Document 6478830

THE
TREATMENT
OF
IMMOBILISATION
WITH
THE
AJAY
From
COLLES’
LNJP
WRIST
FRACTURE
DORSIFLEXED
GUPTA
Hospital,
New
DeThi
In a prospective
study, 204 consecutive
patients
with displaced
Colles’ fractures
had closed reduction
then plaster immobilisation.
Three different
positions
ofthe wrist in plaster were randomly
allocated:
palmar
flexion, neutral and dorsiflexion.
The results in the three groups were compared.
Fractures
immobilised
with
the wrist in dorsiflexion
showed
the lowest incidence
of redisplacement,
especially
of dorsal tilt, and had the
best early functional
results.
Immobilisation
of the wrist in palmar flexion
has a detrimental
effect on hand function;
it is suggested
that it is also one of the main causes for redisplacement
of the fracture.
This is discussed
in relation
to the
functional
anatomy
of the wrist and the mechanics
of plaster fixation.
Colles’ fracture
is a very common
injury, but there is no
agreement
on the best way of treatment.
A wide variety
ofmethods
have been described,
including
reduction
and
immobilisation
of the wrist
and forearm
in various
positions,
percutaneous
reduction
with
pinning,
external
internal
fixation.
open
quite
Although
easily,
especially
where
there
metacarpophalangeal
results
different
neutral
(Gartland
Dorsiflexion
so it was
of
is comminution
or intra-articular
Werley (1951)reported
that 60%
in an unreduced
position.
immobilised
in palmar
flexion,
ofthe fingers, and especially
the
joints.
This
is a common
compli-
and Werley
1951 ; Bacorn and Kurtzke
is the best functional
position
for the
decided
to evaluate
and compare
the
immobilisation
positions
and
and
a Colles’ fracture
can usually be reduced
it is difficult
to maintain
the reduction,
extension.
Gartland
and
oftheir
patients
healed
When
the wrist is
there is a risk ofstiffness
cation
1953).
hand,
fixation
of
of the
Colles’
wrist
fractures
joint
in
: palmar
three
flexion,
dorsiflexion.
PATIENTS
assistant,
AND
MS Orth,
Maulana
Azad
002, India.
©
Medical
Assistant
College
METHODS
Professor
and
is applied
1991
British Editorial
Society ofBone
030l-620X/91/2082
$2.00
JBoneJointSurg[Br]
1991; 73-B:312-5.
312
in Orthopaedics
LNJPN
Hospital,
and Joint
with
holding
selected
position
dorsiflexion(Fig.
A prospective
study was made of204 consecutive
patients
with displaced
Colles’ fractures
at LNJP
Hospital,
New
Delhi from June to November
1986. Of these, 60 were
A. Gupta,
immobilised
New
Surgery
___________
Delhi
110
the
wrist
in
palmar
flexion,
75
in
neutral
position
and 69 in dorsiflexion.
Selection
was
made on a random
basis. There were 122 women
and 82
men, with 106 left sided and 98 right sided fractures.
The
mean age of the patients
was 46 years (range
18 to 74),
evidence
of the younger
population
at risk in India.
Management.
Anteroposterior
and lateral
radiographs
were taken of both the injured
and the uninjured
wrists.
The
fractures
were
manipulated
under
intravenous
diazepam
and
pentazocine
sedation,
using
manual
traction
with the forearm
in pronation.
A below-elbow
plaster
cast was applied,
and moulded
very carefully
around
the fracture.
The distal
radial
fragment
was
pressed in a volar direction
with counter
pressure
against
the proximal
fragment
in a dorsal
direction
(Fig. la).
This
local
moulding
holds
the fracture
in flexion,
maintaining
the normal
anterior
tilt of the distal radial
articular
surface.
While
the surgeon
was moulding
the plaster,
an
carpal
to the
bones.
the
fingers,
moved
of palmar
flexion,
lb). It is essentialthat
This
lower
end
is best
of the
ensured
the
wrist
to
the
neutral
position
or
the volar pressure
radius
and
if the
wrist
not
to the
is moved
into dorsiflexion
: volar pressure
can then only be applied
to the distal radius.
