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неправильно срастающийся перелом дистального луча - тактика?
Ортопедия и травматология Отправлено Danil Bliznets 27 Сентябрь 2008, 12:41
Уважаемые коллеги!
Пациент 23 лет, травма 6 недель назад. В течение всего этого периода проводилась гипсовая иммобилизация.
Какую выбрать тактику?
1.хирургическое воссоздание анатомии?
2.или только лишь разработка движений?
можно ли пренебречь данными смещениями, учитывая сроки и признаки сращения?
Данил Близнец, Екатеринбург, Россия

Dear colleagues!

Patient 23 years old with fracture of the distal radius, managed nonoperatively for 6 weeks.

What tactic should be preferred?
1. anatomical reconstruction by surgery?
2. or only mobilization?

May this displacement be neglected taking into account the time passed after trauma and X-ray evidence of consolidation?

Danil Bliznets, Ekaterinburg, Russia

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    Re: неправильно срастающийся перелом дистального
    Дедок Михаил 27 Сентябрь 2008, 18:49
    Смещение есть, но им можно пренебречь.
    оставить "как есть", ЛФК.
    [ Ответить ]

    Re: неправильно срастающийся перелом дистального луча - тактика?
    Abdurashid Turaev 27 Сентябрь 2008, 20:53
    Уважаемый Данил! А больного что-то беспокоит?
    Какие клинические изменение? имеется ли нейротрофические изменения и т.д?
    С уважением Абдурашид.
    [ Ответить ]

    Re: неправильно срастающийся перелом дистального луча - тактика?
    anurag dixit 27 Сентябрь 2008, 22:05
    well good time has passed and good mobilization is the key to get the good PAIN FREE ROM. SURGERY may greate another good looking x ray but some time ROM is compromised.
    [ Ответить ]

    Re: неправильно срастающийся перелом дистального луча - тактика?
    Krunoslav Margic' 27 Сентябрь 2008, 22:35
    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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    неправильно срастающийся перелом дистального луча - тактика?
    Бен Эльайфар Мохамед 28 Сентябрь 2008, 06:00
    Во первых остеоклазия, а восстановить анатомию вы сможете только с помощью костной пересадки(скорее всего из гребня подвздошной кости), затем остеосинтез пластиной если получится, если нет то спицами.
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    Re: неправильно срастающийся перелом дистального луча - тактика?
    CHERIAN KOVOOR 28 Сентябрь 2008, 09:33
    why not mobilise and see how the function is

    DR C CHERIAN KOVOOR
    KOCHI
    INDIA
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    Re: неправильно срастающийся перелом дистального луча - тактика?
    Антон Андрианов 29 Сентябрь 2008, 18:03
    Все данные-молодой активный возраст, лучевая девиация кисти, угловая деформация, говорят о том, что оставлять деформацию нельзя.Вопрос о виде оперативного пособия.На мой взгляд, подобные случаи были в практике, лучшим видится остеотомия узким остеотомом\типа кортикотомии\ без сминания спонгиозы, дистракция в аппарате до полной коррекции угловой деформации и длины лучевой кости\сравнить на снимке с другой рукой!\Метод проверен в стране Илизарова до прихода АОгруппы!
    [ Ответить ]

    Re: неправильно срастающийся перелом дистального луча - тактика?
    David Nelson 30 Сентябрь 2008, 18:13
    I have read the abstracts cited above (not the full presentations and certainly not any published paper, as I presume these are not yet printed) and would offer this opinion.

    (1) It is difficult to make pronouncements about the outcome of distal radius fractures without closely examining the details of the fractures. Not all aspects are equal; for instance, intraarticular displacement is not the same as loss of radial tilt. So, before making pronouncements that they all do well or they all develop arthritis, we need to see the details of the fractures and the details of the studies.

    (2) While the Knirk and Jupiter paper of 1986 is the most widely-cited paper in the literature regarding distal radius fractures and the development of arthritis, Jupiter has stated publicly and privately that, of all the papers he has published, this is the one he most would like to retract. It was a retrospective study, there was no clinical exam, the rating system is defective, and it did not take into account any ligamenous injuries.

    (3) Also, no outcomes can be intelligently discussed unless we also state the patient's activity level. For instance, not all 65 year olds are the same: some play competitive tennis or golf, others just want to do ADL's. To discuss outcomes without discussing activity level is impossible.

    Therefore, I view the cited abstracts as of limited value.

    To get to the case in question, while I think that the current alignment is not ideal (there will be no disagreement there), but I think that the data available to us in the literature do not decisively give any guidance. I would probably not recommend any osteotomy as "necessary". I would discuss with the patient (and document in the chart) that the data is not clear, but there is no certainty or even any strong suggestion that this alignment will result in disability, even in one so young. The patient needs to understand and accept that we do not have a crystal ball and participate (and take responsibility) for their decision. If it were my wrist, I would not have surgery, but I am not the patient.

    David Nelson, MD
    Hand surgeon, San Francisco
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    • Re: неправильно срастающийся перелом дистального луча - тактика?
      Отправитель: Myles Clough 30 Сентябрь 2008, 18:16
      Interesting and thoughtful post, David.
      Is there anything to say that the results of (say) an osteotomy to restore the alignment are much better early (in the first few months) than later after the assessment of long term disability (1-2 years). I found the following paper and am also sending a link to its "Related Articles" Has the conclusion that the results of early osteotomy are better been supported elsewhere?

      Handchir Mikrochir Plast Chir. 1992 May;24(3):145-50.Links
      [Malposition of healed distal radius fracture. Indications, technique and timing of correction]
      [Article in German]

      Möllenhoff G, Walz M, Sistermann R.

      Chirurgischen Universitätsklinik und Poliklinik, Berufsgenossenschaftlichen Krankenanstalten Bergmannsheil, Bocchum.

      Typical complications of distal radius fractures include post-traumatic malalignment in about 20%. This is associated with ulno-carpal pain and impaired wrist function. Various corrective procedures have been recommended. Between 1972 and 1986, 96 patients with posttraumatic disorders after distal radius fractures underwent surgical treatment. Three different procedures were carried out: simple corrective osteotomy of the distal radius, combined correction of the radius and ulna, as well as isolated correction of the ulna (distal resection, step-cut osteotomy, hemiresection arthroplasty). 83 (86.5%) of the patients were followed up for an average of 7 years postoperatively. The functional results were evaluated according to Lidström. Excellent and good results were found in 58 (69.9%), fair in 20 (24.1%) and bad results in 5 (6.0%). The best results were mostly seen in cases with a short interval between trauma and corrective procedure. Distal ulna resection has not been performed in our department since 1986 because of poor results and concommitant wrist-instability. We recommend combined correction procedures in those patients with painful deformities within a period of no more than six to nine months after trauma. The indication should also take individual aspects such as profession, age, activities, complaints, and radiological findings into account. Signs of osteoarthrosis and wrist disorders due to severe soft tissue problems are contra-indications to any of the aforementioned correction procedures.

      Myles Clough

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