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Fractures of the distal end of the radius in young adults: A 30-year follow-up
FRACTURES OF THE DISTAL END OF THE RADIUS YOUNG ADULTS: A 30-YEAR FOLLOW-UP P. KOPYLOV, 0. JOHNELL, I. REDLUND-JOHNELL
IN
and U. BENGNER
Frwn theDepartments of Hand Surgery, Orthopaedics and Diagnostic Radiology, University of Lund, Malmii, Sweden
76 patients were examined clinically and radiologically 27 to 36 years after a fracture of the distal radius. The average age was 31 years at the time of injury and 63 years at follow-up. In 81% of the patients there was no difference between the fractured and the non-fractured side. No patient had to change his or her occupation or leisure activities because of the fracture. There were more degenerative changes in the fractured wrist than in the non-injured side. A statistically sign&ant correlation was found between axial compression and the presence of degenerative changes in the radio-carpal and distal radio-ulnar joints. Treatment of the fracture of the distal end of the radius in the young adult should aim to conserve the length of the radius. However, after 30 years, complaints are few and correlate with degenerative changes in the radio-carpal joint only. 47 patients with articular fractures of the distal end of the radius were examined in the same way. The average age at the thne of injury was 32 years and 58% of the patients were men. In 87% of the patients there was no difference between the fractured and the non-fractured side. However 37% had minor complaints. A higher proportion of patients with articular fractures developed degenerative changes than those with non-articularfractures. The existence of radiographic signs of osteoarthritis is directly related to axial compression and the persistant incongruity, after reposition, in either the radio-carpal or the distal radio-ulnar joints. Journal of Hand Surgery (British and European Volume, 1993) 18B : 45-49
PART I: FUNCTIONAL OUTCOME RENCE OF OSTEOARTHRITIS
angle between the joint surface and the long axis of the radius (Fig 1). In the postero-anterior view, radial compression was similarly measured as the angle between the long axis of the radius and the joint plane. Axial compression and ulnar variance were measured as the difference between the length of the radius and the ulna (Fig 2). Degenerative changes, such as decreased joint space, subchondral sclerosis and/or cysts, were noted in the radio-carpal and distal radio-ulnarjoints. The original films from the 1950s were retrospectively analysed in the same way. 148 cases of fractures of the distal end of the radius fitted our criteria of selection and were available for follow-up. 76 patients accepted the invitation to come for clinical and radiological examination. There was no difference in the type of fracture or the age between patients who came to follow-up and those who did not. 13 (17%)
AND OCCUR-
The incidence of fracture of the distal end of the radius is h.igh; in Malmij 4 out of 1,000 people will fracture their wrist every year. There are a few long follow-up studies of this type of fracture; in 1967 Frykman, in a five-year follow-up, found 6% with a poor outcome. The purpose of this study was to investigate the longterm results 30 years after conservative treatment of fractures of the distal end of the radius in younger adults with special reference to degenerative changes and function. MATERIAL AND METHODS All X-ray films from 1950-1959 with a diagnosis of fracture of the distal end of the radius have been reexamined and classified according to Frykman (1967). Patients between 18 and 50 years of age at the time of the injury, who were still alive and living in Malmo, were invited for a follow-up examination. All had been treated conservatively with reduction if necessary and immobilization in plaster of Paris for five to six weeks. The clinical examination in 1986-1987 included estimation of grip strength and range of motion. Each patient was questioned about discomfort in the injured wrist compared to the contralateral wrist. Radiological investigation included postero-anterior and lateral projections of both wrists, copying the methods used in the 1950s to permit comparison. Dorsal compression was measured on the lateral view as the
Fig 1 Dorsal compression measured on the lateral view. 4s
THE
46
patients had since sustained a fracture of the contralateral distal radius. The average age at the time of injury was 31 years (range 18-40) and at follow-up 63 years (range 50-80). The average follow-up time was 32 years (range 27-36). Statistics
Chi-square, Student’s t-test and logistic analysis were used in the statistical analysis.
regression
OF HAND
Table I-Angulation
SURGERY
Radiological findings No degenerative changes were found on the original Xrays at the time of fracture. Follow-up X-rays showed minor degenerative changes in the radio-carpal joint on the fractured side in 33% (13% decreased joint space), in the distal radio-ulnar joint in 25% (7% decreased joint space), and in the radio-carpal and distal radio-ulnar joints of the non-fractured side in only 4%.
Fig 2
Axial and radial compression
18B No. 1 FEBRUARY
1993
measured on follow-up X-rays (see Figs 1 and 2).