The final movement,
as the plaster hardened
was to
bring the wrist into slight ulnardeviation.
At the extremes
of flexion
or extension
of the wrist, the joint is locked
(Weber
1984) and ulnar deviation
can take place only at
the fracture
site. This helps to maintain
the normal
alignmentofthe
distal radialsurface.
A check radiograph
was taken the next day, and again after 10 days. Plaster
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
TREATMENT
OF COLLES’
FRACTURE
313
Fig. Ia
Figure
1a - The
fragment.
Figure
was
kept
intra-articular,
after
five
Review.
cast
1b
-
Fig. lb
is moulded
around
the fracture
A well moulded
cast, with the
on for six weeks,
in which
by pressing
the distal
fragment
in a volar direction,
with counter
pressure
wrist in dorsiflexion
making
a tube with a double
curve
in an ‘S’ shape.
V (28%).
except
where
the fracture
was
case the plaster
was removed
weeks.
Fractures
were
classified
radiographically
into
94 type
III fractures
53 type
IV (26%),
the postoperative,
of
Neutral
(n
=
(n = 60)
75)
Dorsiflexion(n
= 69)
Total
*
of fracture
IV
V
28
17
15
34
19
22
32
17
20
94
53
III, extra-articular
no comminution
IV, extra-articular
v, intra-articular
with
H.
wrist
in different
Loss
the
41#{176}),
mean
radial
Volar
Position
of
immobilisation
Palmar
flexion
Neutral
Dorsiflexion
VOL.
73-B,
No. 2, MARCH
1991
Linden
(mean
and
The
mean
and
In type
57
in three
positions
I.
(five
to
months
last available
review
films.
deformities
dorsal
were
angulation
angulation
severe.
was
Before
30#{176}
(14#{176}
to
was 16#{176}
(6#{176}
to 20#{176})
and mean
of the radius
was 13 mm (5 to 20). Normal
is 10#{176}
and normal
radial
angulation
is 22#{176}
(van
Ericson
types
of displaced
IV and
least
in fractures
Volar
tilt was
there
was
was almost
tion. Loss
of position
according
1981).
Table
II shows
the loss of position
which
occurred
between
the postoperative
and the 10-day
radiographs.
Little
difference
was found
between
the 10-day
and the
latest follow-up
films.
comminution
Table
results.
reduction
shortening
volar tilt
Colles’
III
types
RESULTS
der
Type
flexion
10-day,
and 57 type
Anatomical
Table
1. Position
of immobilisation
the wrist and the type ofdisplaced
fracture
of these
is given in Table
was 1 5 months
years).
Measurements
ofvolar
tilt, radial
deviation
and
radial
length
before
reduction
were
made
on
anteroposterior
and lateral
radiographs,
of the injured
and the uninjured
wrist.
Measurements
were repeated
on
with articular
involvement.
from the study.
There
were
(46%),
Palmar
distribution
proximal
to two
five types : type I were undisplaced
and extra-articular;
type
II, undisplaced
with
intra-articular
involvement;
type III displaced,
extra-articular
but with no comminution ; type IV, displaced,
extra-articular
with comminution ; and type V displaced
Types
I and II were excluded
The
position
of immobilisation
The average
follow-up
on the
Colles’
V injuries
immobilised
usually
the loss of volar
in dorsiflexion
maintained
in this
group
even
significant
collapse.
Loss of radial
angulation
the same in all three positions
of immobilisaof radial
length
was greatest
after immobilisa-
fracture
after
immobilisation
of the
and range)
Radial tilt (degrees)
lii t (degrees)
tilt was
(Fig.
ShOrt ening
ofradi
us(mm)
III
IV
V
III
IV
V
HI
IV
V
2
Otoll
8
0to28
10
0to32
2
Oto5
5
Otol6
6
2tol4
1
Oto6
4
Otol4
3
Otoll
8
Otol8
1
Oto
8
8
Oto3l
6
Oto3O
1
Oto3
8
Otol7
8
2to18
2
Oto8
6
Otol8
I
Oto
9
2
OtolO
3
Otoll
2
Oto6
5
ltol3
4
Otol2
1
Oto3
2
Oto
8
2
OtolO
2).
if
A. GUPTA
314
tion in the neutral
position
and least
in dorsiflexion
(Table
II).
articular,
no comminution)the
of the wrist
Functional
Sarmiento
made
no significant
results.
