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Fracture of the distal radiusOskam, Jacob

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FRACTURE OF THE DISTAL RADIUS

SELECTED ISSUES OF

EPIDEMIOLOGY, CLASSIFICATION, AND TREATMENT

J. OSKAM

2

3

Lay out: Dr. W.F.M. Fritschy

Druk: Print Partners Ipskamp BV, Enschede

4

RIJKSUNIVERSITEIT GRONINGEN

FRACTURE OF THE DISTAL RADIUS

SELECTED ISSUES OF EPIDEMIOLOGY, CLASSIFICATION AND TREATMENT

PROEFSCHRIFT

TER VERKRIJGING VAN HET DOCTORAAT IN DE MEDISCHE WETENSCHAPPEN

AAN DE RIJKSUNIVERSITEIT GRONINGEN

OP GEZAG VAN DE

RECTOR MAGNIFICUS, DR. D.F.J. BOSSCHER,

IN HET OPENBAAR TE VERDEDIGEN OP

WOENSDAG 29 SEPTEMBER 1999

OM 16.00 UUR

DOOR

JACOB OSKAM

GEBOREN OP 18 DECEMBER 1963

TE ALKMAAR

5

PROMOTORES: PROF. DR. H.J. KLASEN

PROF. DR. R. VAN SCHILFGAARDE

REFERENT: DR. J. KINGMA

ISBN 90-367-1116-9

6

7

BEOORDELINGSCOMMISSIE: PROF. DR. H.J. TEN DUIS

PROF. DR. P.A.M. VIERHOUT

PROF. DR. R.P. ZWIERSTRA

PARANIMFEN DRS. J.P. FRÖLKE

IR. A. VAN DER WIEL

8

Acknowledgement

The names of all the persons to whom I am very indebted are mentioned in this

thesis. I gratefully thank all of them.

Financial support was kindly received from:

Mathys Medical Nederland BV

Medi Nederland BV, Fabrikant verband - en therapeutische elastische kousen

Orthomed BV

Voor Didi, voor onze kinderen, en voor onze toekomst.

9

CONTENTS

CHAPTER 1

Introduction……………………………………….……..………………….…..…..…….9

CHAPTER 2

The Groningen Trauma Study….……………….…………………………………….19

European Journal of Emergency Medicine 1994; 1: 167-172

CHAPTER 3

Fracture of the Distal Forearm: epidemiological developments in the period1971-1995………… ……………………………………………………………..….....31

Injury 1998; 29 : 353-355

CHAPTER 4Recognition of 10 distal radial fractures types by residents….……………….…..39

Submitted

CHAPTER 5The basic categories of the AO/ASIF’s systems as a frame of reference forclassifying distal radial fractures..……………………………….……………..….…47

Submitted

CHAPTER 6Fractures of the distal radius and scaphoid…………………….….…………….…57

Journal of Hand Surgery 1996; 21B: 772-774

CHAPTER 7Dorsal fracture-dislocation of the radiocarpal joint………………….……….…….65

Submitted

CHAPTER 8K-wire fixation for redislocated Colles’ fractures……….……………………...…..73

10

Acta Orthopaedica Scandinavica 1997; 68: 259-261CHAPTER 9Corrrective osteotomy for malunion of the distal radius………………………….81

Archives of Orthopaedic and Trauma Surgery 1996; 115: 219-222

CHAPTER 10Ulnar shortening osteotomy after fracture of the distal radius…………..………89


CHAPTER 11Summary and Conclusions…………………………………………………..……..95

CHAPTER 12Samenvatting en Conclusies………………………….………………………..…103

APPENDIX……………………………………………………………………………..113

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12

CHAPTER 1

INTRODUCTION

13

HISTORICAL DEVELOPMENTS

It was generally believed in the eighteenth century that a displacement of the wrist

after injury was caused by a dislocation and not by a fracture. The notion that a

distal radial fracture was a usual cause of wrist displacement gained popularity in

the beginning of the nineteenth century. Autopsies or observations of patients with

open fractures showed that a fracture of the distal radius was not rare at all. The

famous French surgeon Dupuytren was most explicit in this regard (11). He wrote:

”Almost all authors who have written on dislocations of the wrist, have described

as many as four kinds; and the only point in which these writers at all difer from

each other is respecting the number. ….. I have for a long time publicly thought

that fractures of the carpal end of the radius are extremely common; that I had

always found these supposed dislocations of the wrist turn out to be fractures; and

that , in spite of all which has been said upon the subject, I have never met with or

heard of, one single well authenticated and convincing case of the dislocation in

question”.

Different types of distal radial fractures were distinguished by physical examination

in the nineteenth century, by which in fact the first step in classification was made.

Surgeons in several countries like Pouteau in France (21), Colles and Smith in

Ireland (5,24), and Barton in the USA (1), described a specific type of distal radial

fracture and their names are still connected to particular fractures. It seemed that

there was not much controversy about the first choice of treatment and the

ultimate functional outcome in those days. Abraham Colles reported that reduction

was relatively easy, and good outcomes could usually be obtained after several

weeks of immobilisation with specially designed lower arm splints (5). Dupuytren

focussed the attention on the importance of early reduction, but also on technical

problems to obtain adequate immobilisation (11): “The surgeon should proceed to

reduce these fractures (comminuted fractures of the distal radius, Oskam) as soon

as possible, and that a misapprehension of the nature of the injury is always

attended by impaired use and deformity of the fore-arm”. If the fracture is not

adequately immobilized it will dislocate again: “If the tendency of the hand to move

towards the radial side of the fore-arm be not counteracted, union will take place

14

whilst the bones are in this position; and deformity together with impaired power of

rotating the fore-arm are the consequences. In some instances the displacement

in question is so great, that this bone appears as if curved ; and many

practitioners have been thus misled into the belief that there was dislocation of its

carpal extremity”. To prevent dislocation of the fracture fragments, Dupuytren

developed a device in which the hand was kept in an abducted position: “I have,

by the above simple method succeeded to my entire satisfaction in curing the

troublesome (unstable, Oskam) fractures, without any deformity or sacrifice of the

rotatory motions of the fore-arm”.

After the introduction of radiography in 1895 it was soon appreciated that in the

majority of wrist injuries the distal radius was fractured. It was also confirmed that

malunion after healing of a distal radial fracture occurred more often than was

usually thought. Due to radiology, surgeons could assess the quality of reduction,

bone healing, and anatomical end results. It appeared that in a large number of

patients a normal anatomical relationship was not obtained resulting in a malunion

of the distal radius (12). A malunion of the distal radius was characterized by

radial shortening, radial deviation, and dorsal angulation as Dupuytren had

described earlier without the help of X-rays. Many surgeons thought that instability

of the fracture was not the only cause of failure but that technical failure also

played an important role (25). So, it was thought that malunion could be prevented

in all instances by early adequate reduction and immobilisation.

It was observed in the first decades of the twentieth century by several surgeons

that the functional outcome of distal radial fractures was not favourable in patients

with malunion. Disturbed anatomical relationships after fracture healing

compromise wrist function and may cause pain, loss of wrist motion and

diminished gripstrength of the hand. Particularly American surgeons became

interested to treat anatomical deformations of the wrist, such as a prominent distal

ulna due to radial shortening. This classical disorder was treated by resection of

the distal ulnar head as was advocated by Darrach (9). Another technique to treat

a prominent distal ulna was introduced by Milch. He developed ulnar shortening

osteotomy as alternative for ulnar head resection (18). Apart from operations on

the ulnar side of the wrist, operations for the malunited distal radius were also

15

promoted. For instance, Campbell developed radial corrective osteotomy to

restore radiocarpal angulation and radial length (4).

It became obvious that primary anatomical reduction could prevent late

complications, and might prevent secondary reconstructive operations in many

wrists. Nevertheless, most surgeons remained reluctant to perform primary

operative fracture treatment. Primary surgery was only considered to be indicated

in irreducible fractures, and in these cases open reduction was ususally followed

by plaster immobilisation (25). Despite the fact that several progressive surgeons

developed new operative techniques on the basis of sound clinical observations,

these procedures were not generally accepted and, consequently, seldom

mentioned in handbooks. Because these books usually reflected the conservative

opinions of prestigious surgeons, all attention remained focussed mainly on closed

reduction and plaster immobilisation (2,26). So, conservative treatment was

undisputedly the treatment of first choice, irrespective of new insights on operative

treatment for unstable fractures.

PARADIGM SHIFTS IN TREATMENT OF DISTAL RADIAL FRACTURES

Lambotte (16) and Matti (17) were two representatives of surgeons practising in

the first decades of the twentieth century, who advocated open reduction and

operative fixation if anatomical reduction could not be obtained by conservative

methods. Their aggresive approach was based on the assumption that a strong

relation exists between complete restoration of anatomy and wrist function.

Lambotte and Matti challenged the leading opinions of conservative treatment

protocols for wrist fractures. The interest in operative treatment remained modest

despite their efforts. The quality of fixation material was rather poor in the years

preceeding World War II, which at the time contributed to rather high rates of

infection and redisplacement after operative treatment. This may well have

contributed to the lack of succes of efforts to promote operative treatment of distal

radial fractures.

16

It was confirmed by clinical studies published after World War II that the functional

outcome after conservative treatment of a fracture of the distal radius was not

always favourable. Gartland and Werley showed in 1951 that about 20% of

patients complained of wrist pain and showed loss of wrist motion (13). As a

consequence, attention was again focussed on the advantages of early restoration

of anatomical relations to improve functional outcome. New clinical studies were

undertaken in the nineteen-fifties to evaluate the results of osteosynthesis

techniques in unstable fractures. Closed reduction and fixation with Kirschner

wires became the first paradigm shift. It was the most popular method of operative

treatment in the period 1950-1970 (3,8,10,22). The approach of the distal radius

was usually not open, because it was assumed that adequate reduction can be

obtained by closed means. Open reduction was only indicated for irreducible

fractures.

Another paradigm shift in treatment occurred after 1970, largely due to the

influences of the “Arbeitsgemeinschaft für Osteosynthesefragen” (AO) (8,19). The

AO stressed that the basic principles of joint fracture treatment should be

restoration of joint congruency, followed by rigid stabilisation of fractures to enable

early practising and functional recovery. With respect to the wrist, restoration of

anatomical relationships in the radiocarpal joint was considered to be a

prerequisite for good functional recovery. The most appropriate procedure to

reach this goal was open reduction and internal fixation (ORIF). To enable

osteosynthesis of the distal radius with it’s specific shape, a so called radius T-

plate was designed to enable rigid fixation.

Although the advantages of ORIF were theoretically promising it became gradually

apparent that ORIF was not suitable for all fracture types (6,12,23). The best

indications are presumably fracture-dislocations, like Barton’s fracture, or unstable

extra-articular volarly- or dorsally-displaced fractures (7,12). The principles of the

AO and the assumed benefits of open reduction and internal fixation do not

appear to be valuable for each distal radial fracture type. The most important

disadvantages of ORIF are devitalization of fracture fragments and additional

trauma to soft tissues which compromise fracture healing and may contribute to

the occurence of infection. Most likely, closed fixation techniques are more

17

feasible to treat comminuted fractures, because the damage to soft tissues and to

the vascularisation of bone fragments is less with a closed technique.

Understandably, closed fixation techniques, like external fixation, became popular

in the nineteen-eighties and constituted the third, and latest, paradigm shift (14).

OUTLINE OF THE THESIS

Quantitative epidemiological factors, like the incidence of wrist fractures or the

incidence of particular fracture types, are likely to affect therapeutic decisions and

surgical care. So, against the background of optimal clinical care, epidemiological

information is an issue. Not only the incidence of distal radial fractures may be an

interesting issue, but also aetiological or biological determinants of distal radial

fractures are worth to be studied. For instance, the pattern of injury or the age of

the patient are factors which eventually determine the fracture pattern in the distal

radius. Little is known of epidemiological aspects of distal radial fractures. This

lack of knowledge justifies further research because of the possible clinical

consequences. Therefore, epidemiological issues are adressed in this thesis.

There is a need for a sound classification system for distal radial fractures.

Obviously, a correct diagnosis is required for choosing an appropriate treatment

for a particular fracture type. Usually, a historical classification system with

synonyms or eponyms is employed to reach this goal. Such historical systems do

usually not contain well defined fracture items with the considerable risk that

observer agreement is low. A more reliable classification system may be the AO

classification system for distal radial fractures. It has been claimed by the AO

foundation that this system contains all clinically meaningful fracture types and

that it is treatment-based. Since it is important to choose the most appropriate

treatment modality for a particular fracture, we have investigated the reliability of a

historical classification system and the AO classification system.

Conservative treatment can be performed in about 70 to 80 percent of distal radial

fractures (7,12). If operative treatment is required, several technical approaches

are available in most instances. There is no doubt that the adequate choice should

18

be made on the basis of sound evidence, preferably derived from prospective,

randomized, controlled studies. In case of distal radial fractures, however, the

number of such studies is regretfully low. As explanation may serve the

observation that the number of different fracture types of the distal radius is more

than thirty, in addition to the fact that each type can be treated with several

operative techniques and that many of these fracture types have a very low

incidence. Understandably, therefore, published observations as to success or

failure of operative treatment of these fractures are mostly restricted to

retrospective studies. Since we, too, have focussed on rare types of distal radial

fractures, the studies presented in this thesis are retrospective by necessity.

The first concern of this thesis regards the incidence and aetiological patterns of

distal radial fractures in the Groningen population. No epidemiological studies of

injury patterns have been published in The Netherlands. A unique achievement of

the Department of Surgery of the University Hospital Groningen is that a trauma

registration system with a database has been maintained since 1970. With that

database, epidemiological aspects of a large group of trauma patients such as the

incidence of wrist fractures in the Groningen area could be studied. Long term

trends of incidence and injury patterns for all trauma patients treated at the

University Hospital Groningen are presented in Chapter 2. More detailed incidence

rates and injury patterns of patients with wrist fractures are discussed in Chapter

3.

The second concern of this thesis is the reliability of classification of distal radial

fractures. Many classification systems have been developed since 1950, but most

systems are incomplete since they do not describe all possible types of distal

radial fractures (12). A requisite for a proper classification system is that it covers

the large number of fracture types which is estimated to be more than thirty, and

that it is helpful in choosing an appropriate treatment. Therefore universal,

treatment-based classification systems have been designed in the nineteen-

eighties. The universal system of the Mayo Clinics was introduced in the United

States of America (7), while in Europe the universal system of the AO was

propagated (20). The clinical value of these universal classification systems is not

19

known precisely. Recently, a validation study of the AO system showed that

agreement between several observers is not very good (15). It appears that no

reliable universal classification system is available to support clinical decision

making. This could be the reason why many surgeons still use familiar, historical

classification systems to deal with the complexity of distal radial fractures. We

have confronted a group of surgical residents with a variety of X-rays with distal

radial fractures, in order to decide upon the consistency of traditional classification

systems. The results of the study are described in Chapter 4.

Since the concept of a universal treatment-based classification system to support

decision making is very attractive, we studied the applicability of the AO/ASIF

classification system which is presently used by many in Europe. We determined

observer agreement in a series of 124 distal radius fractures which was classified

according to the AO/ASIF’s system by two experienced observers. Chapter 5

contains the rates of agreement and a qualitative analysis to causes of

disagreement.

Finally, the third concern of this thesis is to assess the value of selected operative

techniques which were performed to restore anatomic relationships in particular

rare fracture types in order to investigate the postulated association between

anatomy and function after healing of a distal radial fracture. In the ninety-

seventies the concepts of the AO movement were also adopted by the trauma

surgeons of the surgical department of the University Hospital Groningen, and as

a result the treatment of distal radial fractures changed, too. Initially, most primary

operations were performed in young patients with complex fracture types or high

energetic wrist injuries. An example of such a complex wrist injury is a

combination of fractures of the radius and scaphoid. The results of treatment of

one of the largest published series is presented in Chapter 6. Another example of

a complex, high-energetic wrist injury is dorsal fracture-dislocation of the

radiocarpal joint. Although the most appropriate operation technique for this injury

has yet not been esthablished, the best treatment is probably open reduction and

internal fixation. Because the injury is rare, only small series or case reports have

been reported so far. The experiences of the Groningen Department of Surgery

20

with a series of six patients, and the latest developments in the literature, are

presented and discussed in Chapter 7.

An issue in the treatment of distal radial fractures is how to deal with unstable

fractures in mentally and physically healthy, elderly patients. The problem with this

group of patients is that these patients commonly suffer from secondary

osteoporosis. Osteoporosis causes technical difficulties during surgery because

the mechanical properties of the distal radius do not allow firm fixation. Fractures

in osteoporotic bones are frequently unstable after reduction and heal in malunion

causing poor functional outcome. The classical approach in these patients is to

start with conservative treatment. The X-rays usually show a satisfactory reduction

of the fracture, but during follow up it appears that the fracture redislocates.

Currently it is still not clear whether patients with redislocation may benefit from an

operation in which wrist anatomy is restored. But if surgery is pursued several

technical options may be used, among which closed reduction and Kirschner wire

fixation is an attractive option because it is minimally invasive. Our experiences

with closed reduction and Kirschner wire fixation after redislocation are presented

in Chapter 8.

If a fracture has healed in malunion the anatomic relationship of the radius and

ulna can be restored secundarily by a corrective osteotomy. Corrective

osteotomies of the wrist have been performed in the Groningen surgical

department since nineteen-eighty. Most of these reconstructions took place in

young patients because of poor wrist function after conservative treatment. The

preferred types of reconstructions were ulnar shortening osteotomy and radial

corrective osteotomy. A surgical audit to evaluate the clinical outcome and

suggestions to improve surgical techniques are described in Chapters 9 and 10.

REFERENCES

1. Barton JR. Views and treatment of an important injury of the wrist. The Medical Examiner 1838;

1: 365-368.

2. Boehler L. Die Techniek der Knochenbruchbehandlung, Verlag Wilhelm Maudrich, Wien 1932,

pp. 304-308.

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3. Boehler L. Die techniek der Knochenbruchbehandlung, Erganzungsband, Verlag Wilhelm

Maudrich, Wien 1963, pp 2718-2728.

4. Campbell WC. Malunited Colles’ fractures. JAMA 1937; 109: 1105-1108.

5. Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med J 1814; 10:181-

186.

6. Cooney W P, Linscheid R L, Dobyns J H. External pin fixation for unstable Colles’ fracture. J

Bone Joint Surg 1979; 61A: 840-845.

7. Cooney WP and Saffar P. Fractures of the Distal Radius. Martin Dunitz, London 1995

8. Danis R. Theorie et pratique de l’osteosynthese. Masson et Cie, Paris 1949.

9. Darrach W. Partial excision of lower shaft Ulna for deformity following Colles’ fracture. Ann Surg

1913; 57: 764-766.

10. DePalma AF. The management of fractures and dislocations, WB Saunders Comp Philadelphia

1959, pp 472-492.

