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Re: неправильно срастающийся перелом дистального луча - тактика?
послал Krunoslav Margic' 27 Сентябрь 2008, 22:35
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Dear colleague!
In this case of nascent or impending malunion in young man 6 weeks after injury where the radiocarpal joint is spared and only the distal radioulnar joint is involved I will start with mobilization and follow the patient. A word of caution: on AP view S-L joint is widened. Lateral view done in flexion does not permit judgment about carpal stability. Further studies including noninjured wrist are recommended.
After reading the articles cited below I have remembered the old dictum: “If I could know all that I do not know, I would not need that I know”.
Forwar DP, Sithole JS, Davis TRC, The Thirty-Eight Year Outcome of Distal Radial Fractures in Young Adults. OTA 2006. Posters. Orthopaedic trauma association. 2006 annual meeting. Phoenix, Arizona. October 5-7, 2006.
Queens Medical Centre, University of Nottingham, Nottingham, United Kingdom
Purpose: We conducted a clinical and radiologic review of 119 distal radial fractures sustained in young adults to assess the long-term development of symptomatic arthritis and functional impairment.
Methods: 801 patients who had sustained a distal radial fracture between 1960 and 1968 were identified from the hospital records. Of these, 119 who were below the age of 40 (mean 25 years) at the time of injury were reviewed at an average of 38 years (range, 33-42) later. All but one patient had been treated in a Colles plaster with or without manipulation for between 5 and 6 weeks. All underwent a detailed physical examination, completed a self-reported validated questionnaire, and underwent standardized posteroanterior and lateral radiographs of both wrists.
Results: No patient had changed occupation as a result of the fracture and none reported significant limitation of function. No salvage procedures had been performed. 89% reported troublesome pain once per month or less. Flexion-extension was significantly reduced in the fractured wrist but by only 7њ. Grip strength was also significantly reduced but by an average of only 2 kg. 90% of fractures had malunited in at least one radiologic parameter and the fractured wrists had significantly more radiologic arthrosis than the uninjured side. Logistic regression and ordinal logistic regression analysis demonstrated no relation between either malunion or radiologic arthrosis and the objective or subjective outcome measures. Objective and subjective measures were, however, significantly related. The strongest predictor of fracture outcome was the function of the uninjured wrist.
Conclusions/Significance: Malunion was well tolerated in this group of patients. We demonstrated no significant incidence of symptomatic posttraumatic osteoarthritis.
Földhazy Z, Hans Törnkvist H, Elmstedt E, Andersson G, Hagsten B, Ahrengart L. Long-Term Outcome of Nonsurgically Treated Distal Radius Fractures. J Hand Surg 2007;32A:1374–1384.
From the Karolinska Institute, Department of Orthopaedic Surgery, Karolinska University Hospital, Huddinge, Sweden; Karolinska Institute, Department of Orthopaedic Surgery, Stockholm Söder Hospital, Stockholm, Sweden; Karolinska Institute, Department of Occupational Therapy, Karolinska University Hospital, Huddinge, Sweden.
Purpose: To study the long-term outcome after nonsurgically treated distal radius fractures including recovery of grip strength, mobility, and radiographic parameters. Methods: Eighty-seven patients, mean age 55 (range 19–78) years, treated with closed reduction and casts, were evaluated radiographically and clinically during the first 6 months and finally after 9–13 years. Fifty patients had extra-articular fractures (AO Class A), 4 had simple intra-articular fractures (AO Class B) and 33 had complete intra-articular fractures (AO Class C).
Results: Fifty-two of 66 patients with unilateral fractures were, after 9–13 years, rated as excellent/good according to the Green and O’Brien score as modified by Cooney et al (GOBC score). Fracture class according to AO did not correlate to outcome. Considerable fracture displacements remained: dorsal angulation (mean 13њ in <60 y, 18њ in ™60 y), greater radial shortening than initially (mean 2 mm in <60 y, 3 mm in ™60 y). Five patients had remaining joint step-off (1–2 mm) after reduction, but only one developed mild osteoarthritis. Patients with an unsatisfactory outcome had sustained more displaced fractures that also healed with greater displacement. The remaining subjective complaints were pain or reduced function during heavier tasks. Outcome was not correlated to age. Wrist mobility returned notably faster than grip strength. Patients over 60 years of age recovered slower in both mobility and strength. Closed reduction and plaster improved dorsal angulation but not radial shortening.
