University of Groningen
Fracture of the distal radius
Oskam, Jacob
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1999
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Oskam, J. (1999). Fracture of the distal radius: selected issues of epidemiology, classification and
treatment Groningen: s.n.
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64
CHAPTER 6
FRACTURES OF THE DISTAL RADIUS AND SCAPHOID
J Oskam, J S de Graaf, H J Klasen.
Department of Surgery, University Hospital Groningen
Groningen, the Netherlands
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 posttraumatic 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-
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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
Extra-articular
Intra-articular
Scaphoid
Middle third
Waist
Distal third
Undisplaced
1
6
1
Colles’
4
2
1
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
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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