11. Dupuytren G. On the injuries and diseases of bones, selections from the collected edition of the

clinical lectures. Translation F LeGros Clark, Sydenham Society, London 1847.

12. Fernandez DL and Jupiter JB, eds. Fractures of the distal radius, Springer-Verlag New York

1996.

13. Gartland J J, Werley C W. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1951; 33A:

895-907.

14. Haas J L, Caffiniere de la J Y. Fixation of distal radial fractures: Intramedullary pinning versus

external fixation. In Fractures of the distal radius (Eds Saffar P, Cooney WP). Martin Dunitz

London 1995; 27: 229-239.

15. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivery G, Swiontkowski MF. Consistency of AO

fracture classification for the distal radius. J Bone Joint Surg 1996; 78B: 726-731.

16. Lambotte A. L’ intervention operatoire dans les fractures, Lamertin, Bruxelles 1907.

17. Matti H. Die Knochenbruche und ihre Behandlung, Springer Verlag, Berlin 1931, pp. 674-683.

18. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg 1941; 23A:

311-313.

19. Mueller ME, Allgoewer M, Willenegger H. Manual der Osteosynthese AO-technik, Springer

Verlag, Berlin 1968.

20. Mueller ME. Two pamphlets of the Comprehensive Classification of Fractures, edition 1996.

AO/ASIF Documentation Center Davos, Switzerland 1996.

21. Pouteau C. Oeuvres posthumes. PhD Pierres, Paris 1784, tome second.

22. Rayhack J M. The history and evolution of percutaneous pinning of displaced distal radius

fractures. Orthop Clin North Am 1993; 24: 287-300.

23. Riis J, Fruensgaard S. Treatment of unstable Colles’ fracture by external fixation. J Hand Surg

1989; 14B: 145-148.

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24. Smith RW. A treatise on fractures in the vicinity of joints and on certain forms of accidental and

congenital dislocations. Hodges and Smith, Dublin 1847.

25. Speed K. Fractures and Dislocations, Lea & Febiger, Philadelphia 1928, pp. 448-469.

26. Watson-Jones R. Fractures and other bone and joint injuries, E&S Livingstone, Edinburgh

1940, pp390-405.

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CHAPTER 2

THE GRONINGEN TRAUMA STUDY:INJURY PATTERNS IN A DUTCH TRAUMA CENTRE

J Oskam, J Kingma, H J Klasen

Department of Surgery, University Hospital Groningen

Groningen, The Netherlands

European Journal of Emergency Medicine, 1994; 1:167-172

24

A trauma registry is an essential part of trauma care, and can be employed to

evaluate injury characteristics (5,9). Registration systems give access to

information on past injury patterns, and may provide directions for public health

and trauma care management (25). Previous studies of large trauma populations

mainly involved analyses of trauma mortality, because death is often best

documented (1,5). In contrast, only one large Northern American study has also

addressed characteristics of non-fatal injury in a large group of trauma victims

(10). To our knowledge, injury patterns describing the entire spectrum of trauma

care in a European trauma centre have not yet been reported.

At the University Hospital of Groningen, a computerized trauma registry has been

established since 1970, in which all primary visits irrespective of severity grade

have been recorded. Thus, long-term information on trends of a large group of

trauma victims (n=245,251) is currently available. This retrospective study was

undertaken to analyse specific characteristics of injury patterns in our hospital. We

will assess how this information was used to support trauma care management.

Furthermore, the usefulness and future implications of trauma registry in the

Netherlands will be discussed.

MATERIAL AND METHODS

The University Hospital of Groningen is a 1050-bed centre and is situated in the

north of The Netherlands. The A&E department is freely accessible and maintains

a 24-hour service. Since 1970, all trauma visits have been recorded on a

standardized chart. Each case record comprises patient identification, external

cause of injury, co-morbidity, trauma diagnoses, therapeutic procedures,

complications, length of hospital stay and other treatment characteristics. All

patient maps were reviewed and completed by staff traumatologists. The input of

the data was performed by trained personnel.

Diagnoses of the injuries and the external cause were recorded according to ICD-

8 untill 1981, and according to ICD-9-CM from 1982. In order to analyse injury

causes for the 24-year period, all ICD-9 E-codes were converted into ICD-8

25

categories (6). The aetiologic category Fall was defined as an unintended fall not

restricted to a certain height, and not related to work. Traffic was defined as

accidents that happened in an area reserved for traffic. The victims are either

drivers or passengers of cars, motorcycles, mopeds and bicycles and pedestrians.

Violence was defined as incidents purposely inflicted, irrespective of the use of

arms. In this category, however, a separate group of firearm injuries was selected.

The group of Sports and unspecified injuries consisted of accidents which took

place while a person was at home or engaged in some kind of sports activity.

Information on age, sex, trauma visit, hospital admission and hospital mortality

were collected from the database. Mortality was defined as death occurring during

either hospital admission or hospital stay. To describe the influence of age on

injury cause, a subdivision into seven age groups of 10 years each, and a group of

70 years and older was made. To analyse sex differences, the Male to Female

ratio (M/F) was used. The case fatality ratio (CFR) per cause category was

employed to describe the distribution of fatal and non-fatal injury. So, the relative

contribution to mortality of each injury cause could be assessed.

Cause category % ICD 8 E-code

Fall 27 E887

Sports/unspecified 26 E929

Traffic 19 E807 - 841

Cutting/piercing instr. 10 E920

Violence 4 E958-999 + 922

Late effect 4 E946

Falling object 3 E926

Machinery 3 E928

Animal 1 E906

Rest (drowning, etc.) 3

26

Table 1. Distribution of the major causes of trauma visit (n=245,251) in the period 1970-1993.

RESULTS

Injury causes and trends

During the 24-year period, 245,251 primary trauma visits were registered. The

mean annual incidence rate was 10,219 patients. In total, 29,430 hospital

admissions (12%) occurred with a mean annual rate of 1,226.

Table 1 shows that fall was the main injury cause, while almost a quarter of all

patients suffered from injuries that resulted from some kind of leisure activity

(26%). Remarkably, causes related to occupation, like machinery (3%) or falling

objects (3%), were observed in a minority of cases. Injuries due to violence

concerned only 4% of the primary visits, thus, not being a major contributor to

trauma morbidity in Groningen.

The incidence trends of the principal trauma causes are shown in Figure 1. The

total incidence of trauma visits remained approximately 10,000 victims per year.

However, a clear alteration in the distribution per cause category can be found.

Although, both traffic and accidental fall remained two major trauma causes, a

decrease in incidence can be observed. During the past 10 years, sharp objects

and violence were causes of increasing importance.

Trends in traffic accidents

A traffic accident was the cause of injury in 19% of trauma patients. Figure 2

shows a comparison of the incidence of hospitalized patients treated at the

University Hospital Groningen and all Dutch hospitals (Central Bureau of

Statistics). It appears, that the local traffic injury pattern resembles the national

pattern, while the overall incidence is currently decreasing. In Figure 3, the

incidence rates for specific types of traffic accidents are shown. It can be seen that

the incidence of injuries due to car accidents has decreased, while the incidence

of injuries due to motor cycle accidents remained stable. The incidence of

pedestrian injury decreased, but the sharp increase of bicycle injuries upto 939

patients is remarkable. Bicycle and pedestrian injuries comprised 66% of all traffic

27

casualties, while 52% of traffic mortality occurred in these traffic participants.

Altogether, pedestrians and bicyclists constituted a major proportion of trauma

patients, with children and elderly being most at risk

28

1

10

100

1000

10000

100000

70 72 74 76 78 80 82 84 86 88 90 92

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nu

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UHG

Figure 2. Incidence of hospitalized trauma patients treated at the University Hospital Groningen (UHG) and all hospitals in the Netherlands.

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1500

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2500

3000

3500

4000

4500

70 72 74 76 78 80 82 84 86 88 90 92

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Traffic

Cutting/ piercing instr.

Violence

Figure 1. Annual incidence rates of trauma visits to the University Hospital Groningen inthe period 1970 - 1993.

0

100

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300

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70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93

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CarMotorcycleBicyclePedestrian

Figure 3. Annual incidence rates of trauma visits for several subgroups of traffic accidents

29

Demographic characteristics

An analysis of sex and age patterns revealed that the mean Male to Female (M/F)

ratio was 1.8 (157,245 men, and 88,006 women). The highest incidence rate per

age and sex group could be attributed to men of 20-29 years. This particular

pattern could also be observed in the cause categories traffic and violence.

However, in accidental fall the highest incidence was found in both children (0-9

years) and women above 70 years. It also appeared that the local pattern did not

differ from the national age and sex characteristics. The general demographic

picture reflects a pattern in which young men in particular are susceptible to

traumatic injury.

Cause Number % CFR

Traffic 746 66 63

Fall 186 16 357

Sports/ unspecified 57 5 1132

Violence 36 3 278

Falling objects 15 1 515

Machinery 13 1 521

Rest 67 6 -

Total 1138 216

Table 2. Survey of the principal causes of trauma mortality (n=1138) during the period 1970-1993 at

the University Hospital Groningen (Note: The Case Fatality Ratio (CFR) is the quotient of the

number of deceased victims and all treated victims per injury cause)

Trauma mortality

In total, 1138 patients died soon after or during hospital admission, resulting in a

mean of 48 deaths per year. The mortality rate of trauma patients was 0.5%, while

the mortality rate of hospitalized patients was 4%. Not surprisingly, mortality was

highest in the age group above 70 years, and was caused by both accidental fall

and traffic accidents.

30

It can be seen in Table 2 that traffic contributed most to mortality. Violence was

not a major cause of death, because homicide comprised only 3% of mortality.

Remarkably, only 165 firearm injuries were registered during the 24-year period of

observation. Traffic accidents caused the relatively most fatal injuries, while

violence was the second most lethal injury cause. The mean CFR of all motor

vehicle injuries was 40, which means that these injuries were the most dangerous.

DISCUSSION

The data of this study were retrieved from the Groningen Trauma Registry, a

system which was computerized from the onset in 1970, with the WHO

classification of diseases (ICD-CM) as a central tenet. Because we record all

trauma visits, we have the opportunity of assessing the entire workload of a large

trauma centre. The Groningen Trauma Registry has therefore been used as an

information supply for the development of trauma care policy (8). However, since

in present study the data of a single hospital have been used, it could be argued

that selection might have biased the injury patterns. Therefore, the question arises

whether single hospital data are appropriate for the purpose of trauma care

management.

A strong argument against the issue of selection is the observation of a striking

resemblance between Groningen and Dutch injury trends. Furthermore, the local

and national demographic patterns also appeared to be similar. Apart from the

above mentioned resemblance of local and national trauma care statistics, the

contemporary organization of the Dutch trauma care system might also explain

why selection is probably of less importance. Usually, most trauma victims in The

Netherlands are transported to the nearest hospital in the area where the accident

took place. This means that the Dutch trauma care system is not regionalized and

that almost all patients with thoracic, abdominal and extremity injuries are being

treated in local hospitals (7,8). Only patients with severe head and spine injuries,

and critically ill patients with secondary organ failure following severe trauma are

reffered to the Groningen trauma clinic. Since, in our hospital the yearly incidence

31

is 10,000 victims on average, and referred patients are only a small fraction of the

total trauma incidence, the injury patterns presently under study will probably not

be biased. Thus, it seems that the present hospital population might be a

reasonable sample of the Dutch trauma care system. From the above point of

view, we think employing information of a hospital-based system for a broader

perspective than just clinic management is justified.

It has been discussed previously, that injury dynamics of a distinct population are

determined by both time-related developments and geographic influences (26).

Currently, the role of a difference in geographic area can be well demonstrated.

For example, the Groningen inhospital mortality rate of 4% is much lower than the

reported rate of 9% in the Major Trauma Outcome Study (MTOS) (5). The MTOS

is a well known multicentre study, describing several aspects of trauma care in the

USA. The variation in mortality rate undoubtedly reflects a difference in trauma

severity. The observed contrast might be better understood by what Eastman

called inclusive and exclusive trauma care (9). Most trauma centers of the US

trauma care system provide exclusive care, which is mainly directed at critically

injured patients. In Groningen, however, trauma care comprises all types and

severities of injury, and this can be considered inclusive trauma care. The fact that

88% of patients were treated in an outpatient setting, and 99,5% suffered from

non-fatal injury, underlines the inclusive character of trauma care in Groningen.

Apart from differences, several similarities between the Groningen trauma

population and other trauma populations can be discerned. For example, the

demographic pattern is characterized by what can be called the young male peak.

This peak is nearly universal (2,10,11,12), and is thought to result from the

particularly high risk behavior of young men. The young male peak is present in all

cause categories except in accidental fall, in which boys (0-9 years) and women

older than 70 years are the major at-risk groups. These findings are in agreement

with studies from the USA and Scandinavia (3,20,22). Furthermore, most deaths

occurred in the elderly and resulted from traffic injuries and falls, a pattern which

has also been observed in other Western societies (21,23). Traffic injuries caused

most trauma deaths, in particular in young men between 10-19 and 20-29 years, a

pattern which has been described elsewhere (4,5,12). The present case fatality

32

ratio of motor vehicle injury was 40 and resembles closely the CFR of 41 in the

USA (24). In summary, not withstanding the differences, a striking similarity with

Northern American, Scandinavian, and British trauma populations appears to be

present.

The strength of trauma registry systems lies in the ability to obtain information for

the management and organization of trauma care (9). The costs of registration,

however, are only justified if they are incorporated in a trauma system which is not

only directed to the clinical level, but is also aimed at preventative measures (25).

Currently, the Groningen Trauma Registry is not just being used for hospital

management, but also to support preventative programmes. A good example of

such a programme is a local project to prevent assaultive injury. In several papers,

we described the role of alcohol consumption (15,16), the effects of increased

waepon use (17,18), and a model to study the streams of violence victims (19). As

a result, a program to prevent violence injuries was developed in association with

police, county, and public health officers. The outcome of the program will be

evaluated, also with the help of the trauma registry.

Another application of the trauma registry is a national study of bicycle injuries.

This study has been initiated by the Dutch Association of Safe Traffic (Veilig

Verkeer Nederland) on the basis of our observation of an increase in trauma visits

of bicyclists and pedestrians. This rather surprising information could be retrieved

because the registry is well equiped to monitor long-term trends. Because the

national and Groningen incidence patterns of traffic injury seem to be related

closely, it was suggested that this trend could also exist in other parts of The

Netherlands. As a result, a national project to study bicycle injuries was started in

order to obtain more insights into the aetiology and prevention.

Investigations of the underlying mechanisms of occupational-related accidents are

scarce. Since, approximately 35-40% of incidence comprises minor trauma due to

leisure-related or occupational accidents, we initiated new research in the field of

non-fatal injury. An example is our recent observation that industrial hand injuries

occurred mainly to men older than 50 years (13,14). It was discussed that factors

like visual acuity might play a crucial role and, thus, this issue is now under study.

Although, complete solutions are not to be expected, it must be realized that the role

33

of trauma registry in this kind of research is mainly description of injury patterns, and

monitoring of the effects following introduction of preventative measures.

In line with Trunkey's arguments (25), future trauma research must be directed to

the evaluation of non-fatal injuries, in order to become more efficient in trauma

care. Trauma registries must be used as tools to reach this goal. The present

study shows that hospital registries may supply the data for analysis of non-fatal

injury. Because the Groningen Trauma Registry records inclusive trauma care

since 1970, changing trauma trends across the whole spectrum of injury severity

could be assessed. The information thus derived served as a starting point for

community trauma care programmes. Therefore, we conclude that trauma

registration is an important instrument to monitor specific characteristics of

patients, as well as causes of accidents, providing a tool for trauma management

and public decision making.

REFERENCES

1. Burns CM. The 1990 Fraser Gurd lecture: A Canadian trauma registry system nine years

experience. J Trauma 1991; 31: 856-866.

2. Carlsson GS, Svardsudd K, Carlsson S, Tibblin G. A study of injuries during life in three male

populations. J Trauma 1986; 26: 364-373.

3. Centers for Disease Control. Childhood injuries in the United States. Am J Dis Child 1990; 144:

627-646.

4. Cesare J, Morgan AS, Felice PR, Edge V. Characteristics of blunt and personal violent injuries.

J Trauma 1990; 30: 176-182.

5. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW, Flanagan ME, Frey

CF. The Major Trauma Outcome Study: Establishing national norms for trauma care. J Trauma

1990; 30: 356-365.

6. Commission on Professional and Hospital Activities. The International Classification of

Diseases. Nineth Revision-Clinical Modification. Ann Arbor,MI: WHO 1980.

7. Draaisma JMTh, De Haan AFJ, Goris RJA Preventable trauma deaths in the Netherlands - A

prospective multicenter study. J Trauma 1989; 29: 1552-1557.

8. Dutch College for Hospital Supplies. Report Workgroup on Trauma Care. Utrecht, The

Netherlands: Ministry of Health 1991.

9. Eastman AB. Blood in our streets; the status and evolution of trauma care systems. Arch Surg

34

1992; 127: 677-681.

10. Fife D, Barancik JI, Chatterjee BF Northeastern Ohio Trauma Study: II. Injury rates by age, sex,

and cause. Am J Public Health 1984; 74: 473-478.

11. Honkanen R, Koivumaa H, Smith G. Males as a high risk group for trauma: The Finnish

experience. J Trauma 1990; 30: 155-162.

12. Guirguis EM, Hong C, Liu D, Watters JM, Baillie F, McIntyre RW. Trauma outcome analysis of

two Canadian Centres using the TRISS method. J Trauma 1990; 30: 426-429.

13. Jonge de JJ, Kingma J, Lei van der B, Klasen HJ. Phalangeal fractures of the hand; an analysis

of gender and age-related incidence and aetiology. J Hand Surg 1994; 19B: 168-171.

14. Jonge de JJ, Kingma J, Lei van der B, Klasen HJ. Fractures of the metacarpals. A retrospective

analysis of incidence and aetiology and a review of the English-language literature. Injury 1994;

25: 365-368.

15. Kingma J, Klasen HJ. Alcohol consumption in victims of traffic accidents; car and motorcycle

drivers in the period 1982-1993. Tijdschrift Alcohol en Drugs 1994; 19: 107-116.

16. Kingma J, Oskam J, Klaver A, Klasen HJ. Alcohol consumption in victims of assault: A trend

study of the period 1970-1991. Tijdschrift Alcohol en Drugs 1992; 18: 197-205.

17. Kingma J, Oskam J, Eijken T, Klasen HJ. Use of weapons is increasing in Groningen. Tijdschrift

Samenleving Criminaliteitspreventie 1994; 8: 33-37.

18. Oskam J, Kingma J, Klasen HJ. The use of objects and waepons in violental injuries. Tijdschrift

Criminologie 1994; 36: 120-128.

