): Radial height before and after reduction.
5 5
12. Table (12): Associated radiological features.
5 6
13. Table (13): Management at casuality and the first visit in the referred clinic. 14. Table (14): Compliance to physiotherapy.
5 7 5 8
15. Table (15): Clinical and radiological union.
5 8
16. Table (16): Complications.
5 9
17. Table (17): Wrist flexion before and after physiotherapy.
6 0
18. Table (18): Wrist extension before and after physiotherapy.
6 1
19. Table (19): Ulnar deviation before and after physiotherapy.
6 2
20. Table (20): Radial deviation before and after physiotherapy.
6 3
11
21. Table (21): Supination before and after physiotherapy.
6 4
22. Table (22): Pronation before and after physiotherapy.
6 5
23. Table (23): Grip strength before and after physiotherapy.
6 6
24. Table (24): Finger stiffness before and after physiotherapy.
6 6
25. Table (25): Presence of pain before and after physiotherapy.
6 7
26. Table (26): Satisfaction.
6 8
27. Table (27): The extend of involvement in previous activities.
6 8
28. Table (28): The objective and subjective functional outcome.
6 9
12
List of figures Figures
Pages
1. Figure (1): Sex distribution.
70
2. Figure (2): Age distribution.
71
3. Figure (3): Mechanism of injury.
72
4. Figure (4): Injuries associated with Colles’ fracture.
73
5. Figure (5): Volar angle before and after reduction.
74
6. Figure (6): Radial angle before and after reduction.
75
7. Figure (7): Radial height before and after reduction.
76
8. Figure (8): Other radiological findings.
77
9. Figure (9): Complications.
78
10. Figure (10): Wrist flexion before and after
79
physiotherapy.
13
11. Figure (11): Wrist extension before and after
80
physiotherapy. 12. Figure (12): Ulnar deviation before and after
81
physiotherapy. 13. Figure (13): Radial deviation before and after
82
physiotherapy. 14. Figure (14): Supination before and after
83
physiotherapy. 15. Figure (15): Pronation before and after physiotherapy.
84
16. Figure (16): Grip strength before and after
85
physiotherapy. 17. Figure (17): Finger stiffness before and after
86
physiotherapy. 18. Figure (18): Pain before and after physiotherapy.
87
19. Figure (19): Satisfaction.
88
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Contents
Content
Page
1. Acknowledgement
i
2. English Abstract
ii
3. Arabic Abstract
iv
4. List of Tables
vi
5. List of Figures
viii
Chapter One: Introduction and Literature review 6. Anatomical consideration.
1
7. Functional anatomy and biomechanics.
2
8. Colles’ fracture.
4
9. Presentation.
5
10. Diagnosis.
6
15
11. Classification.
7
12. Pathological anatomy and function.
10
13. General Plan of Management.
11
14. Conservative management:
15
15. Non-conservative management:
19
16. Evaluation of outcome:
22
17. Complications:
24
Objectives
25
Chapter Two Patients and Methods 18. Nature of the study.
26
19. Study area.
26
20. Study population.
26
21. Duration of the study.
26
22. Case definition.
26
23. Inclusion criteria.
26
24. Exclusion criteria.
27
25. Study sample.
27
26. Number of cases available for final assessment.
27
27. The protocol of management.
27
28. Evaluation.
29
16
29. Follow up at the referred clinic.
32
30. Consent.
34
31. Questionnaire.
34
32. Data analysis.
34
Chapter Three Results 33. Demographic characteristics of people in the study:
35
34. Assessment at initial presentation at casuality.
35
35. The radiological appearance.
37
36. Management and follow up.
39
37. Assessment at removal of the plaster.
40
38. Final assessment after physiotherapy.
43
Chapter Four: Discussion, Conclusionand
89
recommendations 39. Appendix
107
17
Chapter one
Introduction and literature review
18
1. Introduction and Literature review Colles’ fracture is of one the fractures most frequently seen at the causality; yet all that is available about it is that written in literature. There are no previous trials to evaluate our local experience. There is general impression that it is more of less similar to what is mentioned in literature. This impression lacks the evidence. We also know that there are a lot of factors that may affect the pattern of presentation and the outcome indirectly; for example by affecting the bone quality. This study is baseline to establish our own figures and compare them with literature. 1.1. Anatomical consideration: The complex wrist joint is made of articulation between the distal radius and proximal raw of the carpal bones
(1, 2, 3)
. The
scaphoid articulates with the triangular facet and the lunate
19
articulates with the rectangular facet of the distal articular surface (2, 3, 4, 5)
of the radius
, in addition to a narrow rim of articulation
between the radius and the fibro-cartilage
(1, 4)
. The articulation
between the distal ulna and the carpal bones is not direct (Ulno(4)
carpal joint
); the triangular fibro-cartilage in sandwiched
between them (1, 2, 3, 4). The joint capsule is lined by synovial membrane and strengthened by a number of important ligaments. The anterior and posterior ligaments are much thicker, attaching the distal radius to the carpi
(2, 4)
. The medial collateral ligament extends between the
ulna and fibro-cartilage (1, 2). The lateral collateral ligament extends between the radial styloid and the waist of the scaphoid (1). The wrist is not a single cavity joint
(1)
. It is separated from the
distal radio-ulnar joint (where the ulna articulate with the radius at the sigmoid notch (4, 5)) and the inter-carpal joints (1). The joint is supplied by the anterior interosseous nerve and the deep branch of the radial nerve (1). The wrist joint is related to very vital and important structures. Anteriorly the flexors of the wrist and the digits, the latter, with the main trunk of the median nerve pass through the fibro-osseous carpal tunnel made between the concave carpal raw and the flexor retinaculum (1).
20
The wrist joint is capable of all modalities of movement except rotation which is compensated for by the rotation at the forearm (1, 2)
1.2.
. Functional anatomy and biomechanics: The stability of the wrist during movements depends on
capsulo-ligamentous integrity and contact surface contours of the wrist bones(4,6). During flexion and extension, most motion occurs at the radio-carpal joint, with some occurring through the midcarpal area. During radial and ulnar deviation, the proximal carpal row rotates and translocates or shifts at both the mid-carpal and radio-carpal joints, with motion occurring at both the radio-carpal and inter-carpal joints(4). For purposes of understanding the ways in which forces are transmitted through the wrist, the concept of a wrist consisting of three columns has become popular. These columns generally are described as the central (force-bearing) column, the radial column, and the ulnar column (4). The axial loads generated by muscles during daily activities are estimated to be 500 kg during the normal functional activities. 80% of it is transmitted through the distal radius (Central and radial columns), of this; 46% is supported by the lunate fossa, 43% supported by scaphoid fossa and remaining 11% by the fibro-
21
cartilage
(6)
. The load on the fibro-cartilage and, thus the ulna
(Ulnar column) is increased in extreme of ulnar adduction and when the angles of the distal radius are disrupted
(5)
. Disruption of
any of these angles of or loss of radial height may associate with dysfunction of the radio-ulnar joint and weakness of the grip due to disturbance of the normal biomechanics. The distal radius is connected to the styloid of ulna by the strong radio-ulnar ligament and the fibro-cartilage (TriangularFibro-Cartilage-Complex _ the TFCC (4, 5)). Fractures of the distal radius may associate with avulsion of the ulnar styloid; the radiologically unseen fibro-cartilage is certainly disrupted (5). The strong anterior and posterior ligaments that reinforce the capsule are important in production of the fracture, help closed reduction by ligamentotaxis and stabilize the fragments by splinting them
(5, 6)
. The usual mechanism of injury is a fall on
outstretched hand, where an increasing tension is applied to the palmar cortex of the distal radius through these ligaments. The anterior cortex fails in tension (gap) and posterior cortex (the posterior pillars) are faced by increasing loads of compressive stresses. Then posterior cortex fails and displacement, impaction or comminution results (5).
22
The amount of force necessary to produce the fracture is different between males and females and at the different angles of flexion during the insult with lesser amount in female at small angles (5). 1.3.
Colles’ fracture: 1814, Abraham Colles (1773 - 1837) described a fracture of the distal
radius, which now bears his name (1814)
(5, 7, 8)
. Colles’ fracture is the
fracture of the distal radial metaphysis (5, 8, and 9) within the terminal 2.5 cm from the radio-carpal joint affect the upper limb
(9)
. It is the commonest of all fractures that
(5, 9)
. The fracture occurs mainly in osteoporotic
middle-aged and elderly women
(5, 9)
. It generally results from a fall on
outstretched hand(5,9). The fracture has characteristic deformities; if displaced (9). The characteristic deformities are: 1.3.1. There
is
dorsal
and
radial
displacement
(deviation) of the distal fragment (6, 9). 1.3.2.
Volar (anterior) angulation with loss of the normal 5 to
14 degrees of forward and downward tilt of the distal articular surface of the radius, associated with the posterior displacement 9)
.
(6,
23
1.3.3.
Radial (lateral) angulation with loss of normal 22 to 23
degrees of forward and ulnar-ward tilt of the distal articular surface of the radius (6, 9). 1.3.4.
There is always a rotational element that can not be seen
in the radiographs (9). 1.3.5.
Shortening of the distal radius due to metaphyseal
impaction (5). 1.3.6.
There may be fracture of ulnar styloid or one of the
carpal bones (5, 9). Disruption of the distal radio-ulnar joint may be present (5, 9). 1.4.
Presentation: The patient usually a post-menopausal elderly woman with
osteoporosis
(5, 9)
. When children (usually between the age of 6 to 10
years) are affected; the fracture is known as “Juvenile Colles’ fractures”(5).There is a history of a fall on the outstretched hand; with complaint of pain, swelling; and/or deformity of the affected wrist(5,9). Examination may show the following: 1.4.1.
Only tenderness in the distal radius (9).
1.4.2.
Tenderness and swelling (9).
1.4.3.
Typical dinner-fork deformity (silver-fork deformity (5, 8))
of different grades; which leaves little doubt about the diagnosis 9)
.
(5,
24
The examination must include assessment of the median nerve and radial artery (5, 9). The X-rays may show the deformities mentioned above. When the fracture is undisplaced or impacted; the clue to diagnosis may only be the an alteration in one of the angles (radial and volar angles) between the longitudinal axis of the radius and the articular surface (5 to 14 degrees of forward and downward in lateral projection, 22-23 degrees of forward and ulnar-ward in postero-anterior projection), or there may be only alteration in the contour of the anterior (gap) or the posterior cortex (increased concavity) (5, 6, 9). 1.5.
Diagnosis: The fracture is suspected when middle-aged or an elderly
woman gives a history of a trauma to the wrist; usually fall on outstretched hand and present with tenderness or swelling at the wrist; even if there is no visible deformity
(9)
. In cases with severe
displacement; the carpal bones are carried backward and radially with the characteristic dinner fork deformity (9). The mechanism of injury is common to most fractures of the upper limb
(9)
. These must be ruled out by a through clinical and meticulous
radiological assessment including the elbow and the shoulder
(5, 9)
. Other
injuries of the wrist may associate with this fracture; e.g. Carpal instability (5, 9).
25
1.6.