Dorsal (degrees) -2.4 SDk11.6 Fractured side side - 11.2 SD + 6.8 Non-fractured 8.8 SD+11.3* Difference
Radial (degrees)
Axial (mm) 3.1 SDk2.7 1.6 SDk2.1 1.5 SD+2.8*
67.6 SDk5.3 63.8 SDk5.7 3.8 SD+6.6*
*P
of motion of the wrist joint measured at the follow-up
findings
In 81% of the patients there was no difference between the fractured and the non-fractured side; 37% described minimal complaints (pain, decreased mobility, cosmetic deformity). No patient had had to change his or her occupation or leisure time activities because of the fracture. In all patients there was a significantly increased dorsal, axial and radial compression (Table 1) and decreased flexion (Table 2) and grip strength (Table 3) in the injured wrist and hand, compared to the non-injured side. There was no significant difference between the two sides regarding pronation, supination or ulnar deviation. Clinical examination of the fractured wrist did not indicate significantly more pain or instability of the distal radio-ulnar joint compared to the non-injured side.
VOL.
Compression
Table 2-Range
RESULTS clinical
JOURNAL
Fractured side side Non-fractured Difference
Flexion (degrees)
Extension (degrees)
65.8 SD + 18.3 72.0 SD + 14.9 -6.2 SD+ll.S*
59.5 SD + 16.1 61.9 SD& 16.7 -2.4 SDk10.7
‘P-CO.05
Table 3-Grip
strength measured at the follow-up Grip strength (kg/cm=)
Fractured side Non-fractured side Difference
0.63 0.72 -0.09*
SD +0.23 SD +0.23 SD&O.13
*P-co.05
A statistically significant correlation was found between axial compression and presence of degenerative changes in the radio-carpal and the distal radio-ulnar joints (Table 4). Correlation between clinical and radiological findings
Patients with degenerative changes in the distal radioulnar joint did not have significantly more complaints; those with radio-carpal degenerative changes had significantly more complaints (Table 5). Patients with pain in
measured
on the AP view.
FRACTURES
OF THE
Table 4-Dilference
DISTAL
41
RADIUS
in angulation measured on follow-up X-rays and their correlation with degenerative changes (see Figs 1 and 2) Compression (fractured us non-fractured side) Axial (mm)
Dorsal (degrees)
Degenerative changes RCJ No degenerative changes RCJ Degenerative changes DRUJ No degenerative changes DRUJ
11.2 7.8 11.4 8.0
SD? 14.2 SDk9.5 SDk14.3 SD _I 10.0
2.7 0.9 2.8 1.0
SD + 3.8** SDk1.9 SD+4.2* SD+1.9
Radial (degrees)
4.7 2.1 4.6 2.9
SD+lO.l SDk4.4 SD+ 11.0 SD+4.3
*p
Table 5-Correlation
between complaints and degenerative changes Complaints
Degenerative changes DRUJ No degenerative changes DRUJ Degenerative changes RCJ No degenerative changes RCJ
37% 33% 50%** 27%
'P
joint
Table 6-Difference in augulation measured on follow-up X-rays and their relation to complaints (see Figs 1 and 2) Compression (fractured Dorsal (degrees)
Complaints No complaints
13.5 5.9
us non-fractured side)
Axial (mm)
2.3** 1.1
Radial (degrees)
4.9** 2.0
*p
these joints showed significantly more axial and radial compression (Table 6). Women had significantly more symptoms than men, but did not have more degenerative changes. They had more dorsal compression however. A stepwise logistic regression analysis was performed including all measurements from the early X-rays to find out which variables were precursors of degenerative changes 30 years later. For degenerative changes of the distal radio-ulnar joint, a difference in axial compression on the last X-rays from the 1980s between the fractured and the non-injured side, was the only independently significant finding (1 mm increased compression was associated with a 50% increased risk of degenerative changes). For degenerative changes of the radio-carpal joint at follow-up, the axial and the dorsal compression measured on the last X-ray from the 1980s and in relation with the non-injured side, were significant. To study the correlation between dorsal, radial and axial compression (on the X-ray from the 1980s) and degenerative changes, a logistic regression was performed. Axial compression was significantly related to degenerative changes (1 mm more axial compression the risk of having degenerative
changes increased 20%) but not to symptoms. The radial and dorsal compression were only related to symptoms (5” more radial compression increased the risk of having symptoms by 90% and 10”dorsal compression by 80%). DISCUSSION Fracture of the distal end of the radius is the most common fracture in women (Bengntr and Johnell1985). Thus even a small proportion of poor results will leave a large number of individuals suffering disability as a result of this injury. Frykman (1967) carried out a follow-up study within three years and found some subjective symptoms in 52% of the patients, whereas poor results where only found in 6% of the patients examined. Our results are in accordance with Frykman since the patients managed fairly well, and experienced only minor discomfort after 30 years. No one had changed occupation or leisure time activities. More recent reports (Cooney