19. Oskam J, Kingma J, Klasen HJ. The treatment of victims of violence in a hospital. Justitiele

Verkenningen 1994; 20: 86-96.

20. Peclet MH, Newman KD, Eichelberger MR, Gotschall S, Guzzetta PC, Anderson KD, Garcia

VF, Randolph JG, Bowman LM. Patterns of injury in children. J Ped Surg 1990; 25: 85-91.

21. Ryynanen OP, Kivela SL, Honkanen R, Laippala P, Soini P. Incidence of falling injuries leading

to medical treatment in the elderly. Public Health 1991; 105: 373-386.

22. Sjogren H, Bjornstig U. Unintentional injuries among elderly people: Incidence, causes, severity,

and costs. Accid Anal Prev 1978; 21: 233-242.

23. Smith DP, Enderson BL, Maull KI. Trauma in the elderly: Determinants of outcome. South Med

J 1990; 83: 171-177.

24. Soderstrom CA, Birschbach JM, Dischinger PC. Injured drivers and alcohol use: Culpability,

convictions and pre- and post-crash driving history. J Trauma 1990; 30: 1208-1214.

25. Trunkey DD. Future shock. Arch Surg 1992; 127: 653-658.

26. Waller JA. Methodologic issues in hospital-based injury research.J Trauma 1988;28:1632-1636

35

36

37

CHAPTER 3

FRACTURE OF THE DISTAL FOREARM :

EPIDEMIOLOGICAL DEVELOPMENTS IN THE PERIOD 1971 -1995.

J Oskam, J Kingma, H J Klasen.


Groningen, The Netherlands

Injury 1998; 29: 353-355

38

In spite of the fact that fractures of the distal forearm are often diagnosed,

epidemiological studies to distal forearm fractures are scarce. A search in Medline

over the period 1960-1996 revealed only two epidemiological studies that dealt

exclusively with distal forearm fractures. In a study from Oslo in Norway, age and

gender specific incidences of patients older than 20 years were described (1).

Another study from Malmo in Sweden reported on the incidence across the whole

lifespan (2). In this study, a comparison was performed with historical data from

the period 1953-1957 and 1981-1982 in the same hospital. It was concluded, that

the incidence of distal forearm fractures was increased significantly, and that

people older than 60 years were the highest risk group. Furthermore, the authors

extrapolated the results to the future, and they forecasted that the incidence of

distal forearm fracture would increase further. However, this extrapolation has

been based on the assumption that the observed trend would continue to increase

in the nineteen-eighties.


The purpose of the present study was to investigate the longterm incidence rate in

the period 1971-1995, enabling us to evaluate the forecasted trend. Another

concern was to analyze aetiologic factors and the clinical workload of distal

forearm fractures in our department.

Since 1970, a trauma registry has been established at our institute and

information on a large group of patients is nowadays available (3). The records of

all patients with a fracture of the distal forearm treated from 1 January 1971

through 31 December 1995 were reviewed. All patients were seen primarily at the

Emergency and Accident unit of our hospital, which is a 1,056-bed centre with the

largest trauma centre in the northern region of the Netherlands. The unit holds a

24-hour service and is the only institute in the area which is accesible for all kinds

of trauma. The proportion of trauma admissions to our hospital in the catchment

area is 94%. The admission data were obtained from the patient’s history, clinical

and radiological assessment at the time of first consultation. All trauma visits have

39

been recorded on a standardized chart by the attending physician, and were

checked by trauma-surgeons.

Fracture of the distal forearm was defined according to the N-code of the

International Classification of Diseases (N 813.0). The Supplementary

Classification of External Causes of Injury (E-code) was used to study the

aetiology of the injury (3). The category Traffic was defined as an accident in

which at least one vehicle is involved and that happened in an public area (E807-

841). The vicitims are either drivers or passengers of cars, motorcycles, mopeds,

bicycles, or pedestrians. The group of Sports & leisure consisted of accidents

which took place while a person was engaged in some sport or leisure activity.

Information on age, sex, injury cause, and hospital admission was collected from

the trauma data base. To describe the distribution of age, a subdivision into eight

age groups of ten years each, and a group of 80 years and older was made. The

population was defined as the total of inhabitants living in the catchment area of

the hospital during the period of observation. The populational data were delivered

by the Central Bureau of Statistics (CBS) of the Netherlands. The annual

incidence of distal forearm fractures per 10,000 inhabitants was employed as a

measure of disease frequency rate. The nominator data were the number of

patients, while the denominator was the number of inhabitants in the catchment

area (incidence = number patients / population x 10,000). Apart from the longterm

incidence, the age- and sex-specific incidence, and the incidence for several injury

causes were computed. The absolute number of hospital admission was used to

investigate the workload in our hospital.

RESULTS

Incidence rates

It appeared that 8,567 distal forearm fractures out of a total of 256,431 trauma

visits (3%) were recorded during the period of observation. The mean incidence

rate across the whole population increased in the period 1970-1981, while a

gradual decrease can be observed in the period 1981-1995 (see Table 1). Turning

to riskgroups, the highest age-specific incidence rate ocurred in the group older

40

than 79 years throughout the whole period of observation. The age group of 0 to 9

years was the second greatest risk group at the end of 1995, due to an increasing

incidence rate. In contrast, a decrease was observed in the age groups of 50 to 79

years. While, the incidence rate remained rather stable in the age groups of 20 to

49 years.

In respect to gender characteristics, the mean male to female ratio across the

whole lifespan showed a slight predominance for women (M/F 1:1.4). Under the

age of 40 years almost no sex predominance was present. Whereas, above 50

years a clear turning point in male/female ratio can be noticed, and more women

than men were treated (see Table 1).

Age group(years)

Period (per 10,000) Male/female ratio

71 - 75 76 - 80 81 - 85 86 - 90 91 - 95

0 – 9 75 83 78 79 87 1 : 1

10 – 19 65 67 62 45 63 1 : 1.7

20 – 29 19 24 20 20 20 1 : 1.3

30 – 39 19 30 21 20 22 1 : 1.1

40 – 49 22 27 23 26 18 1 : 0.8

50 – 59 45 45 39 39 29 1 : 4

60 – 69 65 76 48 49 35 1 : 6

70 – 79 76 99 67 70 62 1 : 5

! 79 84 103 89 89 87 1 : 4

mean incidenceper 10,000

47 53 41 39 38 1 : 1.4

population * 845,035 807,656 831,025 839,614 849,197

Table 1. Incidence rate per 10,000 inhabitants of distal forearm fractures (n= 8567) per age group in

the period 1971 to 1995. Generally, a gradual decrease in incidence rate can be observed. If a

subdivision of incidence is made in a low (10 - 29 per 10,000), an intermediate (30 - 59 per 10,000),

and a high risk group (60 - 100 per 10,000), the age groups of 0 - 9, 10 - 19 years, and above 70

years are most at risk. Legend:* total population in adherence area in absolute number.

41

Aetiology

Accidental fall was the major injury cause across the whole lifespan ( see Table 2).

Despite the fact that the incidence rate of accidental fall decreased constantly

from 32 in 1971 to 22 per 10,000 in 1995. Furthermore, it appeared that the

distribution of the three major causes remained stable in 25 years. Another

frequently observed injury cause was sport & leisure, especially in the age groups

of 0 to 9, and 10 to 19 years. However, the longterm trends of both sport & leisure,

and traffic were stable with 7 per 10,000.

Age group Accidental fall Sport & Leisure Traffic Other Total

0 - 9 60 12 4 4 80

10 - 19 28 19 11 3 61

20 - 29 8 5 5 3 21

30 - 39 9 5 5 3 22

40 - 49 14 3 5 1 23

50 - 59 28 3 6 2 39

60 - 69 42 2 8 3 55

70 - 79 59 3 8 5 75

! 79 76 4 5 5 90

Table 2. Distribution of the main causes of distal forearm fractures per age group in incidence rate

per 10,000 inhabitants. The mean over the whole period of 25 years is displayed.

In-patient treatment

In-patient treatment was performed in 886 out of 8,567 patients (10%). The

pattern of injury cause in case of inpatient treatment was respectively accidental

fall in 50%, traffic in 29%, and sports & leisure in 15% of cases. It is shown in

Table 3, that per 5-year period the number of hospital admission changed with

both increases and decreases. However, it seems clearly that on the long term the

42

proportion of in-patient treatment increased almost two-fold from 6 percent in 1971

to 14 percent in 1995. In respect to age, the greatest rise can be seen in the age

group of 0 to 9 years. However, a marked increase also ocurred in the age groups

of 0 to 49 years. Although, in the age group of 70-79 years an increase can be

observed, it appears that the longterm increase of hospital admission can largely

be attributed to patients younger than 50 years.

Age group(years)

Period Total

71 – 75 76 - 80 81 - 85 86 - 90 91 - 95 inpatienttreatment

fractures

0 – 9 18 24 53 38 42 175 1754

10 – 19 24 47 64 35 41 211 1992

20 – 29 13 29 28 19 24 113 948

30 - 39 7 11 14 21 22 75 557

40 - 49 7 10 11 18 15 61 465

50 - 59 16 17 13 16 11 73 763

60 - 69 14 15 12 9 15 65 952

70 - 79 5 14 19 16 28 82 833

> 79 2 2 12 8 7 31 303

Total inpatient 106 169 226 180 205 886

Total fractures 1885 2031 1625 1529 1497 8567

Table 3. An oversight of the clinical workload in the period 1971-1995 across the whole lifespan is

shown. Instead of the incidence, the absolute numbers of patients are displayed. Both the total of all

treated patients and the total of only inpatient treatment are shown in the last two vertical columns.

The trends of inpatient treartment per age group are shown, horizontally.

43

DISCUSSION

This study shows, that the incidence rate of distal forearm fracture increased in

the period 1971 to 1980, but a clear decrease occurred from 1981 to 1995.

Interestingly, the increase in the nineteen-seventies is similar to the incidence

trends that were reported by Scandinavian authors (1, 2). Bengner et al.,

compared the incidence rates of the period 1953-1957 with those of 1981and

1982. It was predicted that an ongoing increase would occur in the years

thereafter. In contrast, we presently found a decrease in incidence rate.

Apparently, an extrapolation of observations based on historical data is not always

warranted, and a forecasted trend may not appear, actually. It seems, that trends

might better be monitored longitudinally to study epidemiological developments.

Turning to risk groups, it appeared that patients older than 79 years remained the

highest risk group during 25 years. It has been reported elsewhere that people

older than 60 years were the main risk group (2). So, a shift from people towards

the oldest patients in the lifespan might have taken place. The clinical context of

this change may be noteworthy, because biological factors like osteoporosis and

comorbidity may interfere with fracture healing, and with functional outcome in

older patients. Furthermore, it seemed that the number of distal forearm fractures

in children has increased enormously. An increase in fractures in children may

pose the clinician more often to specific problems like growth disturbances in the

wrist.

Paradoxically, while the incidence rates decreased the rate of hospital admission

increased two fold since 1971. This rise can not be explained by alterations in the

extent of the population in the area of adherence, because the population grew

with only 0.5 % in 25 years. Therefore, we think that policy changes in the

nineteen-eighties most likely caused the observed change. Firstly, since 1980

reduction of displaced fractures in children was no longer performed under local

but under general anaesthesia causing an increase in registration of inpatient

treatment. Secondly, the observed rise in patients of 30 through 50 years may

44

have caused an increase in clinical treatment. Because these patients are more

often operated on. During the eighties new insights gained popularity in the field of

wrist surgery, and the aim was to strive for optimal anatomical results. As a

consequence, more indications for primary operative treatment were also

employed in our department (4, 5).

REFERENCES

1. Falch JA. Epidemiology of fracture of the distal forearm in Oslo, Norway. Acta Orthop Scand

1983; 54: 291-295.

2. Bengner U, Johnell O. Increasing incidence of forearm fractures. Acta Othop Scand 1985; 56:

158-160.

3. Oskam J, Kingma J, Klasen HJ. The Groningen Trauma Study. Eur J Emerg Med 1994; 1: 167-

172.

4. Oskam J, Bongers K, Karthaus AJM, Frima AJ , Klasen HJ. Corrective osteotomy for malunion

of the distal radius. Arch Orthop Trauma Surg 1996; 115: 219-222.

45

46

CHAPTER 4

RECOGNITION OF 10 DISTAL RADIAL FRACTURE TYPES BY RESIDENTS.

J Oskam, J Kingma, A J M Karthaus, H J Klasen.

Departments of Surgery, University Hospital Groningen and Deventer Hospital

the Netherlands

47

Submitted

Patients with a distal radial fracture are commonly treated by physicians with little

experience. Since, many specific types of distal radial fractures have been

described, and different therapeutic regimens can be choosen, there is a need for

a classification method which is easy to handle. A search in Medline showed that

at least thirteen classification systems have been reported since 1960. It seems,

that no classification system has been proven to be superior, and a generally

accepted frame of reference for inexperienced physicians to classify distal radial

fractures is still lacking. Although, universal classification systems has been

introduced, it appears not to be uncommon that fractures are usually provided with

labels referring to either the first author describing the particular fracture type

(synonyms), or referring to an injury mechanism (eponyms) (2).

Given the fact that a universal classification system is often not being used, a

question to be answered is how the base-line of the clinician’s recognition of distal

radial fractures can be established. Knowledge about the performance of

recognizing the different fracture types may reflect the actual classification ability,

and may serve as a starting point to develope useful programs to teach the

essence of distal radial fractures (7). In addition, a strategy may be designed how

modern, treatment-based classification systems might be introduced to clinicians

(5). The purpose of the present study is to investigate the verbal and visual

recognition of 10 commonly cited distal radial fractures (1,10).


Participants were 30 surgical residents from five teaching hospitals, who had on

the average 2 years clinical experience (range 1- 4 years). The residents

participated in a test in which they were asked to assess a series of 10 different

distal radial fracture types. The series of fracture types was developed with an

increasing level of complexity. Several simple fractures and some specific intra-

articular fractures, fracture-dislocation, and combination fractures were included.

The series of 10 fracture types consisted of respectively: Colles’, Smith’s, distal

48

forearm, a combination of radius & scaphoid, radial styloid process, dorsal

Barton’s, volar Barton’s, pilon, chauffeur’s, and lunate load fracture (1, 4, 8, 10).

The test consisted of two parts; a verbal and a visual part with 10 items each.

Each verbal item consisted of a description of a distal radial fracture. At least two

relevant distinctive features of the specific fracture type were used for the

description of each verbal item (see Appendix). In each verbal item the subject

was asked whether he recognized the particular fracture in the description. The 10

questions were printed on one sheat and each verbal statement was followed by a

question about whether the clinician recognized the particular fracture in a “yes” or

“no” format.

The 10 corresponding visual items contained an X-ray (AP and lateral projection)

of each fracture type. Only those X- rays were included in which there was

complete agreement between the authors about the type of fracture and the

clearness of the X-ray. Each fracture type on an X-ray corresponded with the

concomitant verbal item. The administration of the tasks was in a random order.

The subjects were asked to write down the name (diagnosis) of the fracture type

on a sheat. In case they didn’t know an exact label of the fracture type, they were

asked to write down the relevant distinctive features of the particular fracture.

Before test administration, two introductionary examples were given for each kind

of test to accustom the subjects to the questions that were posed. The verbal test

was administered at first, followed by the visual test. To avoid bias due to

repeated measurement the verbal and visual recognition items were administered

in a random counterbalanced order for each test (9). The administration of the 10

verbal and visual items together took about 45 minutes. For each verbal item

affirmative responses (“yes”) were scored as 1, and “no” responses were scored

as 0. For each visual item, a correct respons (score 1) was defined as either a

correct diagnostic label, or a description in which at least two distinct features from

the corresponding fracture description were correctly used. A zero score was

given in all other instances. The maximal total score per participant ranged from 0

to 10 for both the verbal and visual counterparts.

The percentage of positive (“yes”) answered verbal questions, and correctly

diagnosed X-rays was computed per fracture type for the whole group of subjects.

49

By definition, the criterion of a score more than 80 percent correct responses per

item for both verbal and visual recognition was choosen as a standard of

adequately diagnosing the particular fracture (9). The binomial (Z) test was used

to test the percentage of correct responses against the criterion of 80 percent for

each fracture type. The Spearman rank correlation coefficient (Rs) was employed

to show the extent of agreement between the rank order of scores in the verbal

task and the rank order of scores in the visual task. For each individual fracture

type the number of correct responses on the verbal items was tested against the

number of correct responses on the visual counterpart with the McNemar test. In

all tests, a p-value < 0.05 was considered as the level of significance.

RESULTS

VISUAL TASK VERBAL TASK

Figure 1. Frequency distributions of correct answers in the visual task (left diagram), and affirmative

responses (“yes”) in the verbal recognition task (right diagram). The median score per participant

was 3 (range 0-10) in the visual task (left diagram), and 6 (range 0-10) in the verbal task (right

diagram). Legend: On the X-axis the total score of a subject is displayed. On the Y-axis the number

of subjects with a particular total score is displayed.

The frequency distributions of the total scores per participant are shown in Figure

1. It can be seen that the median was at the score of 3 on the visual recognition

task, whereas the median for the total score on the verbal recognition task was 6.

0123456789

101112131415

0 1 2 3 4 5 6 7 8 9 10

Total s core s

N o

f s

ub

jec

ts

0123456789

101112131415

0 1 2 3 4 5 6 7 8 9 10

Total s core s

N o

f s

ub

jec

ts

50

Although, the overall performance differed between the two types of tasks, the

rankorder of the total scores per participant on the verbal task showed a very

strong association with the rankorder of the total scores on the visual recognition

task (Spearman rank correlation coefficient (Rs) = 0.91).

Figure 2 shows, that the mean score of verbal recognition (68% “yes”) was

statistically significantly greater than the mean score of visual recognition (33%

correct). Turning to the performance per fracture type, the highest scores on both

verbal and visual recognition were observed in respectively: Colles’, Smith’s, and

distal forearm fracture. The percentage of correct responses per fracture type was

also tested against our criterion of more than 80% correct responses. Although, 8

verbal tasks did not differ statistically significantly on the 80% criterion (Z-test),

only 3 corresponding items (Colles’, Smith’s, and distal forearm fracture) satisfied

the criterion in the visual task.

According to the McNemar test, visual and verbal recognition were in accordance

in 6 fracture types. However, a statistically significant difference was found in

dorsal Barton’s, volar Barton’s, pilon, and radius & scaphoid fracture. Taken

together, it may be concluded that in the group of 30 residents only Colles’,

Smith’s, and distal forearm fracture met the 80% perfomance criterion. Almost no

correct radiographic asssessment was found in 5 particular fracture types (pilon

fracture, radial styloid process, volar and dorsal Barton’s fracture, and radius &

scaphoid fractures). In addition, the lowest performance on the corresponding

verbal recognition task was found in chauffeur’s and lunate load fracture.