Classification: Colles’ fracture is considered as one of the important fractures that
affect the distal radius and usually classified as one of these. Gartland and Werly, in 1951, classified the fracture on the basis of the presence (but not the extent) of displacement at fracture site, and the involvement of distal radio-carpal joint (6). Older et al, in 1965, classified the fracture on basis of the extent of the displacement, dorsal angulation, shortening of the distal end of the radius and the presence and extent of comminution of the dorsal metaphyseal cortex (6). Frykman et al, in 1967, identified the involvement of radio-carpal and radio-ulnar joints and the presence of ulnar styliod fracture
(5, 6, and 8).
They divided the fracture into intra-articular and extra-articular with or without involvement of the radio-ulnar joint (5, 8). Later; the fracture was subdivided according to displacement, stability and reducibility (The Universal Classification) (5). Fernandez subdivided the fracture as a variant of distal radial fractures according to the mechanism of injury (6): 1.6.1. Bending: The metaphysis fails due to tensile stress (Colles’ and Smith).
26
1.6.2. Compression: Fracture of the surface of the joint and impaction of subchondral and metaphyseal bone (die-punch fracture). 1.6.3. Shearing: Fracture of joint surface (Barton’s and reversed Barton’s) 1.6.4. Avulsion: of the ligamentous attachments (the styliod of the radius and ulna). 1.6.5. Combination. MacMurtry and Jupiter classified the fracture on basis of intraarticular involvement and the number of the parts (6): 1. Two parts with no displacement: The opposite portions of the radio-carpal joint remain intact. 2. Three parts with displacement: The lunate and the scaphoid facet separate from each other and from the metaphysis. 3.
Four parts: the lunate facet further separates into dorsal and volar parts.
4.
Five and more parts.
1.7.
A. O classification: The A.O classification based on the severity of the osseous and
articular lesion (6): 1.7.1. Type A (extra articular) (5, 8, and 9).
27
1.7.1.1. Type A1 (Isolated fracture of distal ulna). 1.7.1.2. Type A2 (extra-articular of radius) when undisplaced it is (A2, 1), when there is posterior displacement i.e. displaced Colles’ fracture it is (A2, 2) and when displaced anteriorly i.e. Smith fracture it is (A2, 3). 1.7.1.3. Type
A3
(extra-articular
with
comminution). 1.7.2. Type B (partial intra-articular) (6, 8, 9). 1.7.2.1. Type B1 (undisplaced partial intraarticular in the sagittal plane) i.e. Colles’ fracture with articular involvement. 1.7.2.2. Type
B2
(partial
intra-articular
involving
the
posterior
cortex)
i.e.
Barton’s fracture. 1.7.2.3. Type
B3
(partial
intra-articular
involving
the
anterior
cortex)
i.e.
Reversed Barton’s fracture. 1.7.3. Type C (complete intra-articular) (6, 8, 9). These are further subdivided into C1 for simple intra-articular
28
and extra-articular fractures, C2 for simple intraarticular and comminuted extra-articular fractures and C3 for comminuted intra-articular fractures (6). 1.8.
Pathological anatomy and function: 1.8.1. Extra-articular anatomy: Although the objective results may be less satisfactory than the
subjective results (6, 8, 10, and 11), recent studies have suggested a direct relation ship between residual deformity and disability (5, 6, 10, and 11). It was found that the functional results are related to original displacement and success of reduction and restoration of the anatomy more than the method of immobilization (5, 6, 12, 13, 14, 15, 16, and 17,)
. Reversal of the normal palmar tilt has deleterious effects;
with progressive loss there is increasing load on the distal ulna and the scaphoid fossa, resulting in pain at the radio-carpal articulation and limitation of grip strength
(5, 6, and 13)
. Loss of the palmar tilt
especially in the young can result in inter-carpal instability that can only be corrected by correction of the palmar tilt (6). The grip strength and endurance are impaired if the fracture healed with dorsal angulation of 20 degrees, radial tilt less than 10 degrees or radial width more than two millimeters (5, 6, and 13). Radial shortening is associated with disruption of radio-ulnar joint and impingement of the ulna (6, 13).
29
1.1.1.
Intra-articular anatomy:
Restoration of intra-articular anatomy to less than two millimeters and early exercises (5, 8, 10, and 18) are necessary to ensure the function of the hand and the wrist and to prevent post-traumatic arthritis
(6, 12, 13, 15)
. Two groups can be identified: older, post-
menopausal women who place the wrist at low functional loads; they generally show favorable outcome
(6, 11)
. The second group is
young adults, whose injury is usually the result of high energy trauma, and common to have other associated ligamental and carpal injuries; they require meticulous restoration of the articular surface by open approaches; as closed manipulation is most likely to fail in reducing the impacted, rotated articular fragments
(6, 11)
.
The ligaments that assist closed reduction “ligamentotaxis” may be torn
(6)
. The joint must be reduced anatomically and fixation must
be stable to allow early function (5). 1.9.
General Plan of Management: Abraham Colles outlined his method of treatment. This consisted
essentially in traction to reduce the fracture and application of anterior and posterior tin splints to maintain reduction of the fracture
(7)
. With
great assurance he remarked, “The cases treated on this plan have all recovered with the smallest defect or deformity of the limb in the ordinary time for a cure of fractures”
(7)
. Now it is recognized that some
30
factors may affect the choice of the technique for reduction (open versus closed) and the method of immobilization; these must be considered (6)
before starting the management
. These factors include:
general
evaluation of the patient and functional demands, evaluation of fracture stability, comminution and articular involvement to select the appropriate management and evaluation of prognostic factors. 1.9.1. Evaluation of the patient: 1.9.1.1. Local
factors:
this
include
following: 1.9.1.1.1. The fracture pattern (5, 6). 1.9.1.1.2. Presence
and
extent
of
displacement (5, 6). 1.9.1.1.3. Presence of dorsal metaphyseal comminution (5, 6). 1.9.1.1.4. Involvement of the articular surface (5). 1.9.1.1.5. Presence
of
other
carpal
injuries (5). 1.9.1.2. General factors: 1.9.1.2.1. The energy that caused the fracture
(5, 6)
this may cause soft
the
31
tissue injuries that are not visible on radiographs. 1.9.1.2.2. The patient’s age (6). 1.9.1.2.3. The patient’s life style (6). 1.9.1.2.4. The psychological outlook of the patient (6). 1.9.1.3. The functional loading of the wrist (6). 1.9.2. Selection of the appropriate management: The selection of appropriate type of management whether conservative or non-conservative is affected by stability, comminution and articular involvement as follows: 1.9.2.1. Stable
fractures:
for
conservative
management using manipulative reduction (if displaced) and immobilization in a cast (5, 6, 8, and 9)
. These are usually extra-articular
fractures,
with
mild
to
moderate
displacement, usually with no extraarticular comminution and no articular involvement
(5)
. These fractures do not re-
displace to the original deformity when reduced (5).
32
1.9.2.2. Unstable fractures: treated by closed manipulative reduction, but immobilized by using percutaneous K. wires (10, 15), pins and plaster (7, 10, 15, and 18) or external fixator (6, 10, 15, and 18)
. Unstable fractures are
fractures
with
severe
impaction
or
comminution of the dorsal metaphyseal cortex. The initial displacement provides some criteria for stability. When initially there is dorsal angulation of more than 20 degrees or recurrence of the angulation after reduction to more than 10 degrees the fracture is most likely unstable
(5)
. If there
is loss of radial height of more than 10 mm or recurrence of the shortening after reduction to more than 5 mm the fracture is also most likely unstable (5). 1.9.2.3. Fractures with comminution involving the articular surface are treated by open reduction and internal fixation using plates and screws both.
(6, 13)
, or external fixation or
33
1.9.3. Evaluation of prognostic factors: 1.9.3.1. Articular involvement is associated with painful restricted wrist movement and post-traumatic arthritis(13,4,6). 1.9.3.2. Loss of the volar angle to more than 20 degrees is associated with mild residual deformity, inter-carpal instability with variable
degrees
of
functional
disability(6,16). 1.9.3.3. Finger stiffness and loss of grip power is related; to a great extent; to the age, compliance to physiotherapy and duration of immobilization (14, 18). 1.9.3.4. Loss of volar angle with little or no effect on the radial angle and height is associated with disruption of the radioulnar joint, prominent ulna, and pain at radio-ulnar articulation (6). 1.9.4. Evaluation of the probability of redisplacement (instability): 1.9.4.1.
Impaction of the metaphyseal cancellous bone of
the distal fragment in the diaphysis, especially when there is
34
cancellous collapse and comminution of the dorsal cortex (posterior pillar), will result in a metaphyseal gap after reduction, which is a significant cause of fracture instability
(13, 19)
. When the
initial dorsal angles is more than 20 degrees, initial shortening of more than 10 mm or if there is redisplacement to original angles after initial reduction; the chance of instability is great. 1.9.4.2.
Of all radiographic features, only the dorsal and
radial displacement are related to each other in such a way that reduction of one is mostly likely to result in reduction of the other, and failure to reduce one of them will most likely lead to failure to reduce the other(17). 1.9.4.3.
High-energy trauma results in complex injuries;
with articular involvement, impaction and rotation of the fragments and various degrees of affection of the soft tissues and ligaments; the result is loss of ligamentotaxis that helps to reduce the fracture and splint them after reduction. These fractures are unlikely to be reduced by closed methods; and if reduced; they are unlikely to stay stable (6, 16, and 19). 1.10.
Conservative management:
The conservative treatment is indicated for stable; undisplaced or minimally displaced fractures (5).
35
Conservative management is an issue of great controversy. There is controversy in both methods of traction and reduction on one hand and position, technique and duration of immobilization on the other hand(5,6). The aim of manipulation is to achieve a volar angle at least neutral or slightly forward, restore the radial height and alignment of the palmar cortex (5, 9). 1.10.1.
Technique of traction:
Many methods have been described; these include: 1.10.2.
Manual traction with the wrist aligned
along the axis of the forearm by two assistants and 9)
1.10.3. (6)
(5, 6,
. Manual traction with the wrist at extension
then reduction is achieved by flexion.
1.10.4.
Traction by finger trap using weight of 5 to
10 pounds(5, 20). 1.11.
Technique of manipulation:
1.11.1.
By using the thenar grip technique (5, 9).
1.11.2.
Direct pressure on the distal fragment
applied by the thumb
(5, 9)
. Pronation and ulnar
deviation may be necessary (5). 1.12.
Position and method of immobilization:
In most cases the plaster is up to but not including the elbow:
36
1.12.1.
Circular cast or posterior splint (17) in slight
flexion and ulnar deviation
(5, 6, 9)
. But the extremes
must be avoided (5, 9). Dorsal splint
(17)
allows wrist
flexion but prevent extension. 1.12.2.
Circular cast or posterior splint
neutral position
(5, 17, 19)
(17)
in the
maintaining the ulnar
deviation (17). 1.12.3.
Circular cast or posterior splint
(17)
in the
neutral position (5, 6, 17) without ulnar deviation (17). 1.12.4. 15)
Immobilization with forearm supinated using functional bracing
(5, 14)
(6,
that extends above
the elbow to maintain supination. The theory behind this is that, the brachio-radialis was considered as the major deforming force and is relaxed by supination. 1.13.
Duration of immobilization: controversy ranged
between 3 to 6 weeks (5, 17). When the fracture is suspected, the patient is given analgesic and the forearm and the wrist are supported in a slab, and held elevated on sling or collar and cuff
(9)
. Then the patient is sent to
the X-ray department to confirm the diagnosis. The fracture must be reduced if:
37
1.
There is visible deformity (9).