et al, 1980; McQueen and Caspars, 1988) noticed a higher incidence of poor results than we found. Villar et al (1987) found 28% poor results in a prospective study of 90 patients; pain and decreased flexion were the most obvious symptoms. The difference could be explained by a shorter follow-up in these studies, higher average age, or better conservative treatment performed during the 1950s than today. In agreement with earlier reports (Lidstriim, 1959; Van der Linden and Ericson, 1981) we found that the shortening of the radius influenced the outcome and the existence of radiological degenerative changes after 30 years. In this study degenerative changes (subchondral cysts and sclerosis) correlated only weakly with complaints. It is difficult to determine the degree of compression that should be accepted. If the most important end-point was the presence of minor degenerative changes, we could estimate from the logistic regressional analysis : 1 mm increased axial compression gave a 20% risk of degenerative changes, 2 mm a 50% risk respectively. It is a matter of opinion which degree of axial compression can be accepted (l-2 mm). In the 20 to 50 age group, the initial reduction should aim to be anatomical, which will usually be possible. If the reduction is difficult or if increased compression has appeared at the time of repeat X-ray seven to ten days
48
THE JOURNAL
later, it may be difficult to decide what degree of compression to accept.
OF HAND SURGERY
VOL. 18B No. 1 FEBRUARY
1993
Table g-Axial compression (fractured vs non-fractured) and relation with degenerative changes (see Fig 2) Axial compression
PART 2: DO ARTICULAR BAD PROGNOSIS?
FRACTURES
HAVE
A
It is thought that an articular fracture has a bad prognosis because of the risk of osteoarthritis due to incongruency. Intra-articular fractures of the distal end of the radius were therefore evaluated 30 years after conservative treatment and compared to extra-articular fractures. During the assessment described above, incongruity was evaluated, being defined as an irregularity of the joint surface. Functional outcome and X-ray appearances of intra-articular fractures were compared to a group of extra-articular fractures and to the contralateral noninjured side.
Extra-articular fracture No degenerative changes DRUJ No degenerative changes RCJ Degenerative changes DRUJ Degenerative changes RCJ
Intra-articular fracture
0.71 SD+ 1.82
1.35 SD* 1.92
0.37 SD + 1.67
1.5 SD* 1.99
1.5 SD+2.35
3.94 SD + 5.26*
2.5 SD+2.5*
2.85 SD f 4.57*
*p
Table !&-Degenerative relation with congruity
changes in i&a-articular
fractures and their
MATERIAL 47 patients of the 76 reviewed (62%) had an intraarticular fracture. The average age was 32 years (2047) years at the time of injury, and 58% were men. At the time of fracture 35% were in heavy work, 40% were factory workers and 25% office workers. No patient had changed either work or leisure activities because of the injury. RESULTS clinical findings 30 years after the initial fracture 87% of the patients found no difference between the injured and the noninjured side. However 37% had minor complaints. Clinical examination showed significantly less flexion (8”) and grip strength, compared with the non-injured side, but there was no difference between the clinical outcome of intra- and extra-articular fractures. Radiological
findings
There were more radiological signs of degenerative changes in the radio-carpal joints in patients with articular fractures than with extra-articular fractures (Table 7). The relationship between axial compression (ulna plus) and degenerative changes (after 30 years) is presented in Table 8. Increased axial compression was Table 7-Degenerative
Degenerative Degenerative
changes changes
Congruity
No congruity
18% 29%
46% 69%*
DRU RC
*p
found both in extra- and intra-articular fractures in those with degenerative changes. If there was incongruity of more than 1 mm in the joint surface after reduction, a significantly higher proportion of patients developed degenerative changes in both radiocarpal and distal radio-ulnar joints (Table 9). Table 10 shows that incongruity by itself is a risk factor for degenerative changes as well as axial compression. In a logistic regression analysis, axial compression was found to be significantly related to degenerative changes in intra-articular fractures without incongruity. There was no significant relationship between axial compression and degenerative changes in intra-articular fractures with incongruity of the joint space. The main factor related to development of degenerative changes was incongruity of the joint surface. The other variables Table lo--Axial compression (fractured vs non-fractured) and its relation to degenerative changes depending on congruity or not (see Fig. 2) Axial compression
changes
Congruency
Degenerative Degenerative
changes changes
DRUJ RCJ
*pt0.05 RCJ : radio-carpal joint DRUJ : distal radio-ulnar joint
Extra-articular fracture
Intra-articular fracture