Apparently, specific intra-articular and fracture-dislocations were the difficult

fracture types to recognize. Finally, an inventory was made of the incorrect

descriptions on the 10 visual items for all 30 residents. It was found that the total

of 68% (n=202) of responses was incorrect. A division could be made in either an

incorrect diagnostic label, or an incomplete description. Remarkably, the labels

Colles’ or Smith’s were used in 98 out of 202 incorrect diagnoses.

Figure 2. (see next page) Survey of the results of self-assessment of verbal knowledge, and the assessment of wrist

radiographs (visual recognition). The data clearly show an empirical division in a group with more than 80% verbal and

visual recognition, and a group of 7 fracture types with less adequate diagnostic performance. In the gray areas the

observed measurement did not differ statistically significantly (Z-test) from the 80% performance criterion. Legend: The

51

maximum score per fracture item is 30.

Fracture type Visual recognition Verbal recognition McNemar

n correct (%)

per item

n “yes” (%)

per item

Colles’ 25 (83) 30 (100) NS

Distal forearm 25 (83) 25 (83) NS

Smith’s 23 (77) 30 (100) NS

Radial styloid

process

16 (53) 20 (66) NS

Barton’s dorsal 4 (13) 20 (66) p < 0.05

Barton’s volar 2 (7) 20 (66) p < 0.05

Pilon 2 (7) 19 (63) p < 0.05

Radius & Scaphoid 1 (3) 22 (73) p < 0.05

Chauffeur’s 0 9 (30) NS

Lunate load 0 8 (27) NS

52

Total 98 (33) 203 (68) p < 0.05

DISCUSSION

This study showed that many residents have difficulties in recognizing the specific

types of distal radial fractures. It appeared, that only Colles’, Smith’s, and distal

forearm fracture were adequately recognized. It also occurred that the Colles’ and

Smith’s labels were most often used in incorrect visual assessments. In other

words, the participants tend to label complex visual pictures in fracture types they

already know. Most participants seemed to reduce the actual number of fracture

types to 3 items in order to cope with 10 different distal radial fractures (6). Most

likely, many subjects rely on a base-line knowledge which represents 3 fracture

types. To our knowledge this observation has not been reported before, although

it may be obvious to those involved in the management of wrist fractures and the

training of residents. However, the results confirm the idea that a simple

eponymous or synonymous classification system may not be the best strategy to

deal with all distal radial fractures (2).

A discrepancy between verbal and visual recognition was found in all fracture

types. The observed difference may be explained by two reasons. Firstly, it

appeared that visual and verbal recognition were statistically significant different in

respectively, dorsal Barton’s, volar Barton’s, pilon, and radius & scaphoid fracture.

The high scores on verbal recognition in these four items may reflect a tendency

to overestimate the skill to visually recognize a fracture type on the X-ray.

Overestimation in inexperienced physicians has been reported before and is also

known as “overconfidence bias” (3). Verbal performance was significantly greater

than visual performance in the mentioned four fracture types, and it seemed that

overconfidence bias influenced diagnostic performance. Secondly, an explanation

for the observed visual recognition rate of 12% in 7 fracture types may be a lack of

verbal knowledge about the relevant distinctive features of distal radial fractures

(3,6). The relevant distinctive features may not be known by inexperienced

53

physicians, because definitions and descriptions are often not described explicitely

in publications. It seems plausible, that recognition might be improved if relevant

distinctive features of distal radial fractures are described more systematically in

handbooks or at educational courses.

The drawback of simple classification systems with synonyms and eponyms, is

that it is historical, not universal, and not treatment-based (7). The AO/ASIF’s

system for classification of fractures has been designed to overcome the above

mentioned shortcomings, and may be a worthwhile tool for inexperienced

physicians (5). The precise clinical value and the rate of agreement of the AO

system for distal radial fractures has yet to be assessed. But, it has also been

advocated by Mueller that the reliability of the AO system can only be improved if

the relevant distinctive features of each fracture are emphasized even more better

(5).

REFERENCES

1. Cautilli RA, Joyce MF, Gordon E, Juarez R. Classifications of fractures of the distal radius. Clin

Orthop and Rel Res 1974; 103: 163-66.

2. Fernandez DL. Classification. In: Fractures of the distal radius (Eds Fernandez D L and Jupiter

J B), Springer-Verlag New York 1996: 26-29.

3. Gordon MJ. A review of the validity and accuracy of self-assessments in health professions

training. Academic Medicine 1991; 66: 762-69.

4. Melone CP. Distal radius fractures: Patterns of articular fragmentation. Orthop Clin North Am

1993; 24: 239-53.

5. Mueller ME. Two pamphlets of the Comprehensive Classification of Fractures, edition 1996.

AO/ASIF Documentation Center Davos, Switzerland 1996.

6. Norman GR, Coblentz C L, Brooks L R, Babcook CJ. Expertise in visual diagnosis: A review of

the literature. Academic Medicine 1992; 67 Oct suppl: s79-s83.

7. Oskam J, Kingma J, Venekamp R, Klasen H J. Colles and Smith as scholars for residents.

Nederlands Tijdschrift voor Traumatologie 1994; 2: 39-43.

8. Oskam J, Graaf de JS, Klasen HJ. Fractures of the distal radius and scaphoid. J Hand Surg

1996; 21B: 772-774.

9. Sheridon CL. Fundamentals of experimental psychology. Holt, Reinhardt, and Winston New

York 1971.

10. Solgaard S. Classification of distal radius fractures. Acta Orthop Scan 1984; 56: 249-252.

54

CHAPTER 5

THE BASIC CATEGORIES OF THE AO/ASIF’S SYSTEM AS A FRAME OF

REFERENCE FOR CLASSIFYING DISTAL RADIAL FRACTURES.



Groningen, the Netherlands

55

Submitted

56

Since 1987, the AO/ASIF’ system for classification of fractures is being used to

predict outcome and to assist in choosing an appropriate treatment regime (2).

The AO system appears to be an attractive frame of reference, because the

Orthopaedic Trauma Association in the United States of America has recently

adopted the AO system as the standard of fracture classification. Moreover, the

AO classification is quite often teached in postgraduate courses and handbooks.

Although the AO system is used worldwide, only few studies to interrater

agreement or reliability have been published as far as we know.

In respect to distal radial fractures, only one study has been published which

reported specifically on agreement of the AO classification (1). In this study, the

focus of interest was the interrater agreement in 36 assessors, with varying clinical

experience, in a selected sample of 30 fractures. Good agreement was observed

for experienced surgeons only (kappa value = 0.68). In addition, it appeared that

agreement was just good for the level of the 3 basic types (A, B, and C), while the

kappa values for the lower levels of the 9 main groups and the 27 subgroups were

0.48 (moderate agreement) and 0.33 (fair agreement), respectively.

May be, it is not surprising that the rate of agreement diminished with ongoing

refinement of the classification system into subclasses. However, the usefulness

of a classification method depends largely on the reliability of the system.

Agreement in the basic categories should be almost perfect before classification at

lower levels is performed, because further refinement in subclasses will inevitably

result in a decrease of agreement. Therefore, it may be interesting to analyze

which problems may rise in the allocation of fracture types into the 3 basic

classes. And, how some issues can be resolved before other levels of

classification are studied. The purpose of the present study was to investigate how

the AO methodology may be employed to assign distal radial fractures which are

usually seen in the emergency unit, and to determine the effect of consensus

stimulation by the so-called Delphi approach on observer agreement. A second

concern was to describe the underlying causes of possible disagreement between

two observers.

57


Study design

A random sample of 124 cases was drawn out of 385 patients older than 18 years

(median age 58 years), who visited the accident and emergency department in

1994 for a distal radial fracture. A fresh fracture and clear AP and lateral wrist X-

rays were available for all 124 patients.

The X-rays were presented in a random order, and were assessed by two expert

surgeons who treat wrist fractures regularly. The two observers assessed the X-

rays independently. No information was given about the performed treatment and

outcome. The observer was asked to classify the fracture according to the

AO/ASIF’s classification system on a separate sheet. The AO/ASIF classification

for distal radial fractures (no. 23.x-x) is composed of 3 basic fracture types, 9 main

groups, and 27 subgroups (2). The 3 basic fracture types are extra-articular

fractures (class A), partial intra-articular fractures (class B), and complete intra-

articular fractures (class C). The observers were asked to assign the fractures to

one of the basic groups A, B, or C, and to group D if a fracture could not be

attributed to a particular AO category (2). The observers were allowed to use the

scheme of the classification system with examples as provided by the AO/ASIF,

and there was no limitation of time to complete the test.

After the test was completed the observers were invited to join a consensus

meeting. The Delphi approach was used to reach a consensus regarding the most

appropriate assignment to the 3 basic AO categories for which a disagreement

between the two observers was found (3). The steps involved in this process are

summarized below.

As a first step in developing a consensus, the two observers employed the criteria

and the assumptions of the AO classification for the 3 basic classes. Having

agreed on these assumptions independent assignment of the fractures to either

class A,B,C or D was then made again by the two observers. During the Delphi

approach conflicting arguments in those fractures with disagreement were

discussed between the two observers, and the X-rays were viewed again. The

58

results of the independent ratings were compared and discrepancies identified.

Then, a discussion followed on the basis of relevant distinctive features of distal

radial fractures (5). Most discrepancies were resolved by discussion of the

relevant distinctive features by both observers and an independent chair. Finally, it

was decided whether consensus was reached. The assignments for which

disagreement remained were identified and recorded to allow further analysis.

Statistics

For each X-ray, a pair wise comparison of the answers of the two observers was

performed in a cross-table. The percentage of agreement was computed both for

before and after the Delphi meeting. Furthermore, the fracture types in which

disagreement occurred were located in the cross-table. Cohen’s kappa statistics

was used to adjust for overall agreement attributable to chance (6). For the

interpretation of the degree of agreement the following criteria were used: Kappa

values 0.0 through 0.20 represent slight agreement, 0.21 to 0.40 fair agreement,

0.41 to 0.60 moderate agreement, 0.61 to 0.80 good agreement, above 0.81 is

considered almost perfect agreement (4).

Categorization By Observer 2

A B C D

A 62 1 5 1


B 2 4 3 1

C 7 27 1

D 2 1 1 6

Table 1a. Cross tabulation of the assessments (n=124) of observer 1 and observer 2 according to

the four basic categories (A,B,C,D) of the AO/ASIF’s classification before the Delphi approach was

undertaken. The figures represent absolute numbers. Agreement for the categories A,B,C, and D

59

are shown in bold numbers. Disagreement between the observers can be seen in not-bold printed

numbers. The sum of the bold numbers (n=99) is the total agreeement in all 124 fractures.

RESULTS

The overall interrater agreement was good because Cohen’s kappa value was

0.65 . Table 1a shows the cross tabulation of the assignment of 124 fractures to

the basic categories by the two observers. If both observers agree completely all

observations would lie on the main diagonal. So, each element on the diagonal

line represents the degree of agreement for a particular category. It can be seen

that the 2 observers agreed on 62 assignments to class A, i.e. 50% (see also

Table 1b) of the 124 X-rays. The majority (72%) of the fractures was assigned to

respectively category A (50%) and category C (22%). The sum of the elements on

the diagonal line represents the overall agreement between the 2 observers, e.g.

agreement was found for 99 fractures (Table 1a), or 80% (Table 1b) across all

categories.

CategorizationBy

Observer 2

A B C D

A 50 1 4 1


B 2 3 2 1

C 6 22 1

D 2 1 1 5

Table 1b. Cross tabulation of the assessments (n=124) of observer 1 and observer 2 according to

the four basic categories (A,B,C,D) of the AO/ASIF’s classification before the Delphi approach was

60

undertaken. The figures represent percentages. The percentage of agreement for the categories

A,B,C, and D are shown in bold numbers. Disagreement between the observers can be seen in not-

bold printed numbers. The sum of the bold numbers (80%) is the total percentage of agreeement in

all 124 fractures. Statistically, Cohen’s kappa value for overall agreement was 0.65.

The elements beside the diagonal line represent the degree of disagreement

between the two observers. Table 1 shows that the highest degree of

disagreement occurred for the categories A and C. Observer 1 assigned 5

fractures to category A, whereas Observer 2 assigned the same fractures to

category C (Table 1a). On the other hand, Observer 1 assigned 7 fractures to

category C, whereas Observer 2 assigned the same fractures to category A. Thus,

analysis of Table 1 shows an A versus C “reversal shift”, i.e. a controversy

between the assignments to either the A or C category.

CategorizationBy

Observer 2

A B C D

A 56 2


B 7

C 5 23

D 1 6

Table 2. Cross tabulation of the assessments (n=124) of observer 1 and 2 according to the four

basic categories (A,B,C,D) of the AO/ASIF’s classification after the Delphi approach was

undertaken. The figures represent percentages. The percentage of agreement for the categories

A,B,C, and D are shown in bold numbers. Disagreement between the observers can be seen in the

not-bold printed numbers. The sum of the bold numbers (92%) is the total percentage of

agreeement in all 124 fractures. Statistically, Cohen’s kappa value for overall agreement was 0.86.

61

The results of the Delphi meeting can be seen in Table 2. It appeared that the

overall agreement was 92%, which was 12% higher than the observed 80%

before the meeting (Table 1b). Due to the consensus meeting the kappa value for

the 3 basic classes increased from 0.65 to 0.86 (excellent agreement). Agreement

on category A increased from 50% to 56%. It appeared that about 5% of this

increase came from category D fractures. Another remarkable shift can be

observed in category B. In this group it was found that agreement rose from 3% to

7%. During the meeting it occurred that disagreement on a B versus C fracture, or

a B versus A fracture could be solved. Despite the increase of agreement in the A

and B fractures, a part of disagreement still remained: some controversy between

class A and C fractures (“reversal shift”) was still observed, although the A/C

reversal shift decreased from 10% to 7% of cases after the meeting.

With respect to the D fractures, disagreement was found in 7% of cases before

the meeting, and decreased to 1% thereafter. The reason for this shift was that in

these particular cases an undisplaced fracture was considered to be displaced by

both observers. These fractures were assigned as category A. However, after the

meeting 8 fractures were still considered to be undisplaced and remained

classified as category D.

DISCUSSION

The AO system showed to be a useful tool for classifying distal radial fractures,

since good agreement (kappa value 0.65) was observed before the Delphi

meeting. The present finding that the presence or absence of articular involvement

can be assessed consistently if classification is undertaken by experienced

observers has also been reported by Kreder et al. However, since the purpose of

their study was just to quantify agreement, analysis to specific causes of

disagreement was not undertaken. Presently, a qualitative analysis to the

underlying mechanisms of disagreement was performed by employing the Delphi

approach. It was found that non-displaced fractures were a major source of

controversy. These results are in agreement with Kreder’s findings, and it seems

62

rational that a separate class for undisplaced fractures has to be defined in the

AO/ASIF’s system to resolve this important issue (1).

Although an increase in interrater agreement was found, perfect agreement on the

3 basic classes could not be reached. May be, the observed “A/C reversal shift” is

one of the causes of disagreement. Apparently, the controversy between extra-

(A) and intra-articular (C) fractures is a basic problem, because disagreement

remained in 7% of cases even after extensive discussion. It might be

hypothesized that the main cause of disagreement is a shortage of information

due to the radiographic imaging technique. In other words, technological

shortcomings may bias classification reasoning with respect to intra-articular

involvement. Therefore, radiological innovations or additional information, for

instance by routinely employing oblique directions of the distal radius, may

increase agreement on articular involvement in the distal radius.

Many conflicting assessments could be resolved during the consensus meeting by

discussing the particular X-rays. It appeared that the sources of conflict were

differences in opinion about relevant distinctive features. However, on the basis of

these relevant distinctive features, the observers were willing to agree on the

choice of a particular classification group. But disagreement remained in several

cases even in experienced observers. It may be impossible to reach perfect

agreement due the above-mentioned A/C reversal shift, or because fracture types

are not good enough defined. However, we experienced that discussion on the

basis of relevant distinctive features was a good starting point to improve

agreement.

It appeared that agreement was only good for the level of the 3 basic classes.

Most likely, the clinical relevance of using only 3 classes is too limited to assess all

types of distal radial fractures. However, we feel that the observed problems at the

basic level, like the issues of the undisplaced fractures and articular involvement,

have to be resolved first. Otherwise, this noise will continue to create problems at

lower, clinically more meaningful levels in the classification system. We feel that

radiological innovations are not the only measures to improve agreement on the

AO/ASIF’s classification system for distal radial fractures. But intercollegiate

63

discussion on relevant distinctive features may also be important to reach the goal

of good agreement.

REFERENCES

1. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of the

AO fracture classification for the distal radius. J Bone Joint Surg 1996; 78B: 726-31.

2. Mueller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of

long bones. Springer-Verlag Berlin, Germany 1990.

3. McKenzey EJ, Steinwachs DM, Shankan BS. An ICD-9-CM to AIS conversion table

development and application. Proc Am Assoc for Auto Med 1986; 30: 135.

4. Landis JR, Kochj GG. The measurement of observer agreement for categorial data Biometrics

1977; 33: 159-74.

5. Oskam J, Kingma J, Karthaus AJM, Klasen H J. Recognition of 10 distal radial fractures types

by residents. 1997 submitted.

6. Reynolds H. The analysis of cross-classifications. Mcmillan Publishing Co. New York, USA

1977.

64

CHAPTER 6

FRACTURES OF THE DISTAL RADIUS AND SCAPHOID

J Oskam, J S de Graaf, H J Klasen.



Journal of Hand Surgery, 1996; 21B: 772-774

65

The usual conservative treatment for isolated distal radial fractures is to apply

ligamentotaxis across the radiocarpal joint by traction with immobilization of the

wrist in a neutral position. However, it is generally believed that tractional forces

should be avoided in scaphoid fractures, while the wrist is best positioned in radial

deviation with immobilization of the thumb. In the case of a combination of

fractures of the distal radius and scaphoid, each immobilization technique may

have opposite effects on fracture healing. Therefore, one might expect either an

increased rate of scaphoid nonunion or malunion of the distal radius.

We have treated 23 patients with simultaneous fractures of the distal radius and

scaphoid over a period of 14 years. A below elbow cast including the thumb was

used as standard treatment, because we feared more scaphoid than distal radius

complications. In the present study, we have evaluated the results of our

treatment policy.

PATIENTS AND METHODS

During the period 1980 to 1993, a fracture of the distal radius and the scaphoid

was diagnosed in 23 patients. There were 10 women and 13 men , with a median

age of 39 years (range 18-74). The dominant hand was involved in 9 patients. The

injury resulted from an accidental fall in 17, sports in 3 and traffic accidents in 3

cases.

X-ray assessment

The scaphoid and distal radial fracture were classified separately. The scaphoid

fracture was assessed for site and displacement. Displacement of the scaphoid

fracture was defined as displacement of at least 1 mm. The scaphoid was divided

in 3 parts to describe the fracture localization (2). The distal radial fracture was

classified by type, and involvement of the radiocarpal joint surface was also

assessed (3).