These
et al (1975).
in those
In the type
position
immobilised
III fractures
(extraof immobilisation
difference.
were assessed
by the
Fractures
immobilised
criteria
with
of
the
wrist in dorsiflexion
had the best results
(Table
III).
Comparison
of various
joint movements
with those on
the uninjured
side showed
that fractures
immobilised
in
palmar
flexion
had more joint stiffness,
particularly
of
the metacarpophalangeal
and interphalangeal
joints.
Even
in Type
III fractures,
where
the position
of
immobilisation
of the
wrist
did
not
significantly
the anatomical
result,
immobilisation
provided
the best recovery
of function
affect
Fig. 2a
Fig.
2b
in dorsiflexion
(Table III).
DISCUSSION
Colles’
fracture
can be difficult
to treat : the major
problem
is maintenance
of reduction.
This is partly due
to its anatomical
site, adjacent
to the multilinked
system
of the carpus,
and partly to our poor understanding
of
the mechanics
of the fracture
itself.
The carpal
bones transmit
forces from the hand to
the forearm,
but are under no direct motor control.
The
main force-bearing
column ofthe wrist includes
the distal
radial
articular
thirds
of the scaphoid,
surface,
joints
ofthe
second
the lunate
and
the capitate,
and
third
the proximal
the trapezoid
metacarpals
Fig.
two-
and the
(Weber
1984).
Colles’
fracture
breaks
the continuity
of this column
proximally,
so the main
muscle
forces
influencing
displacement
are those
acting
on the whole
column.
These are the wrist flexors and extensors
inserted
at the
bases
of the second
and
third
is dorsiflexion,
where
the wrist
extensors
are placed
at a relative
mechanical
disadvantage.
The periosteal
hinge on the concave,
dorsal side of a
Colles’ fracture
can be an important
stabilising
factor.
When it is intact, it prevents
over reduction
; it should
be
exploited
by being kept under
tension
by slight volar
angulation
at the fracture.
Tension
can be maintained
in
the periosteal
hinge
by moulding
the plaster
in the
direction
of over correction.
Flexion
at the fracture
site
is important
since
it makes
‘.
metacarpals.
After a Colles’ fracture,
whatever
the position
of the
wrist, the extensors
of the carpus
tend to increase
the
posterior
displacement
of the fracture
while the wrist
flexors act in the direction
of over reduction.
The radial
extensors
of the wrist are more powerful
than the radial
flexors (Von Lanz and Wachsmuth
1959). This implies
that the best position
for immobilisation
with balanced
forces
Fig. 2d
2c
the
best
use
of the
Fig.2e
Fig.
2f
Radiographs
of a type IV fracture.
Figures
2a and b - Before reduction.
Figures
2c and d - The wrist
in dorsiflexion
in a below-elbow
cast.
Correction
of volar tilt has been possible
only to 0#{176}.
Figures
2e and f Final
radiograph
shows
healing
with
no further
deterioration
in the
volar tilt.
Table
III.
Functional
results
immobilisation
with
number and percentage
Palmar
Type of
fracture
E
the
in displaced
wrist
of each
treatment
flexion*
G
F
Colles’
in different
Neutral
P
fractures
positions,
after
showing
group
position
F
Dorsiflexion
E
G
III
9
11
7
1
13
13
7
P
1
E
20
G
8
F
4
P
Iv
5
5
3
4
4
4
8
3
9
6
20
V
5
4
2
4
6
7
5
411
5
31
19
20
12
9
23
24
20
8
40
19
9
1
34
33
20
13
30
32
27
11
58
28
13
1
0
dorsal
periosteal
hinge,
but the flexed
position
need not be
maintained
at the wrist joint.