2.
The joint line in the lateral projection is tilted more than 10 degrees
posteriorly
than
anteriorly
(i.e.
dorsal
angulation) (5, 6, and 9). 3.
If the radial angle is reduced to less than 10 degrees (5, 6).
4.
If there is displaced fracture of the styloid process of the ulna; irrespective of the other appearance
(9)
. This
fracture means there is disruption to the unseen fibrocartilage. 5.
If the radial height is reduced to less than 3 mm (6).
If there is no displacement; the fracture is immobilized without manipulation (9, 21). The reduction is acceptable if: 1. Dorsal angulation is less than 10 degrees (11, 20). 2. Radial angle of more than 10 degrees (11, 20). 3. Radial shortening of less than 5 mm (11, 20). 4. Intra-articular gap or step of less than 2 mm (11). The fracture must be reduced under G.A, regional intravenous or haematoma block. Traction is applied along the longitudinal axis of the forearm by using the thumb and the three-ulnar fingers to disimpact the distal fragment. The disimpaction is confirmed by holding the distal fragment between the index and the thumb; it is found to move backward
38
and forward easily. First the volar angle and posterior displacement is initially corrected by using the heel of one hand to apply pressure on the dorsum of the distal fragment; while the other acts as a fulcrum. The radial angle and displacement is corrected thereafter by direct press on the distal fragment
(9)
. A short arm (below elbow) slab initially applied
which is completed to full plaster in a few days. It must be short of the distal palmar crease to allow free flexion of the fingers. Proximally, it must allow flexion of the elbow to more than 90 degrees. Then it is molded to conform the shape of the forearm. There must be no constrictions
(9)
. The arm is supported elevated in collar and cuff. The
patient is advised to present immediately when there is swelling, pain, numbness or change in color. He is better seen next morning (or admitted if there is swelling) (9). Then the patient is seen the next week to complete the plaster to a full cast (after the swelling subsides). X-ray is taken to check the position of the reduction
(9)
. Then the patient is seen after two
weeks later (3 week after trauma) to see whether there is any slackening or softening of the plaster. X-ray is taken to check the position of the reduction. At any visit; if manipulation is needed; is carried out. The patient is advised to maintain active physiotherapy to his fingers, elbow and shoulder. After removal of the plaster he is sent to physiotherapy department if there is any loss of grip power, wrist movement or finger stiffness (9).
39
1.14.
Non-conservative management:
Although in the conventional displaced Colles’ fracture, which is stable, the conservative management gives good results; there are still indications for non-conservative treatment
(6)
. In addition, bone healing
can be accelerated by low intensity ultra-sound waves that induce the cellular events through their thermal effects (22): 1.14.1.
Unstable fractures with dorsal metaphyseal
comminution (loss of posterior pillars) and/or metaphyseal
impaction,
potentially
unstable
fractures with initial dorsal angulation more than 20 degrees, initial radial shortening more than 10 mm or severe mechanism of injury and articular involvement in addition to fractures that failed to remain reduced after trials of manipulations(5, 6, 16). These are treated by: 1.14.1.1. Reduction followed by filling the gap with injectable bone cement or bone graft to give mechanical support and prevent collapse of cancellous bone during fracture healing (19). 1.14.1.2. Reduction followed by immobilization using hinged external fixator (dynamic) or
40
pins incorporated in a plaster to apply skeletal traction that helps to maintain reduction(6,15, 18). 1.14.2.
Intra-articular involvement with step or gap
of more than 2 mm (C2)
(16)
. This is stabilized by
closed reduction and percutaneous pinning to maintain articular reduction
(7)
. It requires X-ray
control (10, 14). 1.14.3.
Impacted
intra-articular
fracture
with
communition that is the result of high-energy trauma (C3) (6, 16). Management is directed to ensure the stability (prevent redisplacement) and to allow early joint motion. These are treated with: 1.14.3.1. Open reduction and stable internal fixation using plates and screws to allow early motion. This also allow repair of the associated soft tissue injuries
(5, 13)
. It has
the disadvantage that; it may require anterior and posterior approaches resultant
soft
tissue
(16)
, with
dissection
devascularization of the fragments
and (12)
,
which may delay union and increase
41
stiffness.
The
stable
fixation
allows
intensive early physiotherapy (12, 13). 1.14.3.2. Limited open reduction assisted with arthroscope to accurately reduce the articular surface and to treat the associated carpal and ligamental injuries, followed by internal fixation or dynamic external fixation (12). 1.14.3.3. Open reduction and dynamic external fixator to maintain reduction and allow early motion (6, 15, and 18). 1.14.3.4. Open comminuted anatomical
reduction
for
fractures, restoration
severely to
of
obtain the
joint
followed by combined internal fixation (to maintain the reduction) and dynamic external fixator to neutralize the forces across
the
radio-carpal
joint
during
exercises and healing (13). 1.15.
Evaluation of outcome:
These include radiological, objective functional and subjective functional evaluation (6).
42
1. Evaluation of the radiological anatomy: in addition to the classification of the fracture; four other measures are accepted in the anatomic evaluation of Colles’ fracture
(6, 17, and 23)
. Bone density is also assessed,
because the security of fixation and, for a given impact, the severity of damage is partly determined by the quality of bone (24). a.
The volar angle: also known as anterior or palmar angle. The angle is defined as the palmar slope of the distal end of the radius; and averages 5 to 14 degrees (5, 6, 9, 13, and .17)
. The angle is considered as positive
(+ive) when it is anterior to the line that is perpendicular to long axis of the radius and described as volar angle. When the angle is posterior to this line it considered as negative (-ive) and referred to as dorsal angle (17). b.
The radial angle: also known as lateral angle. Is defined as the angle made between the line drawn from the tip of the styloid process of the radius to the ulnar corner of the articular surface of the distal radius; with the line that is perpendicular to the axis of
43
the radius (6, 17). It averages 22 to 23 degrees 17)
c.
(5, 6, 9, and
. The radial height: is defined as the distance
between the two parallel lines; one drawn at the tip of the radial styloid and the other at the distal surface of ulnar head. It normally averages 11 to 13 mm (6, 17). d.
The radial width:
is measured as the distance
between the longitudinal axis of the radius and the most lateral tip of the radial styloid. It is usually compared to the other wrist (6, 17). e.
The dorsal shift: is defined as the distance between the most dorsal point of the distal radius and the longitudinal axis of the radius
(17)
. It is usually
compared with other wrist (17). 2. Functional evaluation: a.
Objective
evaluation:
these
are
functional
parameters that can be expressed in degrees, millimeters or percentage: i.
The range of movement at the wrist (6, 24).
ii.
The strength and power of the grip (6, 24).
iii.
Stiffness of the fingers.
44
iv.
Presence of complications (e.g. deformity) (6)
b.
.
Subjective evaluation (6): i.
Presence and severity of pain in relation to movement of the wrist (6, 24).
ii.
Degree of involvement in the daily activities (6).
1.16.
Complications:
1.16.1.
Early complications (5, 6, 9):
1.16.1.1. Distal
radio-ulnar
subluxation
or
dislocation. 1.16.1.2. Median nerve stretch, contusion or compression (5, 26). 1.16.1.3. Acute carpal tunnel syndrome (25). 1.16.1.4. Post-traumatic
swelling
and
compartment syndrome (very rare) (26). 1.16.1.5. Tendons
damage
(e.g.
Extensor
Pollicis Longus). 1.16.1.6. Pain dysfunction syndrome. 1.16.1.7. Reflex sympathetic osteo-dystrophy (Sudeck’s atrophy) (26). 1.16.1.8. Associated carpal injury.
45
1.16.2.
Intermediate and late complications:
1.16.2.1. Malunion and deformity (5, 26). 1.16.2.2. Delayed union and non-union (rare) (26)
.
1.16.2.3. Distal radio-ulnar and radio-carpal arthrosis. 1.16.2.4. Stiffness of the hand or stiffness of hand and shoulder
(26)
(shoulder-hand
syndrome) (5). 1.16.2.5. Late median nerve compression. 1.16.2.6. Tendons
adhesions
in
the
flexor
compartment. 1.16.2.7. Extensor Pollicis Longus rupture (5, 26).
46
Objectives
47
Objectives The objective of this study is to evaluate the following in relation to Colle’s fracture:
1. Pattern of clinical presentation. 2. Radiological features. 3. Outcome of conservative management.
48
Chapter Two
Patients and methods
49
2. Patients and Methods 2.1. Nature of the study: Hospital based prospective, randomized study. 2.2. Study area: The study was carried in Orthopaedic Casuality of Khartoum Teaching Hospital (K.T.H). 2.3. Study population: Patients attending the casuality in the period between 1st of March 2002 to 1st of March 2003 with Colle’s fracture. 2.4. Duration of the study: The period between 1st of March 2002 and 1st of March 2003. 2.5. Case definition:
50
Patients with fractures of the distal radius; within the terminal 2.5 cm of the radio-carpal joint with posterior displacement; (if displaced). All patients were diagnosed on the basis of the posteroanterior and lateral radiographs. 2.6. Inclusion criteria: All patients with Colle’s fractures in which the fracture position was acceptable and stable, either initially or after reduction. When articular involvement existed; the gap or step was less than 2 mm with no articular comminution. No age group was excluded; as long as they fulfilled the radiological criteria. 2.7. Exclusion criteria: Patients with severe intra-articular comminution, articular involvement (Either gap or step) of more than 2 mm, extra-articular comminution that rendered the fracture unstable or patients with unacceptable reduction that failed to improve by remanipulation were excluded from this study. 2.8. Study sample: The whole sample size was 234 patients. 23 patients were lost to follow up in the referred clinic before removal of the plaster; these were completely excluded from the study. Additional 109 patients disappeared after removal of the plaster (They did not attend for final assessment after physiotherapy). This last group
51
was excluded from the final analysis, but included in the analysis of the demographic features, such as distribution between males and females. 2.9. Number of cases available for final assessment: Only the remaining 102 patients who were followed up to the end of the period of physiotherapy were included in the final assessment. 2.10.
The protocol of management:
All patients were initially seen by the registrars or the houseofficers, but the diagnosis was confirmed by the registrars. Reductions were done either by the registrar or the houseofficers Supervised by registrars. Undisplaced fractures were immobilized without manipulation. Correction of displacement was achieved by manipulative reduction. Traction was applied along the axis of the forearm until the fracture disimpacted. The fracture thereafter was manipulated using the thenar grip and direct pressure on posterolateral aspect of the distal fragment. Reduction was ensured clinically by apparent correction of the deformity, palpation of the step at the posterior aspect of the distal radius and restoration of the level of the radial styloid. Finally, a well padded below elbow cast in slight flexion and ulnar deviation of the wrist was applied. The plaster ended distally just short of the distal palmar crease; to allow
52
exercise of fingers. Proximally it allowed free flexion of the elbow. The position of the fracture was then checked by antero-posterior and lateral x-ray films. The arm was elevated in a sling or collar and cuff for the first week. Active and assisted movement of the digits, elbow and shoulder was encouraged. The way the patient exercises his fingers was demonstrated to him and told that he needs to do it very frequently. Patients were admitted if there was undue swelling or in presence of other injuries requiring admission. The patient was warned to present immediately if there was pain out of proportion, distal swelling or numbness in the fingers. 2.10.1. 2.10.1.1.