During follow up, X-rays of the distal radius and scaphoid were used to investigate

signs of disturbed bone healing. To assess malunion of the distal radius, the

radiocarpal angle and radial shortening were measured (7). The scaphoid was

66

assessed for pseudarthrosis, avascular necrosis, or cysts. Finally, signs of post-

traumatic osteoarthritis and carpal instability were noted.

Treatment

A below elbow cast including the thumb with the wrist immobilized in radial

deviation and flexion was applied in 18 patients treated conservatively. The mean

immobilization period was 9 weeks, and depended on healing of the scaphoid

bone. Closed reduction of the distal radial fracture was performed in 9 of 18

conservatively treated wrists.

Primary operative treatment was undertaken in 3 patients. A secondary operation

was performed in 2 patients in whom redisplacement of the distal radius occurred

during conservative treatment. An unstable distal radial fracture was the indication

for surgery in all cases. Screw fixation of the radius was performed in a palmar

Barton’s fracture. An external fixator was applied in 2 other cases with a

comminuted intra-articular distal radial fracture. Closed re-reduction and K-wire

pinning was performed in the 2 patients with radial redislocation. Concomitant

fixation of the scaphoid fracture with a cannulated cancellous bone screw was

performed in 4 patients.

Follow-up

The follow-up study comprised both clinical and X-ray examination. Healing of the

fractures was radiologically monitored in all patients a 5 day, 2, 6, 9, and 12

weeks intervals. In total, 21 patients were eligible for examination, because 2

patients were deceased at the time of study. Pain, range of wrist motion, and grip

strength were assessed. The functional end results were judged as good when no

pain occurred with use, and fair if pain and moderate discomfort was present with

use, provided that the patients had completely returned to normal activities. The

functional end result was considered to be poor in all other circumstances.

RESULTS

The mean follow up period was 7 years (range 1-13). The most serious

complication of fracture healing was redisplacement in 3 of 9 initially dorsally-

67

displaced distal radial fractures. An extra-articular Colles’ type fracture with severe

comminution of the dorsal cortex was present in these 3 patients. Closed

reduction and trans-styloid Kirschner-wire fixation was performed to prevent

malunion of the distal radius in these patients. Post-traumatic carpal instability was

not observed in any wrist. Healing of the scaphoid fracture was uncomplicated in

all 23 wrists. It appeared that all serious complications occurred on the side of the

distal radial fracture.

Fracture type

It can be seen in Table 1, that all scaphoid fractures were localized in the middle

or distal third. Displacement greater than 1 mm of the scaphoid fracture existed in

4 of 23 patients. Rotational subluxation or carpal instability was not present. An

extra-articular fracture of the distal radius was found in 15 patients, and in 7 dorsal

displacement (Colles’ fracture) was observed. An intra-articular distal radial

fracture was observed in 8 of 23 wrists.

Distal radius Scaphoid

Middle third Waist Distal third

Extra-articular Undisplaced 1 6 1

Colles’ 4 2 1

Intra-articular 2 4

Chauffeur’s 1

Barton 1

Table 1. Radiological classification of 23 simultaneous fractures of the distal radius and the

scaphoid.

Wrist function

Overall, 21 patients were satisfied with the functional end result and had resumed

normal daily activities. Operative treatment had been undertaken in 4 of them.

68

Wrist pain was reported by 5 patients. Diminished dorsal flexion with disturbed

forearm rotation was observed in 4 patients, of whom 3 were treated surgically.

Subjective loss of grip strength was found in 2 patients with fair and poor

functional results.

After healing of the distal radius, shortening (2-7 mm) was observed in 6 wrists.

Diminished wrist motion was found in 4 patients. Wrist pain and serious limitation

in daily life was found in only 2 patients. One patient could not resume his job and

complained of pain with severe loss of wrist motion due to radiocarpal

osteoarthritis (a poor result), while another patient suffered from malunion of the

distal radius. A good functional result was eventually observed in 18 patients.

DISCUSSION

This study confirms that in most simultaneous fractures of the distal radius and

scaphoid good results can be obtained with conservative treatment (4,6).

However, the finding that nearly all problems with fracture healing occurred in the

distal radius has not been reported before.

The redisplacement of three distal radial fractures might well have been caused by

the position of the wrist in the below elbow cast. In this series the wrist was

immobilized in radial deviation, a position which can provoke radial displacement

because it allows the brachioradial muscle to act on the distal radius. Although we

cannot be certain, we think that radial deviation of the wrist might have contributed

to redisplacement of the distal radius.

Primary surgery was necessary in a minority of cases. The indication for surgery in

the three primarily operated patients was an unstable, intra-articular distal radial

fracture, in which the risk of malunion with conservative treatment was thought to

be unacceptable. We would also have operated on these wrists had the fracture

been isolated, so the presence of the scaphoid fracture did not influence the

decision. In our opinion, standard indications for operation cannot be given, and

surgical treatment should be tailored to the individual patient. Generally, the

decision whether to operate on the simultaneous fractures should be based on the

69

same criteria as isolated fractures, e.g. an unstable, displaced scaphoid fracture

(2,5), an unstable, displaced distal radial fracture (3), and carpal instability.

All scaphoid fractures healed normally, and avascular necrosis was not observed.

The explanation for this observation is most likely the fact that 19 out of 23

scaphoid fractures were undisplaced and localized to the waist. It has been

described previously that healing of fractures near or at the waist of the scaphoid

is complicated in only 5% of cases (2). However, we initially thought that the

scaphoid fracture would produce the more serious complications, so a below

elbow cast including the thumb instead of a dorsal splint was used.

It appears that the outcome of the combined fractures is determined more by the

distal radial fracture. It has been reported that the type of cast used to immobilize

stable scaphoid fractures does not affect the incidence of non-union or other

complications of fracture healing (1), and that good results could be achieved by

applying a dorsal splint with the wrist in neutral position. Immobilization of the

thumb is not necessary and reduction of the scaphoid fracture was not lost with

tractional forces across the wrist. Consequently, there is strong evidence that

treating a scaphoid fracture with the wrist in neutral position is not detrimential.

As a result of this study we shall apply a dorsal splint with the wrist in neutral

position for 6 weeks for non-operative treatment in future cases, because there is

more likelihood of redisplacement of the distal radial fracture than non-union of the

scaphoid.

REFERENCES

1. Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in

scaphoid fractures? A randomised prospective trial. Journal of Bone and Joint Surgery 1991;

73B: 828-32.

2. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to

mangement. Clinical Orthopaedics and Related Research 1980; 149: 90-7.

3. Jupiter JB. Current concepts. Review fractures of the distal end of the radius. Journal of Bone

and Joint Surgery 1991; 73A: 461-9.

4. Smith JT, Keeve JP, Bertin KC, Mann RJ. Simultaneous fractures of the distal radius and

scaphoid. Journal of Trauma 1988; 28: 676-9.

70

5. Szabo RM, Manske D. Displaced fractures of the scaphoid. Clinical Orthopaedics and Related

Research 1988; 230: 31-8.

6. Tountas AA, Wadell JP. Simultaneous fractures of the distal radius and scaphoid. Journal of

Orthopaedic Trauma 1988; 1: 312-7.

7. Warwick D, Prothero D, Field J, Bannister G. Radiological measurement of radial shortening in

Colles’ fracture. Journal of Hand Surgery 1993; 18B: 50-2.

71

72

CHAPTER 7

DORSAL FRACTURE-DISLOCATION OF THE RADIOCARPAL JOINT:

A FOCUS ON OPERATIVE TECHNIQUE.

J.Oskam, RAEC Hermens, HJ Klasen.



Submitted

73

Dorsal radiocarpal fracture-dislocation is defined by dorsal carpal displacement

caused by disruption of the radiocarpal ligaments, while the associated distal

radius fracture has to be confined to the rims and the styloid process (3).

However, a combination of radiocarpal and ulnocarpal ligamentous rupture, and

fracture of the ulnar styloid process are usually also present. Several cases have

been reported in the past 25 years (2, 4, 6, 8). In these papers, mainly clinical and

taxonomic aspects have been discussed. However, specific methods of operative

treatment to improve functional outcome have not yet been reported. In this paper

we will report on 6 patients which have been operated at the University Hospital

Groningen in the period 1982-1994. During this period we performed 3 different

operation techniques. We will discuss our experiences with operative

management, furthermore the functional results will be assessed.

CASE REPORTS

Case 1. A 40 years old man sustained multiple injuries while demolitioning a wall of a house. A part

of the wall fell on the patient, as he tried to hold back the wall with his left wrist dorsiflexed. An open

dorsal fracture-dislocation of the left wrist resulted with a large transverse wound volarly. Besides

the fracture-dislocation, a dorsal intercalated segment instability (DISI) with ulnar carpal

translocation was also present. Sensation was impaired in the second, third and fourth finger. Other

injuries were a large knee wound, and a large degloving injury at the lumbar region of the back. At

operation, debridement was performed and flexor tendons, arteries, and median nerve were found

to be intact. The volar carpal ligament was ruptured. Following reduction, the styloid process of the

radius was fixed with 2 K-wires. A plaster cast was applied to maintain carpal reduction. After 6

weeks the cast and the K-wires were removed, however, the radial styloid process was

redislocated. Three years later, the patient had returned to his previous work without complaining of

pain and with intact rotation of the forearm. However, severe osteoarthritis in the carpus was

present and wrist movement was severely impaired resulting in a functional arthrodesis.

Case 2. A 44 years old municipal worker fell from a 9 meter height and sustained fractures of the

sternum, the first lumbar vertebra, and a dislocation of the left wrist. The skin, circulation and

sensation of the hand were intact. Roentgenograms showed a dorsal dislocation of the carpus with

a comminuted fracture of the styloid proces and the dorsal rim of the distal radius. Closed reduction

and fixation with a K-wire was performed, and the wrist was immobilized with a dorsal plaster splint.

74

The K-wire was inserted proximally, and dorsally over the radiocarpal joint. After the procedure the

carpus seemed to be stable. An additional release of the volar carpal ligament was also performed.

Unfortunately, during the immobilisation period, due to loosening of the K-wire dorsal subluxation of

the carpus occurred. Nine years after the injury, the patient complained of pain while working.

Physical examination showed 40% impairment of flexion and extension compared to the opposite

wrist, with intact forearm rotation. Roentgenograms showed severe osteoarthritis of the radiocarpal

joint. The patient needed to wear a wrist orthesis to be able to work.

Case 3. A 37 years old construction worker fell from a 6 meter height. He sustained head wounds

and a fracture of the right radial styloid process. The left wrist showed a closed dorsal radiocarpal

dislocation without impairment of circulation and sensation. Roentgenograms showed a radiocarpal

dislocation with associated fractures of the radial and ulnar styloid process, as well as, a fracture of

the dorsal radial rim. Closed reduction and K-wire fixation was performed, as well as release of the

volar carpal ligament and application of a dorsal plaster splint. After inserting a K-wire on the wrist

dorsally, radiocarpal stability could only be achieved after fixation of the radial styloid process with a

second K-wire. Although carpal reduction could be maintained, redislocation of the styloid process

occurred during the first weeks, postoperatively. Five years after the injury the patient had not

returned to his previous job. He complained of wrist pain, and a loss of 50% of wrist movement with

intact forearm rotation was present. The roentgenograms showed radiocarpal osteoarthritis of

moderate degree.

Case 4. A 31 years old man fell while racing with a motorcycle. A fracture-dislocation of the right

humerus and a dislocation of the left wrist resulted. Skin, circulation and sensation of the left hand

were intact. Roentgenograms showed a dorsal dislocation of the carpus with concomitant fractures

of the radial and ulnar styloid processes and of the dorsal rim of the radius. During operation, closed

reduction and trans-articular external fixation was performed. Furthermore, release of the volar

carpal ligament was carried out. Radiocarpal reduction was maintained with an external fixator,

which was removed after 5 weeks. It was not possible to fixate the radial styloid process because of

fracture comminution. Postoperatively, no signs of redislocation were observed. Three years later,

the patient had returned to his previous job and did not complain of wrist pain. Physical examination

showed a limited wrist movement of 40% due to moderate osteoarthritis of the radiocarpal joint.

Case 5. A 18 years old man sustained a car accident. A dorsal fracture-dislocation of the right wrist

resulted. Skin, circulation and sensation were intact. A CT-scan showed that a DISI, Scaphoid-

Lunate (SL) dissociation and ulnar carpal translation was also present. At operation, open reduction

and screw fixation of the radial styloid process and the dorsal rim was performed. Radiocarpal

alignment was maintained with a protruding dorsal T-plate, which was fixated dorsally on the distal

75

radius. Because of ulnocarpal instability the ulnar styloid process was also fixated with a 2.7 mm

screw. Practising was started after 2 weeks of immobilization. Removal of the plate was performed

8 weeks, postoperatively. After 1 year, wrist movement was limited to 40% and pain was present.

Severe osteoarthritis of the radiocarpal joint and proximal carpal row existed. Carpal instability with

scaphoid-lunatum (SL)-dissociation and ulnar translation was still present.

Case 6. A 22 years old farmer sustained multiple injuries in a car accident. These comprised brain

concussion, a halfsided maxilla fracture, and a dorsal fracture-dislocation of the left wrist (See

Figure 1a). The dislocation was reduced, and the volar carpal ligament was released. After closed

reduction, the radial styloid process was fixated with a cancellous bone lag screw through a

separate small radial incision. A second dorsal longitudinal incision between the second and third

extensor compartment was also made to perform open reduction and stabilisation of the carpus.

Good radiocarpal alignment was maintained with a protruding T-plate which was fixed on the distal

radius (See Figure 1b). The plaster cast was removed after two weeks, and practising was started.

Following removal of the plate at 6 weeks, full return to normal activities occurred. After three years,

the patient experienced no wrist pain, although wrist movement was limited to 50%, probably due to

moderate osteoarthritis (See Figure 1c).

DISCUSSION

The histories of the six patients show that dorsal radiocarpal fracture-dislocation

usually occurs in multiple injured victims. Most likely, extreme dorsiflexion of the

wrist with pronation of the forearm on the fixed hand is the injury mechanism.

Apart from fracture-dislocation, median nerve palsy and soft tissue laceration are

likely to develop. In some instances, the volar carpal ligament is also ruptured, but

if not, release is strongly indicated (6). Remarkably, circulation of the hand

commonly is not compromised. One of the most striking clinical features is a

severely unstable radiocarpal joint, for which operative treatment is usually

mandatory (2).

It has been advocated, that closed reduction and K-wire fixation followed by

immobilisation with a splint may create adequate stability (4, 5). We followed this

policy in three cases. Surprisingly, a complication occurred in all three patients.

Either carpal subluxation or redislocation of the radial styloid process was

observed. Most likely, forces on the radiocarpal joint could not be compensated by

76

K-wires and a dorsal splint. It was also observed that radiocarpal stability could

only be reached if the radial styloid process was fixated. Therefore, we changed

our policy and fixated the radial styloid process with a lag screw in Cases no. 5

and 6. As a result, carpal reduction was maintained and redislocation of the radial

Figure 1. a Roentgenograms of Case 6, showing a dislocation of the entire carpus dorsally with a

fracture of the dorsal rim and styloid process of the distal radius. b The same wrist, postoperatively.

Fixation of the radial styloid process with a screw, and stabilization of the carpus with a dorsal,

protruding T-plate is performed. c The radiological result three years after operation. Moderate

osteoarthritis and calcifications around the radiocarpal joint are present.

77

styloid process was not observed.

Although ligamentotaxis is an appropriate technique to treat wrist fractures (1),

external fixation may not be the best technique to treat dorsal radiocarpal fracture-

dislocation. Since due to rupture of all radiocarpal ligaments, ligamentotaxis can

simply not be applied over the radiocarpal joint. We feel that carpal reduction can

best be performed by open reduction, while reduction can be maintained by

internal fixation (ORIF). Open reduction and a dorsal protruding T-plate to

maintain radiocarpal alignment was performed in Cases no. 5 and 6. The

advantage of an open procedure is that carpal reduction can be performed under

optimal vision. The latter is important, since the margin to obtain proper

anatomical results is few millimeters (2, 8). The benefit of the dorsal T-plate is that

carpal redislocation can be prevented. Furthermore, early practising of the hand is

possible. A disadvantage of the procedure is that the T-plate has to be removed 6-

8 weeks postoperatively to allow practising of the wrist.

Fortunately, full return to previous activities occurred in all patients. Still, it was

found that poor or fair functional results occurred in 3 patients. Moreover, the

radiographs showed severe carpal instability with degenerative changes in 2

patients. These findings do not confirm the good results reported in many reports

(2, 4, 8). The discrepancy may be explained by the fact that a DISI or SL-

dissociation was not dealt with. However, a difference in follow up period may also

count for the observed discrepancy. Follow up was at least two years in our series,

which is much longer than reported in other papers. Still, several issues remained

unsolved. For instance, the question whether treatment of carpal instability leads

to better functional results remains to be studied. Furthermore, the extent of

osteochondral damage was not known. It is likely that traumatic chondral damage

contributed to the observed posttraumatic osteoarthritis. Many factors play a role

in the ultimate functional result of dorsal radiocarpal fracture-dislocation, and the

question remains whether surgical technology may restore all damage in the

radiocarpal joint.

78

REFERENCES

1. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 1993; 9: 577.

2. Bilos JZ, Pankovic AM., Yelda S. Fracture-dislocations of the radiocarpal joint. J Bone Joint

Surg 1977; 59A: 198.

3. Dobyns JH., Linscheid RL Radiocarpal dislocation. In: Rockwood and Green eds. Fractures.

Vol. 1. JB Lippincott Company, Philadelphia, USA. 1975, pp 372-74.

4. Fernandez DL Irreducible radiocarpal fracture-dislocation and radioulnar dissociation with

entrapment of the ulnar nerve, artery and flexor profundus II-V. Case report. J Hand Surg

1981;6A: 456.

5. Moneim MS, Bolger JT, Omer GE. Radiocarpal dislocation-Classification and rationale for

management. Clin Orthop 1985; 192: 199.

6. Nyquist SR, Stern PJ. Open radiocarpal fracture-dislocations. J Hand Surg 1984; 9A: 707.

7. Riis J, Fruensgaard S Treatment of instable Colles’ fracture by external fixation. J Hand Surg

1989; 14B: 145.

8. Tanzer T, Horne JG. Dorsal radiocarpal fracture dislocation. J Trauma 1980; 20: 999.

79

80

81

CHAPTER 8

KIRSCHNER WIRE FIXATION FOR REDISLOCATED COLLES’ FRACTURES.

J Oskam, J Kingma, J Bart, H J Klasen.