25% 21%
25% 40.5%*
No degenerative changes DRUJ No degenerative changes RCJ Degenerative changes DRUJ Degenerative changes RCJ *p
1.06 1.18 6.5 4.42
SD f 1.58 SD& 1.56 SD+5.55* SD&5.45*
No congruency 2.67 3.5 1.38 1.25
SD + 2.02 SD+ 1.83 SDk5.26 SD+3.19*
FRACTURES
OF THE
DISTAL
RADIUS
which were important in extra-articular fractures, such as dorsal angulation, radial compression, were not important if there was an incongruity of the joint space. The only other important factor was the axial compression. DISCUSSION
Frykman (1967) found that the final result is related to the type of fracture. Patients with intra-articular fractures fared worse than those with extra-articular fractures. In our study, patients with articular fractures had no more complaints than others; none had changed work or leisure activities. Our X-ray findings accord with those of Frykman (1967) and Cooney (1980) in terms of final results and their relation to the type of fracture (articular or extra-articular). Articular fractures differ from the extra-articular fractures in that they have more degenerative changes, especially when the incongruity is greater than 1 mm of the joint surface; our results show that the incongruity itself is the most important factor-and that the axial, dorsal or radial compression are of minor importance. Patients with incongruity greater than 1 mm of the joint surface should always have the fracture reduced. If this is unsuccessful operative treatment should be considered. In patients with no incongruity of the joint surface the outcome and the risk factors are approximately the same as for those with extra-articular fractures, i.e. the axial compression assumes greater importance, and its reduction should be the aim of treatment. All patients were under 50 years of age at the time of injury, and it is difficult to say if the same treatment should be advocated for elderly osteoporotic women. However the symptoms of a minor degree were largely confined to patients’ articular fractures with incongruity of the joint space. CONCLUSIONS
There is a correlation between axial and radial compression and the presence of minor degenerative changes. If these are regarded as important, anatomical reduction should be achieved. Pain and other complaints were not associated with degenerative changes of the distal radioulnar joint but had a significant correlation with changes
in the radio-carpal joint. No patient had major degenerative changes and symptoms were minor. No patient needed to change his or her occupation or leisure activities. There was a small correlation between pain and degenerative changes. However axial compression does correlate with the presence of degenerative changes, so in the treatment of fractures of the distal end of the radius in young adults, one should aim to conserve the normal length of the radius. Articular fractures of the distal end of the radius treated conservatively had an increased risk of degenerative changes in the radio-carpal joint compared with non-articular fractures, particularly when the incongruity of the joint surface was more than 1 mm. Radiographic signs of osteoarthrit.is were related to axial compression of which “ulna plus” is the consequence, and the persistence of an incongruity either in radio-carpal or distal radio-ulnar joints after reduction. Thus the management of articular fractures of the distal end of the radius in the younger age group should aim to minimize axial compression, and eliminate the incongruency at radio-carpal and distal radio-ulnar joint, If that is not possible by closed means, open reduction should be considered. Although radiological signs of osteoarthritis are common, symptoms are few, therefore conservative treatment is normally adequate. References BENGNkR, U. and JOHNELL, 0. (1985). Increasing incidence of forearm fractures: A comparison of epidemiologic patterns 25 years apart. Acta Orthopaedica Scandinavica, 56: 158-160. COONEY, W. P., DOBYNS, J. H., LINSCHEID, R. L. (1980). Complications of Colles’ fractures. Journal of Bone and Joint Surgery, 62A: 4: 613619. FRYKMAN, G. (1967). Fractureofthedistalradius includingsequelae-shoulderhand-finger syndrome, disturbance in the radio-ulnar joint and impairment of nerve function. Acta Orthopaedica Scandinavica, Suppl: 108. LIDSTROM, A. (1959). Fractures of the distal end of the radius: A clinical and statistical study of end results. Acta Octhopaedica Scandinavica, Suppl: 41. McQUEEN, M. and CASPERS, J. (1988). Colles' fracture: Does the anatomical result affect the final function? Journal of Bone and Joint Surgery, 70B: 4: 649-65 1. VAN DER LINDEN, W. and ERICSON, R. (1981). Colles’ fracture: How should its displacement be measured and how should it be immobilised? Journal of Bone and Joint Surgery, 63A: 8: 1285-1288. VILLAR, R. N., MARSH, D., RUSHTON, N. and GREATOREX, R. A. (1987). Three years after Colles’ fracture: A prospective review. Journal of Bone and Joint Surgery, 69B: 4: 635-638.