Evaluation: Radiographic evaluation:
By using the following measures (Table 1): 1. The volar angle: The angle between the line that is perpendicular to long axis of the radius and the radial axis was considered as angle zero. The forward angulation is positive. The normal volar angle ranges between (+5) and (+11) degrees. The limits for acceptable loss are (-5) degrees. Volar angles that are less than ([-5] degrees) are the worse (score of zero point), the range between (-5) and zero given the score of (1 point), between zero and (+5) given the score of (2 points) and score of 3 points for angles more than (+5) degrees.
53
2. The radial angle. The normal radial angle is up to 23 degrees. Angles between zero and 5 degrees is given the score of (zero point), between 6 and 10 degrees given the score of (1 point), between 11 and 15 degrees given the score of (2 points) and angles more than 15 degrees were give the score of (3 points) (Table 1). 3. The radial height: The normal radial height is very controversial. It ranges between 5 to 12 mm. Radial height in the range between that is leveled with the distal surface of the ulnar head i.e. parallel to the distal surface of ulnar head (zero mm) and 3 mm was considered as poor and given the score of zero point. Height in the range between 4 to 7 mm inclusive was considered as score of (1 point), height in the range between 7 to 10 mm was considered as score of (2 points) and any height more than this was given the score of (3 points). 4. The presence of any of the following complications are used in the classification of the fracture but not the assessment: a. Fracture of ulnar styloid and radio-ulnar diastasis.
54
b. Associated
carpal
and
metacarpal
fracture. c. Presence of comminution. d. Articular involvement. e. Presence of osteoporosis. 2.10.1.2.
Subjective functional evaluation:
This evaluation includes assessment of pain, degree of involvement in previous activities and satisfaction. Pain that was continuous or with any movement was considered the poorest and given the score (zero point), pain that was experienced beyond the limited range of movement was considered moderate (score of 1 point) and when there was no pain was considered as good (score of 2 points) (Table 2). The patient were directly asked about the deficit in the wrist and hand function according to his or her activities; and whether he or she can return to his or her previous activities without modification (3 points), with modification (2 points) or he or she needs to change the activities (zero point). The patient’s satisfaction about the outcome was also considered; and whether he or she thinks that both reduction and gain of function were satisfactory. If the patient was satisfied; he was encouraged to tell whether the satisfaction was because his hand and wrist were very much near normal (3
55
points) or satisfied but thinks it was different and far less than the normal (2 points) or completely unsatisfied (zero point) (Table 2). 2.10.1.3.
Objective functional evaluation:
The unaffected wrist and hand were used as reference.
In
addition to presence of complications; any restriction of movement at the wrist, weakness of grip power or stiffness of the fingers was assessed in comparison to the contra-lateral wrist and hand. The range of movement at the wrist was measured in degrees and expressed as percentage of the flexion arch of the unaffected wrist. When the fracture was bilateral, the mean values were considered as reference. The degree of stiffness was assessed by modified Sarmiento score 1980. Loss of more than 50% (e.g. 45 degrees of flexion) were considered as severe, these are given the score (zero point). Loss between 50% and 80% (i.e. 45 – 60 degrees of flexion arch) were considered as moderate and given score (1 point). Above 80% was considered good and given score (2 points) (Table 3). In the assessment of finger stiffness: if the stiff finger can flex about 80% of flexion arch (i.e. only touch the palm of the hand at the thenar eminence); the stiffness were considered as mild (score of 2 points). If the fingers can not be flexed more than approximately 50% of flexion arch (i.e. the line parallel to the
56
plane of the palm) it was considered as severe and given the score (zero point); otherwise (i.e. 50 – 80%) is moderate (score of 1 point) (Table 3). The grip power was assessed by using sphygmomanometer. If it was more than 70 % of the unaffected hand; it was considered as good (score of 1 point), otherwise it is poor (score of zero point). (Table 3). In evaluation of the results: the total number of points is 16. The range between (zero to 4 points) is considered as poor, between (5 to 8 points) inclusive; was considered as fair, (9 to 12 points) inclusive; was considered as good and (13 to 16 points) inclusive; was considered as excellent. 2.10.2.
Follow up at the referred clinic:
The patient was seen at the nearest fracture referred clinic to reassess the adequacy of reduction and immobilization and Consultant opinion was sought. In addition; all mistakes in the plaster technique that could have been missed at the time of the plaster application were corrected. Swelling of the fingers or presence of numbness in distribution of the median nerve were sought; and managed if present. If they were due to tightness or constrictions in the plaster; the plaster was either changed or the constrictions were released. Radiographs were taken to ensure that
57
no displacement has occurred and the position was still acceptable. If reduction was lost, the fracture was remanipulated. Patients were next seen after a week to see if there was displacement that requires manipulation. In the third visit; at the 3rd week; check radiographs for final assessment for possibility of displacement were taken, the plaster was examined for any new defects that could have arisen and may reduce the adequacy of immobilization such as slackening of the plaster or weakness and softening at certain areas. Slackening was treated by changing the plaster and softening by plaster repair. If there were need for manipulation it was done. The plaster was removed at six weeks and healing; on clinical and radiographic grounds; was carefully assessed. If healing was not adequate, the plaster was applied for additional two weeks. Patients were then sent for physiotherapy for another 6 weeks and advised to return to their previous activities avoiding heavy loads. Final assessment was made at three months. A comparison was made between the results at removal of the plaster and after physiotherapy with regard to the restriction of movement at the wrist, finger stiffness, power of the grip and the presence of pain in association with wrist movement. Any limitation in hand function and disability was noticed. 2.10.3.
Consent:
58
Verbal consent was taken from the patients who were told that they will be included in the study as long as they meet the criteria of conservative management. If he or she did not meet these criteria; they were excluded. 2.10.4.
Questionnaire: (See appendix)
2.10.5.
Data analysis:
The data was collected in questionnaire; and entered into Microsoft access tables. The data was subjected to statistical analysis in Scientific Package for Social and Scientific Studies (SPSS). Frequencies, percentages and cross tabulation were sent to Microsoft word for construction of tables and Microsoft excel where charts were computed. The interpretation of the results was done with help of Microsoft excel and access and again sent to SPSS for statistical analysis.
59
Chapter Three
Results
1. Results 1.1. Demographic characteristics of people in the study: 1.1.1.
Sex characteristic of the sample:
124 patients (60.8%) were females; the remaining 80 patients (39.2%) were males (Table 4) (Fig. 1).
60
1.1.2.
Age characteristic of the sample:
52 patients (33.2%) in age group 40 to 50 years. 122 patients (57.8%) in age groups 30 to 50 years (Table 5) (Fig. 2). 1.1.3.
Occupation:
Almost half of patients were housewives (96 patients with percentage 47%). 20 patients (9.5%) were students and only 16 patients (7.6%) were manual workers. The rest were distributed over a wide variety of other occupations. 1.2. Assessment at initial presentation at casuality: 1.2.1.
Mechanism of injury:
The mechanism of injury was a simple fall on the out stretched hand during rising from a sitting position or during walking in 104 (49.3%) patients. In 41 patients (19%) Colles’ fracture was the result of road traffic accident. 29 patients (13.7%) had fallen from a height. 16 patients (7.6%) had sports injury (Table 6) (Fig. 3). 1.2.2.
The delay between injury and presentation:
155 patients (73.5%) presented immediately after the fracture (within the first 24 hrs). 34 patients (16.1%) presented within the first week after the first 24 hours. 22 patients (10.4%) presented on the second week and after (Table 6). 1.2.3.
Involvement of the dominant hand:
61
The dominant hand was fractured in 109 patients (51.6%). 99 patients (46.9%) were the non-dominant hand and the remaining 3 patients (1.4%) were bilateral (Table 6). 1.2.4.
The severity of the initial deformity:
46 patients (21.8%) presented with severe dinner fork deformity. 98 patients (46.4%) with mild or no deformities, the remainder 67 patients (31.8%) had moderate deformity (Table 6). 1.2.5.
Presence of wound communicating with the
fracture: All fractures were closed except in 2 patients (0.05%). Another 2 patients (0.05%) patients had abrasion in volar aspect of the writ and were treated as closed fractures after dressing of the wound under cover of antibiotics (Table 6). 1.2.6.
Other injuries: None of the patients under study had vascular injury or
manifestation of nerve injury at presentation. 16 patients (7.6%) had multiple injuries. 7 patients (3.3%) had only abrasion on the forehead or the ipsilateral elbow. 3 patients (1.4%) had associated metacarpal or phalangeal fracture. Only one had the tendon of Extensor Pollicis Longus tendon ruptured (Table 7) (Fig. 4). 1.3. The presence of previous wrist injury:
62
Only 4 patients (1.9%) had previous wrist injury. Of these only one had Colles’ fracture (Table 8). 1.4. The presence of previous medical disease affecting bone mass: 86.3% of patients (176) had no previous medical disease. 5.6% (12 patients) were asthmatics (Table 8). 1.5. The use of drugs that may affect bone mass: Most of patients received no drugs that were known to affect the bone mass. 5.6% were asthmatics and received short course of steroids at emergencies. 5 patients (2%) were on contraceptives. 1.6. The radiological appearance: 1.6.1.
Classification of the fracture:
49 patients (23.2%) were A.O class A1 (extra-articular without displacement). 95 patients (45.0%) were A2 (extra-articular with posterior displacement). 28 patients (13.3%) were A3 (comminuted extra-articular). 35 patients (16.6%) were B1 (Undisplaced partial intra-articular). 4 patients (1.9%) were B3 (partial intra-articular with extra-articular comminution). 1.6.2.
The volar angle:
56 patients (26.5%) had loss of more than 15 degrees of the volar angle (i.e. less than –10 degrees). 18 patients (8.5%) had lost between 10 to 15 degrees (i.e. less than -5 to –10). 42 patients
63
(19.9%) had volar angle between (i.e. -5 to zero). 69 patients (32.7%) had angles between zero and +5 degrees. The remaining 36 patients (17%) had angles of more than +5 degrees (Table 9) (Fig. 5). 1.6.3.
The radial angle:
8 patients (3.7%) had initial radial angle less than zero. 13 patients (6.1%) had angles between zero and 5 degrees. 9 patients (4.2%) had angles between 5 and 10 degrees. 61 patients (28.9%) had original angle between 10 to 15 degrees. 120 patients (56.8%) had an angle of more than 15 degrees (Table 10) (Fig. 6). 1.6.4.
The radial height:
The original radial height was less than 4 mm in 59 patients (27.9%). 112 patients had initial radial height between 4 to 7 mm. the remaining 84 patients (39.8%) had initial radial height of more than 7 mm (Table 11 ) (Fig. 7 ). 1.6.5.
Presence of comminution:
153 patients (72.5%) had no comminution. 32 patients (15.2%) had mild comminution. 26 (12.3%) had severe extra-articular comminution (Table 12) (Fig. 8). 1.6.6.
Presence of osteoporosis:
65 patients (30%) had mild osteoporosis. 146 patients (69.2%) had no osteoporosis (Table1 2) and (Fig. 8).
64
1.6.7.
Articular involvement:
39 patients (18.5%) had undisplaced partial intra-articular fractures (Table 12) (Fig. 8). 1.6.8.
Other wrist injuries:
1.6.8.1.
Fracture of ulnar styloid:
42 patients (19.9%) had associated fracture of the ulnar styloid (Table 12) (Fig. 8). 1.6.8.2.