Conclusions: Our data indicate that a number of patients with nonsurgically treated distal radius fractures still experience some hand/wrist impairment a decade after the trauma. The severity of fracture displacement seems to influence the clinical outcome in contrast to patients’ age. Recovery of grip strength is slower than that of range of motion. Elderly patients recover more slowly than young patients. Dorsal angulation was improved but remained considerable (13њ–18њ), while final radial shortening (2–3 mm) increased from the injury status
Martini AK, Fromm B. Radiocarpal Arthrosis Secondary to Malunion of Distal Radius Fractures. Handchir-Mikrochir-Plast-Chir. 23:249-254 1991
The authors report on long-term results of thirty-five unreduced distal radius fractures with malunion. The mean observation period was 11.5 years (5 to 45 years). It was found malalignment of the carpal articular surface of the radius with a resulting decrease in range of motion of the wrist, well tolerated by the patients and apparently not very painful. Much more evident was pain and decreased motion in the distal radio-ulnar joint for pronation and supination, which paralleled the extent of osteoarthrosis of this joint. This reduced forearm rotation was due to shortening of the radius, leading to incongruency and even dislocation of the distal radio-ulnar joint.
AB: This record was specially screened, selected, and commented on by expert physician-editors for Year Book Medical Publishers. ABSTRACT: Objective. -- To define indications for corrective osteotomy, 35 patients with unreduced distal radial fractures healed with malunion were reexamined. The mean period between fracture and late follow-up was 11.5 years. Whether unreduced distal radial fractures healed with malunion lead to osteoarthrosis of the radiocarpal joint, when and to what extent osteoarthrosis develops, and whether there are factors that influence this development were determined. Patients. -- Twenty-two women and 13 men with a mean age of 51 years at the time of the accident were reexamined 5-45 years later. Three patients had bilateral involvement. The mean reduction in radial rotation was 24 degrees, the mean reduction in ulnar rotation was 18 degrees, and the mean shortening of the distal radius was 4.5 mm. Twenty-five patients had a shattered joint and 27 had healing with pseudarthrosis after the ulnar styloid process was torn off by the accident. Results. -- Thirty-three of the 35 patients were satisfied with the cosmetic results. All patients complained of diminished strength in the affected joint. However, examination revealed that 20 patients had this problem only under extreme loading and that only 6 patients had problems with tasks of daily living. Fourteen patients were satisfied with the functional outcome. Eighteen patients had less than 10 years of follow-up and 12 of them stated that function improved as time went on. Of 17 patients with more than 10 years of follow-up, 5 still had relatively few problems. In the remaining patients, problems had gradually increased. Radiographic reexamination showed that 11 patients had osteoarthrosis of the distal radioulnar joint, 4 had osteoarthrosis of the radiocarpal joint, 8 had osteoarthrosis in both wrists, and 12 had no osteoarthrosis. All 12 patients with no evidence of osteoarthrosis had less than 10 years of follow-up. Two thirds of the patients had a 20-30 degree decrease in range of mot ion (ROM), and half of them had decreased ROM in supination. Conclusions. -- All patients who sustain a distal radial fracture will eventually have osteoarthrosis of the wrist. More than 20 degrees of dorsal deviation and more than 15 degrees of radial deviation, particularly when associated with radial shortening and a shattered joint, can be defined as a prearthritic condition and it is only a matter of time until problems arise. Prophylactic correcting osteotomy is recommended only for young patients employed in the manual trades or those active in sports. COMMENTATOR: R.L. Linscheid, M.D.
Sincerely,
Krunoslav Margic
Prim.dr. Krunoslav Margic, dr.med
Department of Plastic and Reconstructive Surgery
General Hospital
SI-5290 Sempeter pri Gorici
Slovenia
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