Acta Ortrhopaedica Scandinavica, 1997; 68: 259-261

82

External fixation is commonly used for redislocated distal radial fractures (1), but

percutaneous K- wire pinning is an alternative. It offers the advantage of a minimal

invasive procedure with the ability to move the wrist early, while anatomic

radiocarpal alignment is being achieved (9).

We have evaluated the anatomical and functional results of K- wire fixation

performed for redislocated distal radial fractures of Older’s type 3 (extra-articular)

and Older’s type 4 (intra-articular) fractures, respectively (7).

PATIENTS AND METHODS

During the period 1987-1994, 21 patients (15 women) with a dorsally redislocated

distal radial fracture were operated on at our hospital. The wrist fracture resulted

from an accidental fall in 17, and a traffic accident in 4 cases. The mean age was

57 (25-78) years. The total incidence of distal radial fractures at our department is

300-320 per year. About 40 wrists were primarily operated during the observation

period (8). Secondary treatment by K-wire fixation was performed in 2-3 patients,

yearly, corresponding to a frequence of one percent of all distal radial fractures.

Every fracture was initially treated with a dorsal plaster splint after reduction.

Redisplacement was diagnosed on a routine radiograph within 12 days. Closed

reduction and operative fixation were performed within two weeks. Three (12

cases) or two (9 cases) 1.8 mm K-wires were inserted percutaneously and were

drilled through the radial styloid process anteriorly and posteriorly into the opposite

cortex. The wires were left subcutaneously. Postoperatively, all wrists were

immobilized with a dorsal splint for two weeks, and thereafter the patients were

allowed to move the wrist. Wires were removed six weeks after the operation.

Radiographic assessment

The fractures were classified according to Older’s system, which is specifically

designed for dorsally displaced distal radial fractures (7). An Older’s type 3 (extra-

articular) fracture was found in 8, and an Older’s type 4 (intra-articular) fracture

was found in 13 wrists (Table 1).

83

The dislocation pattern was described by three radiographical parameters: The

radiocarpal angle on the lateral projection, the radial inclination angle and the

relative ulnar length (ulnar variance) on the postero-anterior projection. The

relative ulnar length was used as an indirect measure of radial length.

The three radiographical parameters were measured on the preoperative, the

postoperative and the follow up routine wrist radiographs. We used the following

criteria for physiological radiocarpal alignment, a radiocarpal angle between 10

degrees volarly or 10 degrees dorsally, a radial inclination of 20-30 degrees, and

an ulnar variance of -2 to +3 millimeter (2,12). If at least one of the three

radiological parameters was not in the physiological range, the result was

considered a malunion.

Older’s classification End result

Excellent /Good

Fair Poor Total

1 & 2

Non-displaced, or displaced with minimal comminution -

dorsal angulation, radial articular surface not lower than 3

mm below ulnar head.

- - - -

3

Displaced with comminution of dorsal radius, radial surface

below ulnar head, minimal comminution of distal fragment.

5 2 1 8

4

Displaced with severe comminution of radial head, radial

articular surface 2-8 mm below ulnar head.

3 9 1 13

Total 8 11 2 21

84

Table 1. Survey of the classification according to Older’s, and the end results according to Gartland

and Werley’s of 21 redislocated distal radial fractures treated with K-wire fixation.

Follow up examination

A follow up study comprising clinical and radiological examinations was performed

after a mean period of two years (1-8 years). Motion was measured in both wrists

using a goniometer and the result is expressed as a proportion. Wrist motion

exceeding 80% was considered normal.

The point system of Gartland and Werley was used to assess the end result after

fracture healing. In a personal interview, residual deformity, subjective evaluation

of impairment, objective evaluation of wrist movement and complications like

arthrosis were assessed. The end results were graded as excellent (0-2 points),

good (3-8 points), fair (9-20 points), or poor (more than 21 points) (3).

The student’s t-test for matched pairs was used to test for differences between

pre- and post-operative radionanatomic measurements. The binomial (Z) test was

used to test for differences in proportion. A p-value < 0.05 was considered a level

of significance in both statistical tests.

RESULTS

Secondary displacement

Fracture displacement in the postoperative period occurred in 12 wrists. A change

in radiocarpal angle exceeding 6 degrees was found in 8 of 21 wrists, radial

inclination decreased upto 16 degrees in 11 wrists, and radial shortening (2-12

mm) occurred in 11 patients (Table 2).

Secondary displacement was observed in three Older’s type 3 fractures, and nine

Older’s type 4 fractures. This difference was not statistically significant (p = 0.2). A

malunion of the distal radius was found in eight wrists, of which six malunions had

been classified as Older’s type 4.

Wrist function

85

Wrist pain during daily activities was reported by 11 patients. Two patients could

not resume their daily activities and complained of severe pain with osteoarthritis

and decreased grip strength (poor result). Clinical signs of reflex sympathetic

dystrofy occurred in one patient. According to Gartland and Werley’s the end

results were poor in 2, fair in 11, good in 4, and excellent in 4 wrists (see also

Table 1). While, three good or excellent results were observed in the 13 Older’s

type 4 fractures. This difference was statistically not significant (p= 0.1)

Preoperative Postoperative Follow up

Radiocarpal angle 22° (± 13) -1° (± 5) -1° (± 7)

Radial inclination 14° (± 7) 23° (± 3) 20° (± 5)

Rel. ulnar length 4 mm (± 3) 1 mm (± 2) 3 mm (± 2)

Table 2. Mean radio-anatomic parameters measured at different intervals before and after

Kirschner wire fixation (n=21). The standard deviation is placed between brackets. Legend: “ - “

means volarly.

DISCUSSION

It appeared, that the radiocarpal angle remained almost unchanged during

fracture healing. But, radial tilt and radial length could not be maintained in all

patients. Secondary displacement after the operation was observed in 12 wrists,

despite good anatomical restoration, peroperatively. As a result, malunion of the

distal radius occurred to 8 patients. Apparently, the distal radius could still slide

over the K-wires, and both unfavourable anatomical or functional results occurred.

Secondary displacement after K-wire pinning has been reported before, and is

86

explained by residual instability due to fracture comminution or osteoporosis (5,6).

It has been argued, that K-wire pinning is suitable in both extra-articular fractures

and fractures with minimal intra-articular involvement (9). However, the

observation that displacement is a common complication in both extra- and intra-

articular fractures is in conflict with this view. Therefore, we doubt if K-wire fixation

is firm enough to obtain good anatomical results in redislocated distal radial

fractures.

There is general agreement that K-wire fixation is not indicated in severely

comminuted fractures of the distal radius (5,6). In a controlled study, Haas

observed significant secondary displacement after intramedullary K-wire pinning in

unstable intra-articular fractures (4). Moreover, it appeared that the anatomical

results of external fixation were better than with intramedullary K-wire pinning. It

has been shown in several other studies that the results of external fixation are

good with minimal postoperative morbidity, in at least 80% of unstable distal radial

fractures (1,10,11). Consequently, external fixation is accepted as a suitable

technique to treat both comminuted extra- and intra-articular distal radial fractures.

Because it has been shown that external fixation is a firm fixation technique in

unstable fractures, we feel that it would have been a better alternative than K-

wires to treat the redislocated distal radial fractures in our series.

REFERENCES

1. Cooney W P, Linscheid R L, Dobyns J H. External pin fixation for unstable Colles’ fracture. J

Bone Joint Surg 1979; 61A: 840-5.

2. Friberg S, Lundstrom B. Radiographic measurements of the radiocarpal joint in normal adults.

Acta Radiol Diagn 1976; 17: 249-56.

3. Gartland J J, Werley C W. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1951; 33A:

895-907.

4. Haas J L, Caffiniere de la J Y. Fixation of distal radial fractures: Intramedullary pinning versus

external fixation. In Fractures of the distal radius (Eds Saffar P, Cooney WP). Martin Dunitz

London 1995; 27: 229-39.

5. Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius. A prospective

comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg 1995; 77B: 562-7.

87

6. Mah E T, Atkinson R N. Percutaneous Kirschner wire stabilisation following closed reduction of

Colles’ fractures. J Hand Surg 1992; 17B: 55-62.

7. Older T M, Stabler E V, Cassebaum W H. Colles’ fracture: evaluation and selection of therapy.

J Trauma; 1965: 469-76.

8. Oskam J, Kingma J, Klasen H J. Fracture of the distal forearm. Epidemiological trends in the

period 1971-1995. 1998, Injury, in press.

9. Rayhack J M. The history and evolution of percutaneous pinning of displaced distal radius

fractures. Orthop Clin North Am 1993; 24 (2): 287-300.

10. Riis J, Fruensgaard S. Treatment of unstable Colles’ fracture by external fixation. J Hand Surg

1989; 14B: 145-8.

11. Schuild F, Donckerwolke M, Burny F. Treatment of distal radial fractures by external fixation:

techniques and indications. In Fractures of the distal radius (Eds Saffar P, Cooney WP). Martin

Dunitz London 1995; 25: 203-9.

12. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg1989; 14A: 607-12.

88

89

90

CHAPTER 9

CORRECTIVE OSTEOTOMY FOR MALUNION OF THE DISTAL RADIUS:

THE EFFECT OF CONCOMITANT ULNAR SHORTENING OSTEOTOMY.

J Oskam , K M Bongers, A J M Karthaus, A J Frima, H J Klasen.

Departments of Surgery, University Hospital Groningen and Deventer Hospitals



91

Residual complaints following corrective osteotomy for malunion of the distal

radius are generally localized in the distal radioulnar joint. Usually, symptoms can

be attributed to a length discongruency in the distal radioulnar joint due to

inadequate correction of radial shortening. To treat postoperative positive ulnar

variance, additional Darrach or Bowers resection has been proposed (3,9).

However, following distal ulnar resection or hemiresection, pain, loss of grip

strength and ulnar subluxation often remain (4). Ulnar shortening osteotomy has

been said to create a better function in the distal radioulnar joint because of a

lower risk of distal radioulnar instability (9).

To avoid postoperative positive ulnar variance we performed 6 ulnar shortening

osteotomies concomitantly to 22 radial corrections. The idea behind this policy was

to reduce the number of secondary distal ulna (hemi)resections. We will evaluate

whether appropriate functional results could be achieved and how many secondary

operations were ultimately performed on the ulnar side of the wrist.

METHODS AND MATERIAL

During the period 1982-1993, 22 consecutive distal radial corrective osteotomies

in 21 patients were performed. The mean interval between the injury and the

corrective procedure was 10 months (4-120 months). The wrist function of 12 men

and 9 women, with a median age of 42 years (19-59 years) was investigated.

Preoperatively, all patients complained of wrist pain, diminished wrist movement,

and loss of grip strength. Moreover, serious impairment of daily activities existed in

all patients.

A Colles’ fracture was present in 20 wrists, and a distal radius with a concomitant

distal ulnar fracture or an intra-articular pilon fracture was diagnosed in 2 other

cases. The Colles type fractures were extra-articular in 8 cases, and intra-articular

in 12 wrists. Seventeen patients were treated conservatively by means of closed

reduction and a dorsal splint for six weeks. External fixation was performed in 3,

and K-wire fixation in 2 wrists as primary operative treatment.

The radiocarpal angle on the lateral projection, and the radial inclination angle and

92

relative ulnar length on the postero-anterior projection were employed as

radiological parameters of wrist anatomy (6,11). Radiographs were made 6 and 12

weeks postoperatively to monitor bone healing. The anatomical end result was

studied on a radiograph after one year. A radiocarpal angle ranging from 10

degrees volarly to 10 degrees dorsally, a radial inclination angle of 20-30 degrees,

and an ulnar variation of -2 to +4 mm were considered to be physiological (6,11).

The functional end results of the wrist were judged as good when no pain with use

was obtained, and fair if moderate discomfort with use was obtained, if those

patients returned to normal activities completely.

Surgical technique

An X-ray of the opposite wrist was used as indicator of the normal anatomical

situation. The surgical approach to the radius was accomplished through a

longitudinal volar incision in the second compartment in 10 operations, and a

dorsal incision in the third compartment in 12 operations. Depending on wether

the radius should also be corrected in the saggital plane (radial inclination), the

correction was performed either by an opening linear osteotomy or by an opening

biplanar wedge osteotomy. A corticocancellous bone graft from the iliac crest was

cut in such a shape that it restored volar and radial tilts. Internal fixation was

performed with a small T-plate. Exercises were started at two weeks

postoperatively.

In six patients (Case no. 9,10,13,16,21,22) concomitant ulnar shortening

osteotomy was performed through a separate ulnar incision as described in an

earlier paper (7). The indication for this procedure was a positive relative ulnar

length of minimally 6 mm.

RESULTS

Follow up data, after a median period of 30 months (range 12-84) could be

obtained in all cases. Healing of the radial osteotomy was radiographically

adequate in all 22 wrists within three months. Moreover, disturbance of bone

union was not observed in any of the ulnar shortening osteotomies.

93

Two different radiological patterns of distal radius malunion could be

distinguished: one in which a disturbance of the radiocarpal angle prevails, and

one in which a combination of radial deviation with severe radial shortening is

characteristic (Fig 1). Ulnar-shortenings were mostly performed in the latter group.

It can be seen in Figure 1 , that both dorsal and volar tilts were corrected. The

radiocarpal angle could be restored adequately in all but 2 patients. In these two

patients a postoperative dorsal tilt of circa 20 degrees remained. With respect to

the radial inclination angle Figure 1 shows that the most common preoperative

pattern was severe radial deviation of the joint surface. However, the radial

inclination angle could not be corrected anatomically in all wrists. Figure 1 also

shows that the relative ulnar length after correction was usually within the range of

-2 to +4 mm. An ulnar variance of -3 mm was observed in Case no.14, but no

residual complaints occurred.

During follow up all patients reported improvement of wrist function. Good results

were observed in 17 patients ( Case no. 2 - 6, 9 - 16, 18, 19, 21). A fair functional

result was found in 5 patients. In the group with ulnar shortening in combination

with radial correction, good results were achieved in 5 out of 6 patients.

Case Localisation pain Anatomical disorder

7 Radioulnar Discongruency sigmoid notch

8 Radioulnar Positive ulnar variance

17 Ulnocarpal Chondropathy ulna head

20 Radiocarpal

22 Radioulnar Discongruency sigmoid notch

Table 1. Survey of postoperative wrist pain in 5 patients with a fair functional outcome following

corrective osteotomy.

94

The precise localisation of postoperative wrist pain in the 5 patients with a fair

functional outcome are displayed in Table 1. It appears that mainly the ulnar side

radiocarpal angle

-40

-20

0

20

40

60

0 5 10 15 20 25case no.

deg

rees

PRE

POST

radial inclination

-20

0

20

40

0 5 10 15 20 25case no.

deg

rees

PRE

POST

95

Figure 1. Pre- and post-operative measurements of radioanatomical parameters of 22 wrists

corrected for a distal radial malunion. (PRE= preoperative, POST= postoperative)

of the wrist was involved. Positive ulnar variance due to a failure to restore radial

length was only observed in case no. 8. Furhermore, osteoarthritis in the

radioulnar joint due to fracture involvement of the sigmoid notch (incisura ulnaris)

of the distal radius was found in case no. 7 and 22. In order to relieve persistent

pain in patient no. 7 and 8, secondary hemiresection of the ulna head was

performed. This resulted in improvement of wrist function without pain.

DISCUSSION

This study shows that most of the corrective procedures we performed were

technically and functionally adequate because wrist anatomy could be restored,

and all patients reported improvement of wrist function (4,5). The postoperative

disorders in our series consisted of incongruency of the radial sigmoid notch and

ulnar head chondropathy, both of which have been described previously and are

generally not attributed to technical failure (5). During follow up no poor functional

results were observed and all patients were able to resume their normal daily

rel. ulnar length

-5

0

5

10

15

0 5 10 15 20 25case no.

mm

PRE

POST

96

are quite acceptable.

Positive ulnar variance appears to be the most common cause for residual

radioulnar pain after correction of wrist deformity (3). Inadequate lengthening of

the radius is the most likely cause of this postoperative complication. It has been

reported that the maximum length that can be achieved by solely radial correction

is circa 6-7 mm. (5). If larger length discrepancies have to be corrected single

radial osteotomy may not be sufficient. Therefore, we think that if problems of

restoring radial length are to be expected, an concomitant ulnar shortening

osteotomy should primarily be performed. For that reason, we performed 6

concomitant ulnar shortening osteotomies, with a good functional outcome in 5 of

the 6 wrists. Furthermore, a relatively too long ulna could only be observed in 1

out of 22 corrections.

The first reports on failure following correction were published 50 years ago (2,10).

At the time, it had already been reported that disorders in the distal radioulnar joint

commonly induce pain and malfunction, and that Darrach resection may relieve

these symptoms. Fernandez confirmed the drawback of residual radioulnar pain

following radial corrective osteotomy in 1982, and suggested that positive ulnar

variance was the most likely cause (3). Consequently, he performed additional

Darrach resection in 8 of 20 patients (40%). However, Darrach resection can

provoke ulnar subluxation and instability (1). Therefore, hemiresection of the ulnar

head has been developed and can be considered as a better alternative in

combination with radial corrective osteotomy nowadays, because stability of the

distal radioulnar joint is maintained (4, 9).

Stability of the distal radioulnar joint is determined by surface congruity, and

condition of the ligaments (8). Since ulnar hemiresection causes pseudarthrosis,

loss of distal radioulnar stability may occur. To stabilize the distal radioulnar joint in

case of posttraumatic positive ulnar variance, we reported earlier that length

incongruency can be meticulously corrected (7). From this point of view, we found

hemiresection of the ulnar head not the optimal physiological solution, and now we

prefer to perform an ulnar shortening osteotomy if we expect that radial

lengthening will not restore congruency in the distal radioulnar joint. Partial

resection of the ulna head has been reported to be a reasonable alternative (9).

97

However, it is not yet known whether the functional results of hemiresection are

good in the long term. Therefore, we advocate reconstruction of the distal

radioulnar joint by means of ulnar shortening osteotomy, while additional

hemiresection of the ulnar head should only be performed if anatomical

reconstruction is impossible.

REFERENCES

1. Bieber EJ, Linscheid RL, Dobyns JH, Beckenbaugh RD. Failed distal ulnar resections. J Hand

Surg 1988; 13A: 193-200.

2. Campbell WC. Malunited Colles’ fractures. JAMA 1937; 109: 1105-8.

3. Fernandez DL. (Correction of post-traumatic wrist deformity in adults by osteotomy, bone-

grafting, and internal fixation. J Bone Joint Surg 1982; 64A: 1164-78.

4. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal

end of the radius. J Bone Joint Surg 1988; 70A: 1538-51.

5. Fernandez DL. Distal radius fractures. Reconstructive procedures for malunion and traumatic

arthritis. Orthop Clin North Am 1993; 24: 341-63.

6. Friberg S, Lundstrom B. Radiographic measurements of the radio-carpal joint in normal adults.

Acta Radiol Diagn 1976; 17: 249-56.