Presence of radio-ulnar diastasis:
30 patients (14.2%) had distal radio-ulnar diastasis (Table 12) (Fig.8). 1.6.8.3.
Presence of carpal and metacarpal bones
fractures: Only 2 patients had associated metacarpal bone fracture (Table 12) (Fig. 8). 1.7. Management and follow up: 1.7.1.
Necessity of reduction:
The position of the fracture was either undisplaced or acceptable in 61 patients (28.9%); and the fracture was not manipulated (Table 13). 1.7.2.
Accuracy of reduction:
The position of the fracture was almost anatomical in 4 patients (the fracture was only a crack).
65
1.7.3.
Admission:
8 patients (3.8%) required admission because of associated other injuries. All other patients were discharged after check x-rays had confirmed the position of the fracture; none required admission. (Table 13). 1.7.4.
The first visit in the referred clinic:
When the patients were seen at the end of the first week, 45 patients (21.3%) were found to have swelling of the fingers. 41 patients (91.1% of those who had swelling) the cause was tight constrictions in the plaster; 4 patients (9.7%) because they did not keep their arms elevated. In 9 patients (4.2%) it was necessary to change the plaster. The position of the fracture was still acceptable in all these patients; and none of them required remanipulation. None of these patients had symptoms of median nerve (Table 13). 1.7.5.
The second visit in the referred clinic:
When these patients were seen at the end of the 3rd week, 17 patients (8.1%) had new defects such as softening of the plaster at certain areas; in 8 patients (47%) there was need to change the plaster. 5 of all patients (2.4%) the fracture was re-displaced and re-manipulated. None of the patients had a complaint suggestive of compression of median nerve. 1.8. Assessment at removal of the plaster:
66
1.8.1.
Compliance to doctor instructions:
Only 22 patients (10.4%) were either not performing exercises or the exercises were inadequate (Table 14). 1.8.2.
Clinical and radiological union:
6 patients (5.6%) had poor clinical union (tenderness at fracture site) they required additional immobilization for 2 weeks. 22 patients (21.6%) did no show callus formation but had good union on clinical grounds (Table 15). 1.8.3.
Presence of the complications:
There were no complications in 79 patients (77.4%). 19 patients (18.6%) had residual deformity. In 2 patients (2%) there was numbness in the distribution of median nerve; they were managed expectedly. One patient had a cut tendon of Extensor Pollicis Longus due a sharp object. One patient with fracture of the second metacarpal healed with excessive callus (Table 16) (Fig. 9). 1.8.4.
Evaluation of the range of wrist and fingers
movements: 1.8.4.1. Wrist flexion: 54 patients (52.9%) had initial wrist flexion of less than 45 degrees. 24 patients (23.5%) had flexion between 45 and 60 degrees. The remaining 24 patients (23.5%) had flexion of more than 60 degrees (Table 17) (Fig. 10).
67
1.8.4.2. Wrist extension: 74 patients (72.5%) had less than 45 degrees of wrist flexion at removal of the plaster. 12 patients (11.7%) had extension between 45 and 60 degrees. 16 patients (15.6%) had extension of more than 60 degrees (Table 18) (Fig. 11). 1.8.4.3. Ulnar deviation: 10 patients (9.8%) had ulnar deviation of less than 10 degrees. 38 patients (37.2%) had deviation between 10 to 20 degrees. 54 patients (52.9%) had deviation of more than 30 degrees (Table 19) (Fig. 12). 1.8.4.4.
Radial deviation:
50 patients (49%) had less than 5 degrees of radial deviation at removal of plaster. 40 patients (39.2%) had radial deviation between 5 to 15 degrees and only 12 (11.8%) patients had radial deviation of more than 15 degrees (Table 20) (Fig. 13). 1.8.4.5. Supination: 68 patients had supination of less than 45 degrees at removal of plaster. 12 patients (11.7%) between 45 and 60 degrees. 22 patients (21.5%) had supination more than 60 degrees (Table 21) (Fig. 14). 1.8.4.6. Pronation: 32 patients (31.3%) had pronation less 45 degrees. 16 patients (15.6%) had pronation between 45 to 60 degrees. The remaining 54
68
patients (52.9%) had pronation more than 60 degrees (Table 22) (Fig.15). 1.8.5.
Evaluation of grip strength:
The power of the grip was poor in 56 patients (54.9%). 46 patients (45.1%) had good grip power at removal of the plaster (Table 23) and (Fig. 16). 1.8.6.
Evaluation of finger stiffness:
50 patients (49%) had mild or no initial stiffness. 34 patients (33.3%) had moderate stiffness. 18 patients (17.6%) had severe stiffness (Table 24) and (Fig. 17). 1.8.7.
Evaluation of pain:
In 86 patients (84.3%) there was pain only when the range of movement that is allowed by stiffness was exceeded, in 16 patients (15.7%) the pain had been with any movement even within the possible range of movement (Table 25) (Fig. 18). 1.9. Final assessment after physiotherapy: 1.9.1.
Evaluation of improvements in range of wrist: 1.9.1.1. Flexion:
None had flexion less than 45 degrees. 24 patients (23.5%) had flexion range between 45 and 60 degrees. 78 patients (76.4%) had wrist flexion of more than 60 degree (Table 17) (Fig. 10). 1.9.1.2. Extension:
69
12 patients (11.7%) had extension range below 45 degrees. 21 patients (20.5%) had range between 45 and 60 degrees. 69 patients (67.6%) had extension of more than 60 degrees (Table 18) (Fig. 11). 1.9.1.3. Ulnar deviation: None had ulnar deviation of less than 20 degrees. Only 15 patients (14.7%) had ulnar deviation between than 20 to 30 degrees. The rest 87 patients (85.2%) had ulnar deviation of more than 30 degrees (Table 19) (Fig. 12). 1.9.1.4. Radial deviation: 2 patients (2%) had radial deviation less than 5 degrees. 70 patients (68.6%) had deviation between 5 to 15 degrees. The remaining 30 patients (29.4%) had deviation of more than 15 degrees (Table 20) (Fig. 13). 1.9.1.5. Supination: 29 patients (28.4%) had final supination of less than 45 degrees. 36 patients (35.2%) had supination between 45 and 60 degrees. The rest (36.2%) had supination of more than 60 degrees (Table 21) (Fig. 14). 1.9.1.6. Pronation: 31 patients (30.3%) had pronation of less than 45 degrees after physiotherapy. 16 patients (15.6%) had pronation between 45 and
70
60 degrees. 55 patients (53.9%) had range more than 60 degrees (Table 22) (Fig. 15). 1.9.2.
Evaluation of finger stiffness:
Only 4 patients (3.9%) had residual stiffness of the fingers after physiotherapy (Table 23) (Fig. 16). 1.9.3.
Evaluation of improvement in power of the grip:
The improvement in power of the grip was good in 97 patients (95.1%), and poor in the remainder 5 patients (4.9%). 1.9.4.
evaluation of improvement in finger stiffness:
The improvement of the stiffness of the fingers was good in 40 (%) of the patients, poor in the remainder 50 (%) patients (Table 24) (Fig.17). 1.9.5.
Evaluation of the improvement in wrist pain:
There was no pain in most of patients with any movement in 98 patients (96.1%). 10 patients (9.8%) had pain only at the extreme of movement when the residual stiffness is exceeded (Table 25) and (Fig.18). 1.9.6.
Patient satisfaction:
64 patients (62.7%) were satisfied and believe that their wrist looks very much as the normal. 32 patients (31.2%) were partially satisfied and they believe that their wrist is not as normal as the other wrist and hand. The remainder 6 patients (5.6%) were
71
unsatisfied either because they think that their wrists and hands were not functioning well or there is unacceptable deformity (Table 26) and (Fig. 19). 1.9.7.
The involvement in activities and work:
Most of patients required temporary modification in their activities. Only 12 patients (11.8%) were able to return to their full previous activities (Table 27).
72
Table (1): The system for evaluation of radiological anatomy Volar angle
Radial angle
Radial
Score
(In Degrees)
(In Degrees)
height (mm)
(Points)
Less than (-5)
Less than 5
Less than 3
Zero
(-5) to – Zero
6 to 10
4 to 7
1
Zero to (+5)
11 to 15
7 to 10
2
(+5) to (+10)
15 to 20
More than 10 3
More than10
More than 20
4
(modified from Sarmiento et al. 1980)
Table (2): The system for evaluation of the subjective functional outcome. Pain
Satisfaction
Return to activities
Score (Points)
No pain.
Satisfied
Full activities
4
Beyond the limits
Less satisfied
With modifications
2
Within the limits
Unsatisfied
Require change
Zero
73
(modified from Sarmiento et al. 1980)
Table (3):
The system for evaluation of objective functional outcome.
F.E.S.P
R.
U.
Finger
Grip
stiffness
power Poor
< 45
< 10
< 20
Severe
45 – 60
10 – 15
20 – 30
Moderate
> 60
> 15
> 30
mild
Score (Points)
Zero 1
good
2
F.E.S.P stands for flexion, extension, supination and pronation respectively; R. for radial and U. for ulnar deviation. (Modified from Sarmiento et al. 1980).
74
Table (4): Sex distribution for 211 patients with Colles’ fracture presented to K.T.H. Sex
Frequency
Percent
Male.
83
39.2%
Female.
128
60.8%
Total.
211
100.0%
Table (5): Age distribution for 211 patients with Colles’ fracture presented to K.T.H. Age groups
Percent
Frequency
Less than 20 years
13.3 %
28
20 to 29 years.
4.3 %
9
30 to 39 years.
24.6 %
52
40 to 49 years.
33.2 %
70
50 to 59 years.
15.2 %
32
75
60 years and above. Total
9.5 %
20
100.0%
211
Table (6): Clinical presentation for 211 patients with Colles’ fracture presented to K.T.H. At presentation
Frequency
Percent
Mechanism of
On Out stretched hand.
104
49.3 %
injury.
Fallen from Height.
29
13.7 %
Sport injury.
16
7.6 %
Direct blow.
21
10.0 %
R.T. Accident.
41
19.4 %
Right wrist.
109
51.6 %
Left wrist.
99
46.9 %
Both wrists.
3
1.4 %
Affected side
Time of
The same day.
155
73.5 %
presentation
Within a week.
34
16.1 %
More than a week.
22
10.4 %
Severity of
Mild or no deformity.
156
78.2 %
deformity
Marked deformity.
46
21.8 %
Closed or Open
Closed fracture.
209
99.05 %
76
Open fracture.
2
0.05 %
Table (7):
Associated injuries in 211 patients with Colles’ fracture presented to K.T.H.
Other Injuries
Frequency
Percent
No other injuries.
178
84.3 %
Multiple injuries.
16
7.6 %
Head bruises.
7
3.3 %
Head injury.
6
2.8 %
Metacarpal & phalangeal Fractures
3
1.4 %
Cut Extensor pollicis
1
.004 %
Nerve injury
0
0%
Vascular injury
0
0%
77
Table (8):
The past medical history for 211 patients with Colles’ fracture presented to K.T.H.
Disease
Frequency
Percent
176
86.3 %
Previous wrist injury.
4
1.9
Bronchial Asthma.
12
5.6 %
D.M & HTN.
4
2.0 %
HTN & Cardiac.
1
2.0 %
Hypertension.
4
2.0 %
No disease.