Accepted: 19 February 1992 Philippe KOPY~OV, Department of Hand S-214 01 Malm6, Sweden 0 1993 The British Society
for Surgery
Surgery,
of the Hand
General
Hospital,
University
of Lund,
IN
and U. BENGNER
Frwn theDepartments of Hand Surgery, Orthopaedics and Diagnostic Radiology, University of Lund, Malmii, Sweden
76 patients were examined clinically and radiologically 27 to 36 years after a fracture of the distal radius. The average age was 31 years at the time of injury and 63 years at follow-up. In 81% of the patients there was no difference between the fractured and the non-fractured side. No patient had to change his or her occupation or leisure activities because of the fracture. There were more degenerative changes in the fractured wrist than in the non-injured side. A statistically sign&ant correlation was found between axial compression and the presence of degenerative changes in the radio-carpal and distal radio-ulnar joints. Treatment of the fracture of the distal end of the radius in the young adult should aim to conserve the length of the radius. However, after 30 years, complaints are few and correlate with degenerative changes in the radio-carpal joint only. 47 patients with articular fractures of the distal end of the radius were examined in the same way. The average age at the thne of injury was 32 years and 58% of the patients were men. In 87% of the patients there was no difference between the fractured and the non-fractured side. However 37% had minor complaints. A higher proportion of patients with articular fractures developed degenerative changes than those with non-articularfractures. The existence of radiographic signs of osteoarthritis is directly related to axial compression and the persistant incongruity, after reposition, in either the radio-carpal or the distal radio-ulnar joints. Journal of Hand Surgery (British and European Volume, 1993) 18B : 45-49
PART I: FUNCTIONAL OUTCOME RENCE OF OSTEOARTHRITIS
angle between the joint surface and the long axis of the radius (Fig 1). In the postero-anterior view, radial compression was similarly measured as the angle between the long axis of the radius and the joint plane. Axial compression and ulnar variance were measured as the difference between the length of the radius and the ulna (Fig 2). Degenerative changes, such as decreased joint space, subchondral sclerosis and/or cysts, were noted in the radio-carpal and distal radio-ulnarjoints. The original films from the 1950s were retrospectively analysed in the same way. 148 cases of fractures of the distal end of the radius fitted our criteria of selection and were available for follow-up. 76 patients accepted the invitation to come for clinical and radiological examination. There was no difference in the type of fracture or the age between patients who came to follow-up and those who did not. 13 (17%)
AND OCCUR-
The incidence of fracture of the distal end of the radius is h.igh; in Malmij 4 out of 1,000 people will fracture their wrist every year. There are a few long follow-up studies of this type of fracture; in 1967 Frykman, in a five-year follow-up, found 6% with a poor outcome. The purpose of this study was to investigate the longterm results 30 years after conservative treatment of fractures of the distal end of the radius in younger adults with special reference to degenerative changes and function. MATERIAL AND METHODS All X-ray films from 1950-1959 with a diagnosis of fracture of the distal end of the radius have been reexamined and classified according to Frykman (1967). Patients between 18 and 50 years of age at the time of the injury, who were still alive and living in Malmo, were invited for a follow-up examination. All had been treated conservatively with reduction if necessary and immobilization in plaster of Paris for five to six weeks. The clinical examination in 1986-1987 included estimation of grip strength and range of motion. Each patient was questioned about discomfort in the injured wrist compared to the contralateral wrist. Radiological investigation included postero-anterior and lateral projections of both wrists, copying the methods used in the 1950s to permit comparison. Dorsal compression was measured on the lateral view as the
Fig 1 Dorsal compression measured on the lateral view. 4s
THE
46
patients had since sustained a fracture of the contralateral distal radius. The average age at the time of injury was 31 years (range 18-40) and at follow-up 63 years (range 50-80). The average follow-up time was 32 years (range 27-36). Statistics
Chi-square, Student’s t-test and logistic analysis were used in the statistical analysis.
regression
OF HAND
Table I-Angulation
SURGERY
Radiological findings No degenerative changes were found on the original Xrays at the time of fracture. Follow-up X-rays showed minor degenerative changes in the radio-carpal joint on the fractured side in 33% (13% decreased joint space), in the distal radio-ulnar joint in 25% (7% decreased joint space), and in the radio-carpal and distal radio-ulnar joints of the non-fractured side in only 4%.
Fig 2
Axial and radial compression
18B No. 1 FEBRUARY
1993
measured on follow-up X-rays (see Figs 1 and 2).