7. Oskam J, Kingma J, Klasen HJ. Ulnar-shortening osteotomy after fracture of the distal radius.

Arch Orthop Trauma Surg 1993; 112: 198-200.

8. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist-anatomy and

function. J Hand Surg 1981; 6A: 153-62.

9. Posner MA, Ambrose L. Malunited Colles’ fractures: Correction with a biplanar closing wedge

osteotomy. J Hand Surg 1991; 16A: 1017-26.

10. Speed JS, Knight RA. The treatment of malunited Colles’s fractures. J Bone Joint Surg 1945;

27A: 361-7.

11. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg

1989; 14A: 607-12.

98

99

CHAPTER 10

ULNAR SHORTENING OSTEOTOMY AFTER FRACTURE OF THE DISTAL RADIUS


Department of Surgery, University Hospital GroningenGroningen, the Netherlands


100

A well-known complication of a fracture of the distal radius concerns a discrepancy

of the distal radioulnar joint with a long ulna relative to the radius. Due to

increased axial load forces in the ulnocarpal joint, this type of complication may

invoke the ulnar impingement syndrome, which is generally characterized by pain

on the ulnar side of the wrist, particulary, when rotation of the forearm or ulnar

deviation occurs (2).

Restoration of distal radioulnar joint congruety by means of ulnar shortening

osteotomy is a commonly performed alternative to treat the ulnar impingement

syndrome. As a consequence of correcting ulnar length, the ulnar collateral

ligaments, the extensor carpi ulnaris sheat and the radioulnar ligaments will be

simultaneously tightened, and the stability of the distal radioulnar joint will be

improved(2). As a consequence, the ulnocarpal joint is unloaded and wrist pain

relieved.

The purpose of the present study was to investigate the effect of ulnar shortening

osteotomy on patients suffering from ulnar impingement syndrome resulting from a

fracture of the distal radius.


In the period 1977-1988, ten shortening osteotomies on nine patients were

performed. The interval between the initial injury and operation ranged from 10 to

26 months. The mean age of the patients was 48 years (range 30-62). All patients

complained of an ulnar impingement syndrome. In nine cases the main symptom

was pain on the wrist, particulary in the distal radioulnar joint. In one case a click in

the wrist, while rotating the forearm was present. Before ulnar shortening was

performed, all patients had suffered from a fracture of the distal radius due to a

hyperextension mechanism. Initially, all fractures were treated conservatively with

closed reduction and a plaster of Paris for six weeks. The radiocarpal angle and

relative ulnar length were employed as parameters of malunion, and were measured

on lateral and posteroanterior radiographs with the forearm in neutral rotation. The

"project a line" method of Gelberman was used to measure ulnar length, which is

101

considered a reliable technique with respect to observer variability (4).

Operative technique

After diagnosing the ulnar impingement syndrome, the extent of relative ulnar

length was determined. Following this, the recession length was assesed. A lateral

incision was made on the distal third of the ulna. Then a six-hole small compression

AO-plate was bent to fit the distal ulna and three distal screws were drilled,tapped

and fitted with 2.7 mm screws. An AO-tensioning device was inserted proximally by

drilling a hole and fitting a screw proximal of the plate. The site of osteotomy was

marked and the plate was removed. The estimated section of ulna was resected.

Subsequently, the plate was reinserted and the distal screws were fixed. The

tensioning device was placed and compression of the osteotomy was performed.

Finally the proximal screws were fastened and the tensioning device was removed.

By employing this technique optimal compression was achieved and rotation of the

distal ulna was prevented. In order not to compromise distal radioulnar joint stability

the pronator muscle and the interosseous membrane were leaved unstripped. The

forearm rotation was passively tested to ensure that no mechanical problems were

present. After standard closure, a plaster splint was applied. In the third week the

splint was removed and exercises were allowed. Normal use of the wrist was

permitted six weeks postoperatively,. To monitor healing of the osteotomy, a

radiograph was made six and twelve weeks after surgery.

RESULTS

Follow up data were obtained on all cases. The follow up period was at least three

years in all but one case, who was followed for ten months. Table 1 displays age,

sex, relative ulnar length, radiocarpal angle and results of bone healing.

Within three months healing of the osteotomy site was radiographically adequate

in six cases. Union was delayed in four osteotomies, and a long armcast was

applied. These cases showed a disturbed radiocarpal angle due to malunion of

the distal radius fracture. Nonunion, which required replating and bone grafting,

was necessary in two osteotomies. In these cases the volar angle of the distal

102

radius was, respectively, 20 and 25 degrees (see Table 1). After reoperation good

bone union was achieved, so eventually, all osteotomies did heal well.

Patient Age Sex Rel ulnar Radiocarpal Bone healing

length angle

A 30 F 6 + 20 good

B 54 F 5 + 20 good

C 62 F 3 + 10 good

D 40 F 4 - 5 good

E 54 M 5 - 10 good

F 60 F 5 - 20 good

G 36 F 6 - 25 non-union

H 42 M 6 - 20 non-union

I 47 M 4 - 20 del. union

J 56 F 4 + 20 del. union

Table 1. Survey of age, sex, relative ulnar length in mm., radiocarpal angle in degrees, and ultimate

bone healing results. Legend: +" means dorsal angulation, "-" means volar angulation, del." means

delayed.

The overall functional results were judged as good, fair or poor (see Table 2). The

ulnar impingement syndrome was no longer present in eight cases. In these cases

complete union of the osteotomy site was achieved within six months. In the two

cases with a poor functional result, the postoperative course was complicated by

nonunion of the osteotomy. Overall, the range of wrist motion was significantly

better than preoperatively. Movement was normal as compared with the opposite

wrist in five cases. In three cases, a slight decrease of 10 to 15 degrees in dorsal

flexion of the wrist was present, and in two cases movement of the involved wrist

was seriously impaired in all directions.

103

DISCUSSION

The principle of ulnar shortening as a treatment for the ulnar impingement

syndrome was first described by Milch in 1942 (3), although nowadays, a modified

procedure is used. By employing internal fixation with a compression plate, better

Description Functional result Number of osteomies

No pain with use. Good 6

Moderate discomfort with use, Fair 2

full return to work.

Persistent pain with serious Poor 2

limitation of motion.

Table 2. Survey of the functional results.

stability of the distal ulna and improved bone healing of the osteotomy is achieved.

Before plating was common practice, nonunion of the osteotomy was the major

problem of ulnar shortening. Even in the current plating era, bone healing remains

an issue of problem. Several factors may contribute to failure of bone healing, e.g.

the site of the osteotomy, the length of the plates and the duration of

immobilisation. Therefore, an osteotomy in the distal third of the ulna, use of nine

hole plates and applying plaster splints for six weeks are advocated (1,2).

In this series, initial fractures gave rise to malunion with a radioulnar length

discrepancy of approximately 3-5 mm. Because most patients were middle aged,

ulnar shortening was considered the best operative technique to treat the ulnar

impingement syndrome. With this technique, by restoring distal radioulnar joint

congruety and stability, pain may be relieved and wrist motion improved. This goal

was achieved in six patients, with use of both a six-hole plate and an

immobilisation period of three weeks. In the series of Darrow, problems with bone

104

healing were described in nine out of 35 operations (1). In eight cases a long

armcast, and in one case reoperation was necessary to achieve union. In our series,

a favourable effect of a long armcast was seen in two out of four cases with delayed

union. In these two cases, no poor functional results occured. Darrow's study also

showed that immobilisation in a long armcast did not lead to poor functional results.

In the present study, ulnar shortening was performed on wrists in which a loss of

radial length had occured after fracture of the distal radius. Loss of radial length is,

however, only one of the potential sequelae of these fractures. Another frequent

complication is a disturbed radiocarpal angle. In two wrists with nonunion of the

osteotomy a volar radiocarpal angle of 20 to 25 degrees was present. We believe

that the reason for the experienced nonunion is a discongruety, and thus

instability, of the distal radioulnar joint, resulting from an increased volar

radiocarpal angle. In this situation, the process of shortening may create a

biomechanically unfavourable state in which forces on the distal ulna cannot be

compensated by an internal plate, resulting in nonunion of the osteotomy.

REFERENCES

1. Darrow JC, Linscheid RL, Dobyns JH, et al. Distal ulnar recession for disorders of the distal

radioulnar joint. J Hand Surg 1985; 10A: 482-91.

2. Green DP. In: Operative hand surgery. Vol.2, 2nd edition. Churchill Livingstone Inc.,New York

1988, pp 973-6.

3. Milch H. Cuff resection of the ulna for malunited Colles' fracture. J Bone Joint Surg 1941; 23A:

311-3.

4. Steyers CM, Blair WF. Measuring ulnar variance: A comparison of techniques. J Hand Surg

1989; 14A: 607-12.

105

106

CHAPTER 11

SUMMARY

107

108

CHAPTER 1

Introduction

Since the 19th century, the paradigm of wrist fractures was that anatomic

reduction was not mandatory to obtain good functional results. Due to the

introduction of radiography (1895) it became clear that malunion occurred more

often in the distal radius than was thought. However, despite the novel anatomical

insights the treatment of choice was always closed reduction and plaster

immobilisation for four to six weeks. Before the second World War, operative

treatment was generally restricted to open reduction in irreducible fractures, and

secundary operations on the distal radius or ulna in selected cases with severe

wrist symptoms from distal radial malunion.

Large retrospective studies in the 1950’s and 1960’s learned that about 20% of

patients complained of pain with loss of wrist motion following healing of a distal

radial fracture. It appeared that malunion was quite often found in patients with an

unfavourable outcome. To improve anatomical results and functional outcome,

fixation with pins after closed reduction was the most popular to fixate unstable

fractures. A real paradigm shift occurred after 1970. Restoration of anatomical

relationships was considered a prerequisite to obtain good functional recovery. As

a consequence, open reduction and internal fixation (ORIF) was more often

indicated, and performed increasingly. However, it appeared that ORIF was not

always succesful in complex or intra-articular fractures. Therefore, closed fixation

techniques like external fixation or K-wire fixation were re-introduced and became

again very popular in the 1980’s.

Because, about 30 different fracture types may be discerned, and many distinct

treatment regimens can be performed, a need for a universal, treatment-based

classification system is obvious. Presently, little validation studies of classification

systems have been reported. Furthermore, many surgical techniques for distal

radial fractures are still under development, and precise indications when to

perform a particular technique are not known. A selection of epidemiological,

classificational, and clinical issues is presented in this thesis.

109

CHAPTER 2

The Groningen Trauma Study

During the period 1970-1993, 245,251 visits were recorded in the trauma registry

of the University Hospital Groningen (the Netherlands). An analysis of injury

antecedents revealed five principal causes (ICD-CM), respectively: Accidental fall

(28%), sports and unspecified accident (26%), traffic (19%), cutting and piercing

instruments (10%), and violence (4%). Trend analysis across the 24-year period

showed that the incidence of injuries due to traffic and accidental fall decreased,

while the rate of injuries due to assault increased two-fold. Within the subgroup of

traffic accidents, injuries caused by cars and motorcycles declined, while bicycle

accidents increased dramatically.

With respect to sex and age, the highest incidence rate of traumatic injury

occurred to men of 20-29 years. The overall male to female ratio was 1.8. A

predominance of male patients was observed in all cause categories, except in

accidental fall. In this category, a relatively higher incidence of women was

observed.

The overall mortality rate was 0.5%, with the highest mortality rate being in women

above 70 years. The main three causes of fatal injury concerned traffic (66%), fall

(16%), and violence (3%). The injury patterns in the present study are in close

agreement with patterns of other large trauma populations. Some discrepancies

could be discerned. For example, in traffic injury most victims (66%) concerned

pedestrians and bicyclists, and firearms comprised only 1.2% of injuries due to

assault. The usefulness of the registry in current community trauma care

programs, and the broader perspective of trauma registration in the Netherlands is

discussed.

CHAPTER 3

Epidemiological developments of wrist fractures in Groningen

110

This study describes longterm epidemiological trends of 8,361 distal forearm

fractures out of 256,431 trauma patients (3%) treated in a Dutch university

hospital. The mean incidence rate across the whole lifespan was 42 per 10,000

inhabitants. The general picture was that the incidence rate decreased from 47 in

1971 to 38 per 10,000 in 1995. The highest age-specific incidence rate was found

in the age group above 79 years (90 per 10,000), followed by the age group of 0-9

years (80 per 10,000). The pattern of aetiology did not change: The distribution

was accidental fall (62%), sports & leisure (19%), and traffic (14%).

The rate of hospital admission of patients with a distal forearm fracture increased

from 6 percent in 1971 to 14 percent in 1995. It appeared that on the long term the

increase of hospital admission could largely be attributed to patients younger than

50 years of age. It has been discussed that the rise in number of operative

treatment may be explained by a grewing population in the area of adherence,

and a change in surgical policy causing more indications to operate on distal

forearm fractures.

CHAPTER 4

Recognition of 10 different distal radial fracture types

This descriptive study is about the base-line performance of verbal and visual

recognition of 10 different types of distal radial fractures. A verbal recognition and

a visual recognition task was designed for each fracture type. A verbal recognition

task consisted of a description with the relevant distinctive features of the fracture.

The subject was asked whether he recognized the particular fracture. A visual

recognition task consisted of an X-ray, and the subject had to label the fracture.

The test was presented to 30 surgical trainees working in 5 teaching hospitals.

On the verbal task, the performance was greater (68% yes) than on the visual

counterpart (33% correct). Verbal and visual recognition met our criterion of 80%

correct responses in the following fracture types: Colles’, distal forearm, and

Smith’s fracture. In 7 other fracture types (combination radius & scaphoid, radial

styloid process, dorsal Barton’s, volar Barton’s, pilon, chauffeur’s, and lunate load

111

fracture) the 80% criterion was not met. Analysis of the incorrect answers in the

visual recognition task revealed that the residents tend to label unknown fracture

types as Colles’ or Smith’s fracture. Furthermore, the subjects tend to

overestimate their own diagnostic competence (overconfidence bias) in several

fracture types. It has been concluded that in order to improve classificational

reasoning, relevant distinctive features of distal radial fractures should be

instructed.

CHAPTER 5

Observer agreement on AO classification for distal radial fractures

This study is about agreement on the assignment into the 3 basic classes (A,B,C)

of the AO/ASIF’s classification system for distal radial fractures. A random sample

of 124 fractures was classified by two experienced observers. The degree of

agreement was calculated according to Cohen’s kappa statistics. To investigate

the possible causes of disagreement, all conflicting X-ray assessments were

discussed in a consensus meeting (Delphi approach).

It appeared, that the kappa value was 0.65 (good agreement) before the meeting.

While the kappa value rised to 0.86 (excellent agreement) after the Delphi

meeting. It appeared that the undisplaced fractures were a major source of

disagreement. Furthermore, the presence of articular involvement was an

important issue. It was frequently observed that one observer classified the

fracture as extra-articular (A), while the other observer choose for an intra-articular

fracture (C), or vice versa. This phenomena has been called the A/C reversal shift.

It has been concluded, that radiological innovations might enhance agreement on

articular involvement, and a separate category for undisplaced fractures should be

defined in the AO system. However, agreement on relevant distinctive features

and discussion of conflicting assessments may also be important to achieve

excellent agreement.

CHAPTER 6

112

Fractures of the radius and scaphoid

Simultaneous fractures of the distal radius and scaphoid is an uncommon wrist

injury. During the period 1980 to 1993, 23 patients with a median age of 39 years

were treated for this injury. The median follow up period was 7 years. All scaphoid

fractures were undisplaced and located in the waist or distal third. An extra-

articular distal radial fracture was observed in 15 wrists. A below elbow cast

including the thumb was applied in 18 wrists for a mean duration of 9 weeks, and

operative treatment was used in only 5 patients.

All scaphoid fractures healed without complications. During conservative treatment

redisplacement of three distal radial fractures occurred. The final functional results

were good in 18, fair in four, and poor in one patient. Because complications

occurred at the distal radius we have changed our conservative treatment policy

from a below elbow cast including the thumb to a dorsal splint for 6 weeks.

CHAPTER 7

Dorsal radiocarpal fracture-dislocation

Dorsal radiocarpal fracture-dislocation is defined by dorsal carpal displacement

caused by disruption of the radiocarpal ligaments, while the associated distal

radius fracture has to be confined to the rims and the styloid process. Several

cases have been reported in the past 25 years, and mainly clinical and taxonomic

aspects have been discussed. However, specific methods of operative treatment

to improve functional outcome have not been reported.

In the period 1982-1994, 6 patients have been treated at the University Hospital

Groningen. K-wire fixation was performed in 3 cases, external fixation in 1, and

open reduction and fixation (ORIF) with screws in the radial styloid process and a

dorsal protruding T-plate to maintain carpal reduction was perfomed in 2 wrists.

It was observed that there is a risk of loss of reduction if K-wire fixation is

performed. It seems that carpal subluxation or redislocation of the radial styloid

process can be avoided if ORIF is performed. Good radiocarpal alignment can be

obtained by open reduction, provided that a protruding T-plate is inserted dorsally

113

on the distal radius. The precise influence of concomitant carpal instability, like

DISI or SL-dissociation, is not clear. But, it seems plausible that the anatomical

relationschips in the carpus has to be restored, operatively. Although, operative

therapy may be mandatory in dorsal radiocarpal fracture-dislocation, we got the

impression that the ultimate functional results does not only depend on surgical

technique. Because, osteochondral damage also might contribute to the functional

outcome.

CHAPTER 8

Redislocated Colles’ fractures

One therapeutic alternative for redislocation of dorsally displaced fractures of the

distal radius (Colles’ fracture) is closed reduction and transstyloid Kirschner wire

fixation. We describe our results of 21 redislocations treated in this way in the

period 1987-1994. According to Older’s classification, 8 fractures were classified

as type 3, and 13 fractures as type 4. After a median follow up period of 2 years

most patients had regained normal volar tilt, but significant secondary loss of

radial tilt and radial length was found in 11 patients. Malunion occurred in 8 wrists

due to either fracture comminution or insufficient K-wire fixation. According to the

scoring system of Gartland and Werley, the end results were poor in 2, fair in 11,

good in 4, and excellent in 4 wrists. Secondary displacement and malunion was

commoner in intra-articular fractures (Older’s type 4). We concluded that closed

reduction and K-wire pinning is not suitable for redislocated distal radius fractures .

CHAPTER 9

Radial corrective osteotomy

Positive ulnar variance due to inadequate correction of radial length is a common

sequalum after radial corrective osteotomy. To avoid this complication we

performed a combination of ulnar shortening osteotomy and radial corrective

osteotomy in 6 of 22 radial corrections. The indication for the combined procedure

114

was a relative ulnar length of minimally 5-6 mm. The functional outcome was fair

in 1 and good in 5 cases with combined osteotomy. Overall, the functional results

were good in 17 cases.

Pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar

variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of

the ulnar head (Bower’s arthroplasty) were performed. It appears that positive

ulnar variance following radial corrective osteotomy is caused by inadequate

lengthening. The present study showed that in malunions with a relative ulnar

length of at least 5-6 mm, concomitant ulnar shortening osteotomy can prevent

pain in the distal radioulnar joint, and may reduce the number of secondary distal

ulnar resections.

CHAPTER 10

Ulnar shortening osteotomy

The ulnar impingement syndrome due to a relatively long ulna is one of the

complications of a fracture of the distal radius. We performed 10 ulnar shortening

osteotomies to restore distal radioulnar joint congruity. The mean relative ulna

length was 4-5 mm. Insufficient bone healing was encountered in 4 osteotomies.

Replating and cancellous bone grafting was necessary in 2 cases because of non-

union. The functional outcomes were good in 6, fair in 2, and poor in 2 patients.

Non-union and poor functional outcome were related to a malunion of the radius

with a volar radiocarpal angle of 20 or 25 degrees. Incongruity of the distal

radioulnar joint favored non-union.

It appears that the ulnar impingement syndrome following a fracture of the distal

radius is best treated with ulnar shortening when a solely loss of radial length is

present. The present study showed, that if the radiocarpal angle is also disturbed,

healing of the osteotomy is often insufficient, leading to poor functional results.

115

CHAPTER 12

SAMENVATTINGEN

116

HOOFDSTUK 1

Historisch perspectief

Gedurende de afgelopen twee eeuwen kunnen verschillende stadia worden

onderscheiden in de denkpatronen over distale radius fracturen. In het begin van

de achttiende eeuw werden letsels van de distale radius beschouwd als luxaties.

Fracturen van de distale radius werden nauwelijks genoemd in chirurgische

boeken uit die tijd. Dupuytren was een van de chirurgen in de negentiende eeuw

die benadrukte dat letsels van de pols meestal leidden tot distale radius fracturen

in plaats van luxaties. Betere inzichten in de diagnostiek en fractuurbehandeling

werden verkregen na de introductie van radiologische technieken in 1895. Deze

ontwikkeling heeft mede geleid tot het gaan verrichten van secundaire correctie

operaties om de anatomische relaties in de pols te herstellen. Een paar chirurgen

probeerden met operatieve technieken a chaud de resultaten bij instabiele

fracturen te verbeteren, maar echte aandacht voor primair herstel van

polsfracturen kan niet eerder worden bespeurd dan na 1930. Het merendeel van

distale radius fracturen werd nog steeds behandeld door middel van gesloten

repositie en een gipsspalk, ongeacht bredere indicaties voor operatieve

behandeling. Hoewel Kirschner draad fixatie na gesloten repositie een

geaccepteerde techniek was voor instabiele fracturen, trad de grootste paradigma

shift in de behandeling pas op na 1970. Het werd destijds geadviseerd door de

AO dat de anatomie van de distale radius moest worden hersteld, omdat het werd

verondersteld dat herstel van anatomie een voorwaarde was om een normale

polsfunktie te verkrijgen. Omdat de oorspronkelijke anatomie niet gereconstrueerd

kan worden bij alle fracturen, en vitale weke delen structuren kunnen worden

beschadigd door open operatietechnieken, trad een nieuwe paradigma shift op in

de tachtiger jaren. Vanaf die tijd werden gesloten repositie-technieken met

verschillende stabilisatiemethoden gepropageerd, vooral in comminutieve intra-

articulaire fracturen.

117

In dit proefschrift wordt d.m.v. capita selecta de ervaring weergegeven op het

gebied van epidemiologie, classificatie, en behandeling van distale

radiusfracturen, zoals die na 1970 in de Chirurgische Kliniek van het AZG zijn

opgedaan

HOOFDSTUK 2

De Groningense Trauma Studie

Gedurende de periode 1970-1993 werden in de Registratie van Letsels en

Ongevallen Groningen (RLOG) van het Academisch Ziekenhuis Groningen

245.251 trauma-bezoeken opgenomen. Een analyse van ongevalsoorzaken wees

vijf hoofdoorzaken uit (ICD-CM): Respectievelijk, accidentele val (28%), sport en

niet-gespecificeerd (26%), verkeer (19%), scherpe voorwerpen (10%), en geweld

(4%). Een trend-analyse over de 24-jarige periode wees uit dat ongevallen ten

gevolge van verkeer en accidentele val verminderde, terwijl het aantal ongevallen

veroorzaakt door geweld verdubbelde. In de subgroep van verkeersongevallen

verminderde motor- en auto-ongevallen, terwijl fietsongevallen enorm toenamen.

Wat betreft geslacht en leeftijd was de hoogste incidentie te zien bij mannen in de

leeftijdsgroep van 20 tot 29 jaar. De gemiddelde man-vrouw ratio was 1,8 : 1. Een

overwicht van mannelijke patienten was te zien bij alle ongevalsoorzaken, behalve

bij de groep accidentele val. In die categorie was een relatief hogere incidentie

van vrouwen waar te nemen.

Het sterftecijfer van alle patienten binnen de RLOG was 0,5%, waarbij het hoogste

sterftecijfer te vinden was in de groep van vrouwen boven de 70 jaar. De drie

belangrijkste doodsoorzaken waren verkeer (66%), accidentele val (16%), en

geweld (3%). De ongevalspatronen in deze studie vertonen een grote mate van

overeenkomst met traumapopulaties uit andere Westerse landen. De

bruikbaarheid van het registratiesysteem in programma’s voor traumazorg , en het

bredere perspectief van trauma-registratie in Nederland wordt bediscussieerd.

118

HOOFDSTUK 3

Epidemiologie van polsfracturen in Groningen

In dit hoofdstuk worden de lange-termijn trends beschreven van 8.361 patienten

met een distale onderarmsfractuur die de afgrelopen jaren zijn behandeld in het

AZG. Het gemiddelde incidentie-cijfer voor alle leeftijden was 42 per 10.000

inwoners. Het algemene beeld was dat het incidentie-cijfer daalde van 47 per

10.000 in 1971, naar 38 per 10.000 in 1995. Het hoogste leeftijds-specifieke

incidentie cijfer werd gevonden in de leeftijdsgroep boven 79 jaar (90 per 10.000),

gevolgd door de leeftijdsgroep van 0-9 jaar (80 per 10.000). Het etiologie-patroon

veranderde niet gedurende 25 jaar in Groningen. De verdeling van d eoorzaken

was accidentele val bij 62%, sport en vrije tijd bij 19%, en verkeer bij 14% van de

patienten.

Het aantal ziekenhuisopnamen voor polsfracturen steeg van 6% in 1971, naar

14% in 1995. Het bleek dat op de lange termijn deze stijging toe was te schrijven

aan meer opname van patienten jonger dan 50 jaar. Het wordt bediscussieerd dat

de stijging van het aantal operatieve ingrepen kan worden verklaard door een

toename van de bevolking in het adherentiegebied, en een verandering van

chirurgisch beleid waardoor een bredere indicatie voor operatieve behandeling

werd gehanteerd.

HOOFDSTUK 4

Herkenning van 10 verschillende typen distale radiusfracturen

Dit hoofdstuk handelt over de verbale en visuele herkenning van 10 verschillende

typen distale radius fracturen. Een verbale en een visuele herkennings-opdracht

was ontworpen voor elk fractuur type. Een verbale herkennings-opdracht bestond

uit een beschrijving van de relevante, te onderscheiden kenmerken van iedere

fraktuur. De proefpersoon werd gevraagd of hij de bepaalde fraktuur in verbale zin

119

herkende. Een visuele opdracht bestond uit een rontgenfoto. De proefpersoon

moest een diagnose van de getoonde fraktuur geven. De test met opdrachten

werd afgenomen bij 30 assistenten in opleiding, afkomstig uit 5

opleidingsziekenhuizen.

Verbale en visuele herkenning voldeden aan ons criterium van minimaal 80%

correcte antwoorden bij de volgende fraktuurtypen: Colles, Smith, en distale

onderarmsfraktuur. Het 80% criterium werd niet bereikt bij 7 andere typen:

Combinatie radius & scaphoid, proc. styloideus radii, dorsale Barton, volaire

Barton, pilon, chauffeur’s, en lunate load fraktuur. Een analyse van de incorrecte

antwoorden van de visuele herkennings test wees uit dat assistenten voor hen

onbekende frakturen regelmatig incorrect benoemen als Colles of Smith fraktuur.

Tevens heeft men bij bepaalde fraktuurtypen de neiging om eigen diagnostische

vaardigheden te overschatten (overconfidence bias).

HOOFDSTUK 5

Overeenstemming tussen waarnemers bij de AO classificatie

Dit hoofdstuk beschrijft de mate van overeenstemming bij het classificeren in de 3

hoofdklasses (A,B,C) van de AO-classificatie. Een aselecte steekproef met foto’s

van 124 distale radiusfrakturen werd voorgelegd aan 2 ervaren proefpersonen. De

mate van overeenstemming was berekend volgens Cohen’s kappa methode. Om

de mogelijke oorzaken van onenigheid bij de profepersonen te achterhalen

werden alle afwijkende foto-beoordelingen besproken in een consensus-

bijeenkomst (Delphi methode).

Het bleek dat Cohen’s kappa waarde 0.65 was (goede overeenstemming) voor de

consensus bijeenkomst. Na de bijeenkomst was deze waarde gestegen tot 0.86

(zeer goede overeenstemming). Bij analyse bleek dat de niet-gedisloceerde

fracturen een belangrijke bron van meningsverschil waren. Een ander punt van

menigsverschil betrof al of niet aanwezige intra-articulaire betrokkenheid van de

fractuur. Het werd regelmatig waargenomen dat de ene proefpersoon caregorie A

classificeerde terwijl de andere waarnemer dezelfde fractuur als categorie C

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bestempelde. Dit fenomeen werd de “A/C reversal shift” genoemd.

Een van de conclusies luidde dat betere radiologische diagnostiek de mate van

overeenstemming m.b.t. intra-articulaire betrokkenheid kunnen vergroten. Tevens

zal een aparte categorie voor niet-gedisloceerde fracturen binnen het AO-systeem

moeten worden gemaakt om de mate van overeenstemming te vergroten. Maar

discussie over conflicterende beoordeling kan op zich zelf ook een belangrijke

factor zijn in het verbeteren van overeenstemming.

HOOFDSTUK 6

Combinatie van scaphoid en distale radiusfractuur

Een simultane fractuur van zowel de distale radius als het scaphoid is een

ongewoon polsletsel. Gedurende de periode 1980 tot 1993 werden in het AZG 23

patienten met een mediane leeftijd van 39 jaar behandeld voor dit letsel. De

mediane follow up periode was 7 jaar. Bij radiologische classificatie bleek dat alle

scaphoidfracturen niet waren gedisloceerd, en dat alle fracturen gelokaliseerd

waren in de taille of het distale een-derde deel. Een extra-articulaire distale radius

fractuur werd gezien in 15 polsen. Een circulair gips met immobilisatie van de

duim gedurende 9 weken werd voorgeschreven bij 18 patienten.Een operatieve

behandeling werd verricht bij 5 patienten.

Alle 23 scaphoidfracturen genazen zonder complicatie. Bij 3 patienten trad tijdens

de conservatieve behandeling redislocatie van de distale radiusfractuur op. De

functionele resultaten waren goed in 18, redelijk in 4, en slecht in 1 patient. Omdat

de meeste behandelingscomplicaties in de distale radius optraden hebben wij ons

conservatieve beleid veranderd van een naviculare gips naar een dorsale

gipsspalk met de pols in functiestand gedurende 6 weken.

HOOFDSTUK 7

Dorsale radiocarpale luxatiefractuur

De dorsale radiocarpale luxatiefractuur is de laatste 25 jaar beschreven als aparte

klinische entiteit in meerdere case-reports. In deze artikelen zijn vooral

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taxonomische en klinische aspecten beschreven. De functionele prognose lijkt niet

gunstig, echter specifieke operatie-technieken om de functionele resultaten te

verbeteren zijn niet eerder aan bod gekomen in de literatuur.

Gedurende de periode 1982-1994 zijn 6 patienten met dit lestel behandeld. K-

draad fixatie werd verricht in 3, externe fixatie in 1, en open repositie met interne

fixatie (ORIF) in 2 polsen. De interne fixatie bestond uit schroef-fixatie van de

processus styloidii radii, met een dorsale afsteunplaat over het radio-carpale

gewricht om redislocatie van de carpus te voorkomen.

Redislocatie werd gezien bij patienten behandeld met K-draad fixatie. Het leek dat

een stabiel gewricht kon worden verkregen met ORIF. Ernstige arthrose in het

radiocarpale gewricht werd bij 3 patienten waargenomen. De precieze betekenis

van bijkomende carpale instabiliteit (SL-dissociatie, DISI) is niet duidelijk. Hoewel

operatieve behandeling op zijn plaats lijkt, denken wij dat de uiteindelijke

prognose vooral wordt bepaald door het uitgebreide ligamentaire en kraakbeen

letsel in het radiocarpale gewricht.

HOOFDSTUK 8

K- draad fixatie voor geredisloceerde Colles fracturen

Een therapeutisch alternartief voor redislocatie van initieel naar dorsaal

gedisloceerde distale radiusfracturen (Colles fractuur) is gesloten repositie en

trans-styloidaire Kirschner draad fixatie. De resultaten van 21 aldus behandelde

redislocaties in de periode 1987-1994 worden beschreven. Volgens de

classificatie van Older waren 8 fracturen geclassificeerd als type 3 en 13 fracturen

als type 4. Na een gemiddelde follow up periode van 2 jaar hadden de meeste

patienten een normale radiocarpale hoek. Aanzienlijke secundair verlies van

radiuslengte werd gevonden bij 11 patienten. Malunion was aanwezig in 8

patienten. Volgens het scoresysteem van Gartland en Werley waren de

functionele resultaten slecht bij 2, redelijk bij 11, goed bij 4, en uitmuntend bij 4

patienten. Secundaire dislocatie en malunion kwam vaker voor bij intra-articulaire

fracturen (Older type 4). De conclusie luidt dat gesloten repositie en K-draad

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fixatie niet het geschikste alternatief is voor geredisloceerde distale

radiusfracturen.

HOOFDSTUK 9

Correctie-osteotomie van de distale radius

Positieve ulnaire variantie is een probleem dat vaak optreedt na een correctie-

osteotomie van de distale radius omdat de radius-lengte onvoldoende is hersteld.

Om deze complicatiete voorkomen hebben wij bij 6 van de 22 patienten waarbij

een correctie-osteotomie van de distale radius werd verricht tevens een

verkortingsosteotomie van de ulna verricht. De indicatie voor de gecombineerde

ingreep was een relatieve ulna lengte van minimaal 5-6 mm. Het functionele

resultaat was redelijk bij 1, en goed bij 5 van de 6 patienten met een verkorting

van de ulna. Voor de gehele groep was het functionele resultaat goed bij 17 van

de 22 patienten. Pijn in het distale radioulnaire gewricht werd waargenomen bij 3

van de 22 patienten. Een hemiresectie van de ulnakop volgens Bower werd

uiteindelijk verricht bij 2 patienten.

Na bestudering van de literatuur wijst deze studie uit dat in malunions van de

distale radius waarbij de relatieve ulna lengte meer is dan 5-6 mm, een

aanvullende verkortings-osteotomie van de ulna zinvol is, met als resultaat minder

pijnklachten, waardoor minder aanvullende ingrepen van het distale radio-ulnaire

gewricht nodig zullen zijn.

HOOFDSTUK 10

Verkortings-osteotomie van de ulna

Het “ulnar impingement syndrome” als gevolg van een relatief te lange ulna is

frequente late complicatie na genezing van een distale radiusfractuur. Wij hebben

10 verkortings-osteomieen van de ulna verricht om de congruentie in het distale

radio-ulnaire gewricht te herstellen. De gemiddelde relatieve ulna lengte was 4-5

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mm. Problemen met genezing van de osteotomie werd gezien bij 4 patienten. Re-

osteosynthese met een spongiosaplastiek vanwege non-union was noodzakelijk

bij 2 patienten. De functionele uitkomst was goed bij 6, redelijk bij 2, en slecht bij 2

patienten. Non-union en vertraagde consolidatie waren gerelateerd aan een

malunion van de distale radius waarbij een volaire radiocarpale hoek van 20 tot 25

graden bestond. Dyscongruentie van het distale radio-ulnaire gewricht bevorderde

non-union.

Het lijkt dat een geisoleerde verkortings-osteotomie van de ulna alleen

geindiceerd is als een geisoleerde verkorting van de distale radius aanwezig is.

Deze studie laat zien dat als de radiocarpale hoek ook afwijkend is, de

botgenezing van de osteotomie vaak gestoord is met als gevolg slechte

functionele resultaten.

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APPENDIX

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The questions of 10 distal radial fractures that were presented in the verbal

recognition test in Chapter 4. Each question deals with a particular fracture type.

In every question a description with the most relevant features and if possible a

classificational label are given. The relative distinctive features are displayed in

italics.

If you have to look at an X-ray with a distal radial fracture you may recognize the

type of fracture in which .......

1. an extra-articular fracture with a comminuted dorsal cortex, and dorsal

angulation or shortening of the distal radius is present ? This injury is also

known as Colles’ fracture.

Yes / No

2. a distal radial fracture in which radial shortening, volar angulation and volar

displacement of the carpus is present? This injury is also known as Smith’s

fracture.

Yes / No

3. an intra-articular fracture with dorsal displacement of the articular fragment and

dorsal displacement of the carpus with disruption of the volar radiocarpal

ligaments is present? This injury is also known as Barton’s fracture.

Yes / No

4. an intra-articular fracture with volar displacement of the articular fragment and

volar displacement of the carpus with disruption of the dorsal radiocarpal

ligamnets is present? This injury is also known as volar or reversed Barton’s

fracture.

Yes / No

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5. an intra-articular fracture on the radial side of the distal radius (scaphoid facet)

is present. The fracture fragment may be displaced in ulnar direction. This

injury is also known as chauffeur’s fracture.

Yes / No

6. an intra-articular fracture on the ulnar side of the distal radius (lunate facet) is

present. The lunate bone may be displaced proximally. This injury is also

known as lunate load fracture.

Yes / No

7. an intra-articular fracture with severe subchondral comminution, radial

shortening with almost normal radiocarpal angulation is present. This is injury

is also known as “axial load” or “pilon” fracture.

Yes/No

8. a fracture or avulsion of the radial styloid process, with minimal or no

involvement of the radiocarpal joint surfcace is present?

Yes / No

9. simultaneous fractures of the distal radius and distal ulnar shaft are present.

This injury is also known as distal forearm fracture.

Yes / No

10. simultaneous fractures of the distal radius and scaphoid bone are present.

Yes/No

chapter 9 - Rijksuniversiteit Groningen

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