78
Table (9):
Volar angle (in degrees) on lateral films of the wrist before and after reduction for 211 patients with Colles’ fracture presented to K.T.H.
Volar Angle
Before reduction
After reduction
(degrees)
Frequency
Percent
Frequency
Percent
Less (-10).
56
26.5 %
zero
0.0%
(-10) to (-5).
18
8.5 %
4
1.9 %
(-5) to Zero.
42
19.9 %
62
29.3 %
Zero to (+5).
69
32.7 %
89
42.1 %
More than (+5).
36
17.0 %
56
26.5 %
Total
211
100.0%
211
100.0%
79
Table (10):
Radial Angle (in degrees) on lateral films of the wrist before and after reduction for 211 patients with Colles’ fracture presented to K.T.H.
Radial Angle degrees)
Before reduction
After reduction
Frequency
Percent
Frequency
Percent
Less than zero.
8
3.7 %
None
0%
0 to 5.
13
6.1 %
4
1.9 %
5 to 10.
9
4.2 %
None
0%
10 to 15.
61
28.9 %
65
30.8%
More than 15.
120
56.8 %
142
67.2 %
Total
211
100.0%
211
100.0%
80
Table (11):
The height of the radial styloid in mm for 211 patients with Colles’ fracture presented to K.T.H.
Radial height (mm)
Before reduction
After reduction
Frequency
Percent
Frequency
Percent
Less than 4.
59
27.9%
20
9.4 %
4 to 7.
112
53.1%
107
50.7%
More than 7.
40
19.0%
84
39.8 %
Total
211
100.0%
211
100.0%
81
Table (12):
Presence of associated other radiological features in 211 patients with Colles’ fracture presenting to K.T.H.
Associated radiological features
Frequency
Percent
Osteoporosis.
65
30.8%
Fracture of Ulnar styloid
42
19.9%
Articular Involvement
39
18.5%
Mild comminution.
32
15.2%
Severe comminution.
26
12.3%
Radio-ulnar diastasis
30
14.2%
Metacarpal bones fractures
2
0.9%
Carpal bones fractures
0
0.0%
82
Table (13):
Management at the casuality and the first visit in the referred clinic for 211 patients with Colles’ fracture presented to K.T.H.
Frequency
Percent
150
71.1%
Admission required.
8
3.8%
Presence of swelling in 1st visit.
45
21.3%
Change of Plaster in 1st visit.
9
4.2%
Symptoms of median nerve
0
0.0%
Remanipulation in 1st visit.
0
0.0%
Reduction was necessary.
83
Table (14): Compliance to physiotherapy at 3 weeks (in the 3rd visit) and 6 weeks (at removal of plaster) in 211 patients with Colles’ fracture presented to K.T.H.
Physiotherapy
Frequency
Percent
Compliance at 3 weeks.
98
46.4%
Compliance at 6 weeks.
189
89.5%
Table (15):
Clinical and radiological union in 102 patients with Colles’ fracture presented to K.T.H. Union
Frequency
Percent
Good clinical Union.
96
94.1%
Good Radiological Union.
80
78.4%
84
Table (16):
Complications in 102 patients with Colles’ fracture presented to K.T.H. Complications
Frequency
Percent
No complications.
79
77.4%
Deformity.
19
18.6%
Median nerve symptoms.
2
2%
Cut Pollicis Longus.
1
0.9%
Excessive callus (metacarpal #).
1
0.9%
85
Table (17):
Wrist Flexion (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Wrist Flexion
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
Less than 45
54
52.9%
0
0.0%
45 - 60
24
23.5%
24
23.5%
More than 60
24
23.5%
78
76.4%
Total
102
100.0%
102
100.0%
86
Table (18):
Wrist Extension (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Wrist Extension
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
20 - 30
74
72.54%
12
11.7%
45 - 60
12
11.7%
21
20.5%
More than 60
16
15.6%
69
67.6%
Total
102
100.0%
102
100.0%
87
Table (19):
Ulnar Deviation of the Wrist (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Ulnar Deviation
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
10
9.8%
0
0.0%
38
37.2%
15
14.7%
More than 30
54
52.9%
87
85.2%
Total
102
100.0%
102
100.0%
Less than 10 20 – 30
88
Table (20):
Radial deviation at wrist (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Radial deviation
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
Less than 10
50
49%
2
2%
10 to 15
40
39.2%
70
68.6%
More than 15
12
12.7%
30
29.4%
Total
102
100.0%
102
100.0%
89
Table (21):
Supination (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Supination
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
Less than 45
68
66.6%
29
28.4%
45 - 50
12
11.7%
36
35.2%
More than 60
22
21.5%
37
36.2%
Total
102
100.0%
102
100.0%
90
Table (22):
Pronation (in degrees) before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Pronation
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
Less than 45
32
31.3%
0
0.0%
45 – 60
16
15.6%
12
11.7%
More than 60
54
52.9%
80
78.4%
Total
102
100.0%
102
100.0%
91
Table (23): Grip Strength before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Grip Strength
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
Good.
46
45.1%
92
90.1%
Poor.
56
54.9%
10
9%
Total
102
100.0%
102
100.0%
Table (24): Finger Stiffness before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Finger Stiffness
Before physiotherapy Frequency
Percent
After physiotherapy Frequency
Percent
92
Mild or no stiffness.
50
49.0%
98
96.1%
Moderate.
34
33.3%
4
3.9%
Severe.
18
17.6%
0
0.0%
Total
102
100.0%
102
100.0%
Table (25):
Presence of pain before and after physiotherapy in 102 patients with Colles’ fracture presented to K.T.H.
Pain
Before physiotherapy
After physiotherapy
Frequency
Percent
Frequency
Percent
No pain
0
0.0%
92
90.2%
Within the range.
16
15.7%
0
0.0%
Beyond the range.
86
84.3%
10
9.8%
Total
102
100.0%
102
100.0%
93
Table (26):
Satisfaction in 102 patients with Colles’ fracture presented to K.T.H. Satisfaction
Frequency
Percent
Satisfied.
64
62.7%
Not fully satisfied.
32
31.4%
Not satisfied.
6
5.9%
Table (27):
The extend of involvement in previous activities in 102 patients with Colles’ fracture presented to K.T.H. Return to Activities Fully involved.
Frequency
Percent
12
11.8%
94
With modification.
90
88.2%
Require change.
0
0.0%
Table (28):
The the results of objective and subjective functional outcome in 102 patients with Colles’ fracture presented to K.T.H.
Excellent
Fair
Poor Percentage
Frequency
Percentage
Frequency
Percentage
Frequency
Percentage
result
Frequency
Functional
Good
Objective 45
43.7%
27
26.2%
22
21.4%
8
7.8%
52
50.5%
40
38.8%
10
9.7%
0
0%
results Subjective results
95
Figure (1): Sex distribution in 211 patients with Colle's fracture presented to to K
.T.H.
60.8% 70.0% 60.0% 50.0%
39.2%
40.0% 30.0%
Female . 20.0% 10.0%
Male. 0.0%
Male.
Female.
96
Figure (2): Age distribution in 211 patients with Colle's fracture presented to K
.T.H.
33.2% 35.0%
30.0%
24.6% 25.0%
15.2%
20.0%
13.3% 15.0%
9.5% 10.0%
4.3%
5.0%
0.0%
Less than 20 years
20 to 29 years .
30 to 39 years .
40 to 49 years .
50 to 59 years .
60 years and above .
97
Figure (3): Mechanism of injury in
211 patients with Colle's fracture presented to to K
.T.H
49.3% 50.0% 40.0% 30.0%
19.4% 10.0%
20.0%
13.7% 7.6%
10.0% 0.0%
On Out stretched hand. Sport injury. R.T. Accident.
Fallen from Height. Direct blow.
98
Figure (4): Associated injuries in 211 patients with Colle's fracture presented to to K
.T.H
84.3% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0%
0.0%
0.0%
0.0%
1.4%
2.8%
3.3%
7.6%
10.0% 0.0%
No other injuries .
Multiple injuries .
Head bruises .
Head injury .
Metacarpal
Cut Extensor pollicis
Nerve injury
Vascular injury
99
Figure (5): volar angle (in degrees ) before and after reduction in presented to to K .T.H.
211 patients with Colle's fracture
42.1%
45.0% 40.0%
32.7%
35.0%
29.3% 30.0%
26.5%
26.5%
25.0%
19.9% 17.0%
20.0% 15.0%
8.5%
10.0% 5.0%
0.0%
1.9%
Less (-10).
(-10) to (-5).
0.0%
(-5) to Zero.
Before reduction
Zero to (+5).
More than(+5).
Af
100
Figure (6): Radial angle (in degrees ) before and after reduction in presented to to K .T.H.
211 patients with Colle's fracture
67.2%
70.0%
56.8%
60.0%
50.0%
40.0%
30.8% 28.9%
30.0%
20.0%
10.0%
0.0%
3.7%
1.9% 6.1%
0.0% 4.2%
0.0%
Less than zero.
0 to 5.
5 to 10.
Before reduction
10 to 15.
More than15.
101
Figure (7): Radial height (in mm ) before and after reduction in presented to to K .T.H.
211 patients with Colle's fracture
50.7% 53.1%
60.0%
50.0%
39.8%
40.0%
27.9% 30.0%
9.4% 20.0%
19.0% 10.0%
After reduction 0.0%
Less than 4.
Before reduction 4 to 7.
Before reduction
More than 7.
After reduction
102
figure (8): Other radiological finding in 211 patients with Colle's fracture presented to K
1%
13%
.T.H..
0% 27%
11%
14% 17% 17% Osteoporosis .
Fracture of Ulnar styloid
Articular Involvement
Mild comminution .
Severe comminution .
Radio-ulnar diastasis
Metacarpal bones fractures
Carpal
103
Figure (9):Complications in 211 patients with Colle's fracture presented to to K
2%
1%
.T.H.
1%
19%
77%
No complications .
Deformity .
Median nerve symptoms .
Cut Pollicis Longus .
Excessive callus (metacarpal # ).
104
Figure (10): Wrist flexion
(in degrees ) before and after physiotherapy in fracture presented to to K .T.H.
211 patients with Colle's
76.4% 80.0% 70.0%
52.9%
60.0% 50.0% 40.0%
23.5% 30.0%
23.5%
23.5%
20.0%
0.0% 10.0% 0.0%
Less than 45
45 - 60
Before physiotherapy
More than60
After p
105
Figure (11): Wrist extension
80.0%
(in degrees ) before and after physiotherapy in fracture presented to to K .T.H.
211 patients with Colle's
72.5% 67.6%
70.0% 60.0% 50.0% 40.0% 30.0%
20.5% 20.0%
11.7%
11.7%
15.6%
10.0% 0.0%
20 - 30
45 - 60
Before physiotherapy
More than60
Afte
106
Figure (12): Ulnar deviation (in degrees ) before and after physiotherapy .
85.2% 90.0% 80.0% 70.0%
52.9%
60.0% 50.0%
37.2%
40.0% 30.0%
14.7%
20.0% 10.0%
9.8% 0.0%
0.0%
Less than10
20 – 30
Before physiotherapy
More than30
Afte
107
Figure (13): Radial deviation of the wrist (in degrees ) before and after phyiotherapy in with Colle's fracture presented to to K .T.H.