Dorsal (degrees) -2.4 SDk11.6 Fractured side side - 11.2 SD + 6.8 Non-fractured 8.8 SD+11.3* Difference
Radial (degrees)
Axial (mm) 3.1 SDk2.7 1.6 SDk2.1 1.5 SD+2.8*
67.6 SDk5.3 63.8 SDk5.7 3.8 SD+6.6*
*P
of motion of the wrist joint measured at the follow-up
findings
In 81% of the patients there was no difference between the fractured and the non-fractured side; 37% described minimal complaints (pain, decreased mobility, cosmetic deformity). No patient had had to change his or her occupation or leisure time activities because of the fracture. In all patients there was a significantly increased dorsal, axial and radial compression (Table 1) and decreased flexion (Table 2) and grip strength (Table 3) in the injured wrist and hand, compared to the non-injured side. There was no significant difference between the two sides regarding pronation, supination or ulnar deviation. Clinical examination of the fractured wrist did not indicate significantly more pain or instability of the distal radio-ulnar joint compared to the non-injured side.
VOL.
Compression
Table 2-Range
RESULTS clinical
JOURNAL
Fractured side side Non-fractured Difference
Flexion (degrees)
Extension (degrees)
65.8 SD + 18.3 72.0 SD + 14.9 -6.2 SD+ll.S*
59.5 SD + 16.1 61.9 SD& 16.7 -2.4 SDk10.7
‘P-CO.05
Table 3-Grip
strength measured at the follow-up Grip strength (kg/cm=)
Fractured side Non-fractured side Difference
0.63 0.72 -0.09*
SD +0.23 SD +0.23 SD&O.13
*P-co.05
A statistically significant correlation was found between axial compression and presence of degenerative changes in the radio-carpal and the distal radio-ulnar joints (Table 4). Correlation between clinical and radiological findings
Patients with degenerative changes in the distal radioulnar joint did not have significantly more complaints; those with radio-carpal degenerative changes had significantly more complaints (Table 5). Patients with pain in
measured
on the AP view.
FRACTURES
OF THE
Table 4-Dilference
DISTAL
41
RADIUS
in angulation measured on follow-up X-rays and their correlation with degenerative changes (see Figs 1 and 2) Compression (fractured us non-fractured side) Axial (mm)
Dorsal (degrees)
Degenerative changes RCJ No degenerative changes RCJ Degenerative changes DRUJ No degenerative changes DRUJ
11.2 7.8 11.4 8.0
SD? 14.2 SDk9.5 SDk14.3 SD _I 10.0
2.7 0.9 2.8 1.0
SD + 3.8** SDk1.9 SD+4.2* SD+1.9
Radial (degrees)
4.7 2.1 4.6 2.9
SD+lO.l SDk4.4 SD+ 11.0 SD+4.3
*p
Table 5-Correlation
between complaints and degenerative changes Complaints
Degenerative changes DRUJ No degenerative changes DRUJ Degenerative changes RCJ No degenerative changes RCJ
37% 33% 50%** 27%
'P
joint
Table 6-Difference in augulation measured on follow-up X-rays and their relation to complaints (see Figs 1 and 2) Compression (fractured Dorsal (degrees)
Complaints No complaints
13.5 5.9
us non-fractured side)
Axial (mm)
2.3** 1.1
Radial (degrees)
4.9** 2.0
*p
these joints showed significantly more axial and radial compression (Table 6). Women had significantly more symptoms than men, but did not have more degenerative changes. They had more dorsal compression however. A stepwise logistic regression analysis was performed including all measurements from the early X-rays to find out which variables were precursors of degenerative changes 30 years later. For degenerative changes of the distal radio-ulnar joint, a difference in axial compression on the last X-rays from the 1980s between the fractured and the non-injured side, was the only independently significant finding (1 mm increased compression was associated with a 50% increased risk of degenerative changes). For degenerative changes of the radio-carpal joint at follow-up, the axial and the dorsal compression measured on the last X-ray from the 1980s and in relation with the non-injured side, were significant. To study the correlation between dorsal, radial and axial compression (on the X-ray from the 1980s) and degenerative changes, a logistic regression was performed. Axial compression was significantly related to degenerative changes (1 mm more axial compression the risk of having degenerative
changes increased 20%) but not to symptoms. The radial and dorsal compression were only related to symptoms (5” more radial compression increased the risk of having symptoms by 90% and 10”dorsal compression by 80%). DISCUSSION Fracture of the distal end of the radius is the most common fracture in women (Bengntr and Johnell1985). Thus even a small proportion of poor results will leave a large number of individuals suffering disability as a result of this injury. Frykman (1967) carried out a follow-up study within three years and found some subjective symptoms in 52% of the patients, whereas poor results where only found in 6% of the patients examined. Our results are in accordance with Frykman since the patients managed fairly well, and experienced only minor discomfort after 30 years. No one had changed occupation or leisure time activities. More recent reports (Cooney et al, 1980; McQueen and Caspars, 1988) noticed a higher incidence of poor results than we found. Villar et al (1987) found 28% poor results in a prospective study of 90 patients; pain and decreased flexion were the most obvious symptoms. The difference could be explained by a shorter follow-up in these studies, higher average age, or better conservative treatment performed during the 1950s than today. In agreement with earlier reports (Lidstriim, 1959; Van der Linden and Ericson, 1981) we found that the shortening of the radius influenced the outcome and the existence of radiological degenerative changes after 30 years. In this study degenerative changes (subchondral cysts and sclerosis) correlated only weakly with complaints. It is difficult to determine the degree of compression that should be accepted. If the most important end-point was the presence of minor degenerative changes, we could estimate from the logistic regressional analysis : 1 mm increased axial compression gave a 20% risk of degenerative changes, 2 mm a 50% risk respectively. It is a matter of opinion which degree of axial compression can be accepted (l-2 mm). In the 20 to 50 age group, the initial reduction should aim to be anatomical, which will usually be possible. If the reduction is difficult or if increased compression has appeared at the time of repeat X-ray seven to ten days
48
THE JOURNAL
later, it may be difficult to decide what degree of compression to accept.