When
the wrist is palmar
flexed the dorsal
carpal
ligament,
attached
mainly
to the dorsal
aspect
of the
triquetrum,
limits flexion of the proximal
carpal row, so
that most palmar
flexion takes place at the mid-carpal
Percentage
E, excellent;
G, good;
THE
F, fair,
P, poor
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
TREATMENTOF
COLLES’
FRACTURE
315
Radius
\ carpal
Dorsal ligament
Raduu1
.
Radiocapitate
ligament
Volar
radiotriquetral
ligament
Distalrow carpal
carpal
Proximal
I
‘
row
Deforming
forces
PALMAR
DORSIFLEXION
FLEXION
Fig. 3a
Fig.
3b
In palmar
flexion
the dorsal
carpal
ligament
is taut,
but cannot
stabilise
the fracture
because
of its
attachment
to distal carpal
row. The deforming
forces
and the potential
displacement
of the fracture
are
the same
direction.
In dors(flexion,
the volar
ligaments
are taut and tend to pull the fracture
fragment
The deforming
forces
act at an angle which
tends
to reduce
the displacement
of the fracture.
radius,
and resist
any deforming
volar
pull on the distal
fracture
Moreover,
forces
applied
in the
lack of an
parallel,
in
anteriorly.
forces
by providing
a
fragment
(Fig.
3b).
line of the dorsiflexed
carpus
Palmar
act at an angle which
tends to reduce
the fracture.
In palmar
flexion
these
forces
act in a direction
tending
to increase
displacement
(Figs 3a and 3b).
In a grossly
comminuted
fracture
some
collapse
is
flexion
probably
inevitable,
but this is likely
to be minimised
when
the wrist is immobilised
in dorsiflexion.
Figure
4
shows
that collapse
or impaction,
especially
of the dorsal
cortex,
is more likely inside
a straight
or smoothly
curved
tube
Neutral
than
in a tube
Conclusion.
After
with
a double
immobilisation
to provide
better
of the wrist
maintenance
and
are required.
evaluation
curve
manipulation
No benefits
in any form
commercial
party
have
related
in dorsiflexion
ofreduction.
been
directly
in an ‘5’ shape.
of a Colles’
received
or
fracture,
would
appear
Further
trials
or will be received
indirectly
to the
from
subject
a
of this
article.
Dorsiflexion
Fig.
4
The fracture
will collapse
most easily inside
a straight
tube.
When
the wrist
is dorsiflexed,
the plaster
forms
a tube
with
a
double
curve in an ‘S’ shape.
REFERENCES
Bacorn
RW, Kurtzke
from
the New
Bone Joint Surg
JF. Colles’
fracture
: a study of two thousand
cases
York
State
Workman’s
Compensation
Board.
J
[Am]
1953 ; 35-A :643-58.
Gartland
JJ Jr, Werley
BoneJoint
Surg[AmJ
articulation,
This lack
radial
where
of control
extensors
the carpus,
extension,
ofthe
radiotriquetral
VOL.
stabilise
wrist
together
with
with consequent
By contrast,
these
there is no dorsal
ligament
at mid-carpal
level allows
when
and
both
73-B, No. 2, MARCH
to rotate
1991
the proximal
row
the distal
radial
fragment,
loss of reduction.
the wrist
radiocapitate
rows
(Fig. 3a).
the strong
is dorsiflexed
ligaments
of the carpus
with
of
Sarmiento
A,
functional
A:31l-7.
become
taut:
respect
to the
Colles’
Pratt
GW,
Berry
NC, Sinclair
WF.
Colles’
bracing
in supination.
J Bone Joint Surg [Am]
fractures.
der Linden
W,
Erlcson
R. Colles’
fracture
: how
should
displacement
be measured
and how should
it be immobilized?
BoneJoint
Surg[Am]
1981 ; 63-A:l285-8.
Von
Lanz
T, Wachsmuth
Springer-Verlag,
1959.
Weber
ER.
segment
Concepts
of the
W.
Praktische
governing
the rotational
carpus.
Orthop
C/in North
Anatomic.
2nd
J
fractures:
1975 ; 57-
van
into
the volar
CW. Evaluation
of healed
1951 ; 33-A :895-907.
ed.
Berlin:
shift of the intercalated
Am 1984;
15:2:193-207.
its
J