211 patients
68.6% 70.0%
49.0%
60.0%
39.2%
50.0%
29.4%
40.0%
30.0%
12.7% 20.0%
2.0% 10.0%
0.0%
Less than 10
10 to 15
Before physiotherapy
More than 15
Afte
108
Figure (14): Supination (in degrees ) before and after physiotherapy in fracture presented to to K .T.H.
211 patients with Colle's
66.6% 70.0% 60.0% 50.0% 35.2% 40.0%
36.2%
28.4%
30.0%
21.5% 11.7%
20.0% 10.0% 0.0%
Less than45
45 - 50
Before physiotherapy
More than60
After
109
Figure (15): Pronation (in degrees ) before and after physiotherapy in fracture presented to to K .T.H.
211 patients with Colle's
78.4% 80.0% 70.0% 60.0%
52.9%
50.0% 40.0%
31.3%
30.0% 20.0% 10.0%
11.7%
15.6%
0.0%
0.0%
Less than 45
45 – 60
Before physiotherapy
More than 60
After
110
Figure (16): Grip strength before and after physiotherapy in presented to to K .T.H.
211 patients with Colle's fracture
90.1% 100.0% 90.0% 80.0% 70.0% 60.0%
54.9% 45.1%
50.0% 40.0% 30.0% 20.0% 0.9% 10.0% 0.0%
Before physiotherapy
Good.
After physiotherapy
111
Figure (17): Finger stiffness before and after physiotherapy
.
96.1% 100.0% 90.0% 80.0% 70.0% 49.0% 60.0% 50.0%
33.3%
40.0% 17.6%
30.0% 20.0%
3.9% 0.0%
10.0% 0.0%
Mild or no stiffness.
Moderate.
Before physiotherapy
Severe.
After
112
211 patients with Colle's fracture presented to Figure (18): Pain before and after physiotherapy in to K .T.H..
100.0%
90.2% 84.3%
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 15.7% 20.0%
9.8%
10.0%
0.0%
0.0%
0.0%
No pain
Beyond the range .
Before physiotherapy
Within the range.
After p
113
Figure (19): Satisfaction in 211 patients with Colle's fracture presented to to K
.T.H.
62.7%
31.4% 70.0% 60.0% 5.9% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Satisfied.
Not fully satisfied.
114
Chapter Four
Discussion, Conclusion and recommendations
115
Discussion Clinical Presentation Colles’ fracture constitutes one of the most frequent problems presenting to the Orthopaedic casuality. The demographic characteristics of patients with Colles’ fracture; more or less; are fairly typical. In this study it has been shown that the fracture was more common in women than in men with female to male ratio 3:2. It commonly affects middle aged women; with the highest incidence in the age group between 40 and 60 years (62.5% of females).
Females below 30 years are seldom
affected (3.1% of females) and women above 60 year are not frequently affected (12.5% of total women). These differences among females are probably due to the combination of the degree of osteoporosis and the degree of activities as follows: in the young age groups although these are active individuals, thus liable to frequent trauma, there was no osteoporosis; their bones are relatively strong; and minor trauma dose not cause the fracture. In the age group 40 to 60 years; there was relative osteoporosis in still active individuals (which means frequent trauma to weak bones), so that they are more likely to get the fracture. In the age group above 60 years fractures are infrequent because of reduced activities; although it’s expected to increase because of osteoporosis. 77.3% of females are housewives.
116
The study showed that incidence of the fracture with regard to males shows a higher incidence in age group below 20 years (33.7% of males) all are due to relatively severe trauma e.g. during football games or following road traffic accidents. Although the general outline of the demographic characteristics of patient with Colles’ fracture are similar to those mentioned in literature; some differences do exist: In literature; the fracture tend to occur in elderly women above 60 years (age group 60 to 69 years) and female to male ratio was 4:1 (Van Der Linden and Ericson 1981)(14, 17) while in this study the fracture was common in age between 50 to 60 years with female to male ratio only 3:2. In addition; when it occurs in young people; their age in literature was usually under 10 years (Jesse B. Jupiter and Boston 1991) (6). The result of this study was different from that in the literature in this aspect. All young patients are teenagers (age group below 20 years. All patients below the age of ten years; who were initially suspected to have “Juvenile Colles’ fracture” were found to have green stick fracture of the distal ulna. The mechanism producing the fracture was commonly a simple fall on the outstretched hand either from standing position or during walking in 49.3% of all patients with Colles’ fracture. In females; this constitutes the major cause of the fracture (68% of females). Males show no significant repeated mechanism except in the very young age groups
117
where almost all fractures are due to football sport and less frequently to road traffic accidents. This result is similar to study done by Jesse B. Jupiter and Boston 1991(5, 6) who described the mechanism as low energy trauma resulting from simple fall in elderly people, and high energy trauma, for example road traffic accident, in young age group. A careful look at the relationship between the age, sex and the mechanism producing the fracture; these patients can be divided into two groups: The first group was middle aged women following a fall on the outstretched hand (i.e. elderly with low energy trauma) and the second group was young males following either sport injury or road traffic accidents (i.e. young with severe mechanism of injury). The outcome of the fracture was very much related to these groups (will be mentioned latter). Most patients present immediately (in the same day of the trauma) after the fracture. 73.5% of patients with Colles’ fracture presented to the casuality in the first day following injury; the remainder of patients presented within the same week following injury or beyond. The later group who presented late gave one of two causes to explain their late presentation: the first was that the injury was very trivial as simple fall and there were only pain with no deformity; they did not think that a fracture could have occurred. The second cause for those patients who presented late was their belief in bone setters (12 patients which
118
re[represented 46.1% of those who presented late). The presentation of these two groups was very different. In the first group there was no detectable deformity, while in the second group all the 12 patients have marked deformity and swelling. The age of these patients was also characteristic. Most of these patients who presented late were in age group between 40 and 50 years (81.8% of patients who had presented late); this probably due the above mentioned causes of the combination of simple mechanism producing the fracture, mild or no deformity and the belief in bone setters, in addition to the fact that they are the frequent victims. Possible explanation why both age extremes present early is that: Young patients usually sustain Colles’ fracture as a result of relatively severe injury and they present early suspecting the fracture. Very old patients (although strongly believe in bone setters) are compelled to come to the hospital under pressure of their kins. The study showed that patients with Colles’ fracture are usually previously healthy people. 86.3% of these patients have no past history of any medical disease; only 5.6% of patients with Colles’ fracture were asthmatics and received short courses of steroids at emergencies. The remainders were either hypertensive or diabetics. Only one patient has cardiac disease. When patients with Colles’ fracture present to the casuality, the most frequent complaint was pain and swelling with majority of patients
119
having only mild or no deformity (78.2%). Only a minority (21.8%) had severe deformity. The fracture was usually an isolated injury except when the cause was road traffic accident. 84.3% of patients with Colles’ fracture have no associated injury. This is probably due to the mild nature of the mechanism of injury producing the fracture. 6.1% had either head or multiple injuries as a result of road traffic accident and the remaining 9.6% of patients had minor other injuries e.g. metacarpal or phalangeal fracture, bruises on the forehead or the elbows or cut tendon of the Extensor Pollicis Longus. In all patients under this study the fracture was closed except in two where the cause was direct blow. There were no vascular or nerve injury at time of presentation. Most of these patients were initially managed in the casuality and followed up as outpatients in the referred clinic. Only 8 patients required admission because of associated other injuries. The fact that the fracture is usually an isolated injury is more or less the same as the result of study done by William . Cooney III, Ronald L. Linscheid and James H. Dobyns (1996)5 with exception that their study showed median nerve symptoms was present in as high as 13% of patients at presentation. In this study there were only 2 (1.9%) cases of median nerve symptoms; these patients noted the symptom during immobilization in the cast.
120
Two problems were noted during follow up of these patients in the referred clinic; swelling distal to the plaster and poor compliance to doctor instructions. 21.3% of patients had swelling distally and most of these were due to tight plaster (i.e. 91.1% of this group). In literature the percentage of problems arising form plaster constriction was 3.0% (Hugh D. Stewart, Alan R. Inners and Frank D. Burke 1984) 14. Initially most of patients (46.4%) were non-compliant to doctor instructions or they were performing exercises incorrectly (in the 2nd visit), but the compliance was improved after the 3rd visit (89.5%) table (14). 5 patients required remanipulation during the follow up because of redisplacement (2.4%). The rate of displacement following reduction in some studies were in the range about 4.0% (Hugh D. Stewart, Alan R. Inners and Frank D. Burke 1984) 14.
Radiological Features In all patient radiographs in postero-anterior and lateral planes were done. In the lateral projections the results were as follows: there were no detectable losses of the normal volar angles i.e. the fracture was undisplaced in (17%) or the losses were within the acceptable limit (52.6%) in variable degrees. In 35% there were severe loss of volar angles (i.e. the volar angles were not acceptable). The postero-anterior projections showed that in 85.5% of patients the radial angles were either
121
unaffected or the loss was acceptable, only 14.5% the losses were severe and unacceptable. Initial height of radial styloid was either unaffected or reduced to acceptable limits in most of cases (72.1%). This clearly shows that disturbance of the volar angles, radial angles and the height of the radius were initially minimum and acceptable in most of patients, even though 71.1% of patients required manipulation to achieve better radiographic appearance. These figures are similar to the percentage of patients who required manipulation at presentation in study carried by Hugh D. Stewart, Alan R. Inners and Frank D. Burke (1984)14 who found that only 74.4% required manipulation. It was also clear that in the initial radiographs; the brunt of the impact was taken by the volar angle (i.e. the most severely affected), while the radial angles to a lesser degree. Other radiographic feature noted with Colles’ fracture was: fracture of ulnar styloid in (19.9%), undisplaced articular involvement in (18.5%), extra-articular dorsal comminution in (27.7%) and radio-ulnar diastasis in (14%). Only two patients had fracture of the metacarpal bones (2%).