OF HAND SURGERY
VOL. 18B No. 1 FEBRUARY
1993
Table g-Axial compression (fractured vs non-fractured) and relation with degenerative changes (see Fig 2) Axial compression
PART 2: DO ARTICULAR BAD PROGNOSIS?
FRACTURES
HAVE
A
It is thought that an articular fracture has a bad prognosis because of the risk of osteoarthritis due to incongruency. Intra-articular fractures of the distal end of the radius were therefore evaluated 30 years after conservative treatment and compared to extra-articular fractures. During the assessment described above, incongruity was evaluated, being defined as an irregularity of the joint surface. Functional outcome and X-ray appearances of intra-articular fractures were compared to a group of extra-articular fractures and to the contralateral noninjured side.
Extra-articular fracture No degenerative changes DRUJ No degenerative changes RCJ Degenerative changes DRUJ Degenerative changes RCJ
Intra-articular fracture
0.71 SD+ 1.82
1.35 SD* 1.92
0.37 SD + 1.67
1.5 SD* 1.99
1.5 SD+2.35
3.94 SD + 5.26*
2.5 SD+2.5*
2.85 SD f 4.57*
*p
Table !&-Degenerative relation with congruity
changes in i&a-articular
fractures and their
MATERIAL 47 patients of the 76 reviewed (62%) had an intraarticular fracture. The average age was 32 years (2047) years at the time of injury, and 58% were men. At the time of fracture 35% were in heavy work, 40% were factory workers and 25% office workers. No patient had changed either work or leisure activities because of the injury. RESULTS clinical findings 30 years after the initial fracture 87% of the patients found no difference between the injured and the noninjured side. However 37% had minor complaints. Clinical examination showed significantly less flexion (8”) and grip strength, compared with the non-injured side, but there was no difference between the clinical outcome of intra- and extra-articular fractures. Radiological
findings
There were more radiological signs of degenerative changes in the radio-carpal joints in patients with articular fractures than with extra-articular fractures (Table 7). The relationship between axial compression (ulna plus) and degenerative changes (after 30 years) is presented in Table 8. Increased axial compression was Table 7-Degenerative
Degenerative Degenerative
changes changes
Congruity
No congruity
18% 29%
46% 69%*
DRU RC
*p
found both in extra- and intra-articular fractures in those with degenerative changes. If there was incongruity of more than 1 mm in the joint surface after reduction, a significantly higher proportion of patients developed degenerative changes in both radiocarpal and distal radio-ulnar joints (Table 9). Table 10 shows that incongruity by itself is a risk factor for degenerative changes as well as axial compression. In a logistic regression analysis, axial compression was found to be significantly related to degenerative changes in intra-articular fractures without incongruity. There was no significant relationship between axial compression and degenerative changes in intra-articular fractures with incongruity of the joint space. The main factor related to development of degenerative changes was incongruity of the joint surface. The other variables Table lo--Axial compression (fractured vs non-fractured) and its relation to degenerative changes depending on congruity or not (see Fig. 2) Axial compression
changes
Congruency
Degenerative Degenerative
changes changes
DRUJ RCJ
*pt0.05 RCJ : radio-carpal joint DRUJ : distal radio-ulnar joint
Extra-articular fracture
Intra-articular fracture
25% 21%
25% 40.5%*
No degenerative changes DRUJ No degenerative changes RCJ Degenerative changes DRUJ Degenerative changes RCJ *p
1.06 1.18 6.5 4.42
SD f 1.58 SD& 1.56 SD+5.55* SD&5.45*
No congruency 2.67 3.5 1.38 1.25
SD + 2.02 SD+ 1.83 SDk5.26 SD+3.19*
FRACTURES
OF THE
DISTAL
RADIUS
which were important in extra-articular fractures, such as dorsal angulation, radial compression, were not important if there was an incongruity of the joint space. The only other important factor was the axial compression. DISCUSSION