Outcome of Conservative Management Although the clinical union was far better than radiologically visible callus; most patients had a good both clinical and radiological
122
union at sixth week when the plaster was removed (78.4%). Some patients had good clinical union but callus was not seen in radiographs (94.1%) and only very few (5.6%) had poor clinical and poor radiological union. This last group was given additional immobilization for two weeks; after which all showed good clinical union. Hugh D. Stewart, Alan R. Innes and Frank D. Burke (1984) found that the commonest complication following treatment with casting was symptoms of median nerve compression (17%) which was only two patients in this study (1.9%). The commonest complications in patients with Colles’ fracture in this study were residual deformity (18.6%). The deformity noted clinically was two types: mild residual dinner-fork and prominent ulna. Here two relations were noted: the relationship of the deformity to the radiological appearance and the presence of pain at the dorsum of distal radio-ulnar articulation. Of the 17 patients who had deformity 15 had prominent ulna. In this group three observations were noted: clinically; the ulna was prominent and there was pain at the distal radioulnar joint. The radiographs showed severe loss in radial height and angle. They also showed radio-ulnar diastasis. Residual dinner-ford deformity was note in two of the patients and was associated with loss of the volar angle in radiograph. These deformities are probably due to
123
collapse of the metaphyseal cancellous bone at fracture site; thus reducing the height of the radius. Immediately after removing the plaster; the outcome of conservative management was very poor in most of patients with severe restriction in most of wrist movements, stiffness of the fingers and poor grip. The response of these parameters to physiotherapy was generally good to excellent in all types of movement. At removal of the plaster; 18 (17.5%) patient had excellent outcome. 7 (6.8%) patients the outcome was good, and 18 (17.5%) patients had fair outcome; while most of patients 59 (57.3%) the outcome was poor. All the 9 patients under 20 years old fell in the group who had excellent outcome. After physiotherapy the picture was totally different. With regard to parameters of objective functional results; 45 (43.7%) patient had excellent outcome (constituting the majority of patients). 27 (26.2%) patients had good outcome, and 22 (21.4%) patients the outcome was fair; while only 8 (7.8%) of patients had poor outcome. This clearly shows that 71.9% of patient had excellent to good result in objective parameters. Again when we come to regard the parameters of subjective functional results such as pain, patient satisfaction and return to the previous activities; 52 (50.5%) patient had excellent outcome
124
(constituting the majority of patients). 40 (38.8%) patients had good outcome, and 10 (9.7%) patients had fair outcome; non of patients had poor subjective functional outcome. Here we note that 89% of these patients had excellent to good results of subjective functional analysis. At this stage two facts can be observed; the first: the out come of conservative management of patients with Colles’ fracture with regard to both objective and subjective results were excellent to good. The second fact: the results of subjective functional parameters was far better than the results of objective functional parameters. These results are similar to that concluded by Jesse B. Jupiter (1991) that the objective results may be less satisfactory than the subjective results but there is direct relation ship between function and residual deformity (which is objective parameter). Looking at the individual movement at wrist before and after physiotherapy showed each was affected at variable degree. To start with; pronation; was the least affected and showed good range of movement immediately after removing the plaster and good response to physiotherapy Table (22) figure (15). On the other extremity; radial deviation and supination show the poorest outcome immediately after removing the plaster and also the least improvement after physiotherapy Table (20 and 21) figure (13 and 14).
125
Flexion and extension show the best degrees of improvement of all wrist movement (17 and 18) figures (10 and 11). The best effect of physiotherapy was on the improvement of finger stiffness and grip power. There was essentially poor grip in 54.9% and moderate to severe stiffness of the fingers in 51% of patients immediately after releasing the plaster. They reduced to 9% with poor grip and 3.9% with moderate stiffness but no severe stiffness after physiotherapy. Yet no patient had finger stiffness after the end of physiotherapy. Tables(23and4).
126
Conclusions • The aim of this study is to provide a baseline for clinical presentation,
radiological
feature
and
outcome
of
conservative treatment of Colles’ fracture in Sudanese people. 102 cases were available for final assessment. • The fracture commonly affects middle aged women (62.5% of females); and the mechanism producing the fracture was commonly a low energy trauma such as simple fall on the outstretched hand either from standing position or during walking (49.3% of all patients, 68.0% of females). Most of these patients are otherwise fit people (86.6%); present on same day of injury complaining of wrist pain and swelling with mild or no deformity (78.2%). Only in few cases the deformity was marked. The fracture was usually an isolated injury (84.3%) except when the cause was road traffic accident. • Postero-anterior and lateral radiographs showed that the fracture
was
undisplaced
or
the
displacement
and
disturbance of angles at the distal articular surface of the radius are acceptable (69.6 in postero-anterior, 85.5% for the radial angle and 72.1% for radial height) or were made
127
acceptable with manipulation in most of patients with Colles’ fracture.
• The outcome of conservative treatment of these patients had excellent to good objective results in most of patients (71.9% of patients had excellent to good result) and even better subjective results (89% of these patients had excellent to good results).
128
Recommendations • Because of nature of trauma that results in Colles’ fracture (low energy trauma); in most of these patients the disturbance to anatomy was minimal; which fact favours a good outcome. As it has been seen there were little problems with fracture healing; but the follow up showed that there are two problems that are completely avoidable. The first was tight plaster and the second was non-compliance to physiotherapy or physiotherapy was not properly conducted. These can be easily eliminated by good plaster molding; good advice and close follow up. • Some of the fractures were manipulated under sedation only (pethidine and valium); which was painful and there was no muscle relaxation. We recommend that manipulation to be under general anesthesia and muscle relaxation; for both patients’ convenience and better results. • The study has been planed to cover the fractures that fulfill certain criteria, when patients did not meet these criteria they
129
were excluded. I recommend further study to be done to all patients with Colles’ fracture who will be treated conservatively and non-conservatively.
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18. A. Clyburn. Dynmic External Fixation for Comminuted Inra-articular fracture of the Distal End of the Radius. BJS 1987 February; Vol. 69-A (No. 2): 248-254. 19. J. Sanchez-Sotelo, L. Munuera, R. Madero. Treatment of Fractures of the Distal Radius with Remodellable bone Cement. BJS 2000 August; Vol. 82-B (No. 6): 856-862. 20. S. A. Earnshaw, A. Alandin, C. G. Moran. Closed Reduction of Colles Fracture: Comparison of Manual Manipulation and Finger-trap Traction. BJS 2002 March; Vol. 84-A (No. 3): 354-358. 21. Ronald McRae Practical Fracture Treatment, 3rd ed, Churchill Livingstone: ELBS; 1989.P. 170-178. 22. K. Kristiansen, John P, John J, Linda R. Accelerated Healing of Distal radial Fractures with the Use of Specific , Low Intensity Ultrasound. BJS 1997 July; Vol. 79-A (No. 7): 961-972. 23. Dias JJ The Wrist. In: P. B. Pynsent, J. C. T. Fairbank, A. J. Carr Outcome Measures in Trauma, 1st ed, Oxford: Butterworth Helnemann; 1994. P. 264-277. 24. Wigderowitz CA, D. I. Rowley, P. A. Mole, C. R. Paterson. Bone Mineral Density of the Radius in Patients with Colles’ Fracture. BJS 2000 January; Vol. 82-B (No. 1): 87-89.
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Appendex
U. of K. Faculty of Medicine Postgraduate Medical Studies Board Colles’ Fracture Presentation, Radiological Features and Outcome of Conservative Treatment In patients attending the Causality of K.T.H between 1st of March 2002 and 1st March 2003 ﻋﺜﻤﺎن إدرﻳﺲ ﻋﺜﻤﺎن. د: إﻋﺪاد 1. Serial number: ________________ 2. Name:_______________________
135
3. 4. 5. 6. 7. 8.
Age: _________________________ Sex: _________________________ Address: _____________________ Tribe: _______________________ Occupation: __________________ Dominant hand: a. Right. b. Left. 9. Previous medical disease? a. None. b. Diabetes Mellitus. c. Rheumatic disease. d. Chronic renal failure. e. Others (Specify: _____________________________). 10.Is the patient receiving hormonal or steroidal therapy? a. Yes. b. No. 11.Is there any previous wrist injury? a. Yes. b. No. 12.Mechanism of injury? a. Fall on out stretched hand. i. From standing position or walking. ii. From a height. b. Involved in sport injury. c. Direct blow. d. Involved in RTA. e. Others (___________________________). 13.Time lapse between injury and presentation? a. Within the first 24 hours. b. Within the first week. c. After the first week. 14.Affected side? a. Right. b. Left. c. Both 15.Initial deformity? a. Yes . b. No. 16.Closed or open fracture? a. Closed. b. Open.
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17.Associated nerve injury? a. Yes. b. No. 18.Associated vascular injury? a. Yes. b. No. 19.Presence of other injuries? a. None. b. Ipsilateral upper limb. c. Head injury. d. Multiple injuries. e. Others (______________________________________ ). 20.Comment on presentation: _____________________________ Radiological Assessment 21.A/O classification of the fracture? (________________________). 22.Original volar (anterior) angle? (______) After reduction (_____). 23.Original radial (lateral) angle? (______) After reduction (_____). 24.Original radial Height? (______) After reduction (_____). 25.Fracture of ulnar styliod process? a. Yes. b. No. 26.Presence of comminution? a. None. b. Mild comminution (3-4 fragments). c. Severe comminution (more than 4 fragments). 27.Articular involvement; presence of a gap? a. Yes. b. No. 28.Articular involvement; presence of step? a. Yes. b. No. 29.Fracture of carpal bones? a. Yes.
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b. No. 30.Comment on radiological features: _______________________
Causality Management 31.Was reduction necessary? a. Yes. b. No. 32.Reduction? a. Anatomical. b. Acceptable. 33.Does it require admission? a. Yes. b. No. First Visit (one week) 34.Presence of swelling distally (in the fingers)? a. Yes. b. No. 35.Causes of the swelling? a. Tight plaster. b. The patient did not keep his hand elevated. 36.Does this require change of the plaster? a. Yes. b. No. 37.Symptoms of median nerve compression? a. Yes. b. No. Second Visit (three weeks) 38.Presence of new defects the plaster (softening, slackening…)? a. Yes. b. No. 39.If the answer was “yes”; was the plaster changed? a. Yes. b. No. 40.Was there any need for re-manipulation? a. Yes. b. No.
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41.Was the patient maintaining adequate physiotherapy to his fingers, elbow and shoulder? a. Yes. b. No . Third Visit (At removal of the plaster) 42.Was the patient maintaining adequate physiotherapy to his fingers, elbow and shoulder? a. Yes. b. No. 43.Signs of union; clinically? a. Good. b. Poor. 44.Signs of union; radiologically? a. Visible callus. b. No visible callus. 45.Symptoms of median nerve compression? a. Yes. b. No. 46.Was there any need for additional immobilization? a. Yes. b. No. 47.Initial movement at the wrist (compared to the other wrist)? a. Flexion. ___________Degrees (___ %) b. Extension. _________ Degrees (___ %) c. Ulnar deviation. _____ Degrees (___ %) d. Radial deviation. _____Degrees (___ %) e. Supination. _________ Degrees (___ %) f. Pronation. __________ Degrees (___ %) 48.Initial grip strength compared to the other hand? a. Good. b. Poor. 49.Initial stiffness of the fingers? a. No stiffness. b. Mild stiffness. c. Severe stiffness. 50.Presence of pain? a. Continuous even without movement. b. With any movement; even if within the limits of stiffness.
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c. With movement only beyond the limits of stiffness. 51.Presence of other complication? a. None. b. Reflex sympathetic osteodystrophy. c. Rupture of extensor pollicis longus. d. Median nerve symptoms. e. Residual deformity. f. Tenderness at distal radio-ulnar joint. g. Others (Specify: _________________________________). 52.Comment: ___________________________________________ ___ Final Assessment After Physiotherapy 53.Improvement in the range of movement of the wrist? a. Flexion.____________ Degrees (__ %) b. Extension. __________ Degrees (___%) c. Ulnar deviation. ______Degrees (__ %) d. Radial deviation. _____ Degrees (__ %) e. Supination. __________Degrees (__ %) f. Pronation. ___________Degrees (__ %) 54.Final grip strength? a. Good. b. Poor 55.Final finger stiffness? a. No stiffness. b. Mild stiffness. c. Severe stiffness. 56.Presence of pain? a. No pain. b. With any movement; even if within the limits of stiffness. c. With movement only beyond the limits of stiffness. 57.Was there any need for additional physiotherapy? a. Yes. b. No.
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58.The patient satisfaction? a. Satisfied (thinks it’s nearly normal). b. Incompletely satisfied (thinks it’s less than normal). c. Not satisfied. 59.Return to previous activity? a. Full return to previous activities. b. Returned to his previous activities with modification. c. Require change of his activities 60.Comment: _________________________________________