Frykman (1967) found that the final result is related to the type of fracture. Patients with intra-articular fractures fared worse than those with extra-articular fractures. In our study, patients with articular fractures had no more complaints than others; none had changed work or leisure activities. Our X-ray findings accord with those of Frykman (1967) and Cooney (1980) in terms of final results and their relation to the type of fracture (articular or extra-articular). Articular fractures differ from the extra-articular fractures in that they have more degenerative changes, especially when the incongruity is greater than 1 mm of the joint surface; our results show that the incongruity itself is the most important factor-and that the axial, dorsal or radial compression are of minor importance. Patients with incongruity greater than 1 mm of the joint surface should always have the fracture reduced. If this is unsuccessful operative treatment should be considered. In patients with no incongruity of the joint surface the outcome and the risk factors are approximately the same as for those with extra-articular fractures, i.e. the axial compression assumes greater importance, and its reduction should be the aim of treatment. All patients were under 50 years of age at the time of injury, and it is difficult to say if the same treatment should be advocated for elderly osteoporotic women. However the symptoms of a minor degree were largely confined to patients’ articular fractures with incongruity of the joint space. CONCLUSIONS
There is a correlation between axial and radial compression and the presence of minor degenerative changes. If these are regarded as important, anatomical reduction should be achieved. Pain and other complaints were not associated with degenerative changes of the distal radioulnar joint but had a significant correlation with changes
in the radio-carpal joint. No patient had major degenerative changes and symptoms were minor. No patient needed to change his or her occupation or leisure activities. There was a small correlation between pain and degenerative changes. However axial compression does correlate with the presence of degenerative changes, so in the treatment of fractures of the distal end of the radius in young adults, one should aim to conserve the normal length of the radius. Articular fractures of the distal end of the radius treated conservatively had an increased risk of degenerative changes in the radio-carpal joint compared with non-articular fractures, particularly when the incongruity of the joint surface was more than 1 mm. Radiographic signs of osteoarthrit.is were related to axial compression of which “ulna plus” is the consequence, and the persistence of an incongruity either in radio-carpal or distal radio-ulnar joints after reduction. Thus the management of articular fractures of the distal end of the radius in the younger age group should aim to minimize axial compression, and eliminate the incongruency at radio-carpal and distal radio-ulnar joint, If that is not possible by closed means, open reduction should be considered. Although radiological signs of osteoarthritis are common, symptoms are few, therefore conservative treatment is normally adequate. References BENGNkR, U. and JOHNELL, 0. (1985). Increasing incidence of forearm fractures: A comparison of epidemiologic patterns 25 years apart. Acta Orthopaedica Scandinavica, 56: 158-160. COONEY, W. P., DOBYNS, J. H., LINSCHEID, R. L. (1980). Complications of Colles’ fractures. Journal of Bone and Joint Surgery, 62A: 4: 613619. FRYKMAN, G. (1967). Fractureofthedistalradius includingsequelae-shoulderhand-finger syndrome, disturbance in the radio-ulnar joint and impairment of nerve function. Acta Orthopaedica Scandinavica, Suppl: 108. LIDSTROM, A. (1959). Fractures of the distal end of the radius: A clinical and statistical study of end results. Acta Octhopaedica Scandinavica, Suppl: 41. McQUEEN, M. and CASPERS, J. (1988). Colles' fracture: Does the anatomical result affect the final function? Journal of Bone and Joint Surgery, 70B: 4: 649-65 1. VAN DER LINDEN, W. and ERICSON, R. (1981). Colles’ fracture: How should its displacement be measured and how should it be immobilised? Journal of Bone and Joint Surgery, 63A: 8: 1285-1288. VILLAR, R. N., MARSH, D., RUSHTON, N. and GREATOREX, R. A. (1987). Three years after Colles’ fracture: A prospective review. Journal of Bone and Joint Surgery, 69B: 4: 635-638.
Accepted: 19 February 1992 Philippe KOPY~OV, Department of Hand S-214 01 Malm6, Sweden 0 1993 The British Society
for Surgery
Surgery,
of the Hand
General
Hospital,
University
of Lund,