- Email: [email protected]
Treatment of comminuted fractures of the distal radius with self-contained skeletal traction
Treatment of Cornminuted Fractures of the Distal Radius with Self-Contained Skeletal Traction
Henry 0. Marsh, MD, Wichita,
Kansas
Stephen W. Teal, MD, Wichita,
Kansas
In 1814, Colles [I] described the fracture of the distal radius that bears his name and he outlined a course of treatment. Colles also described the residual permanent deformities after this injury which are seen today, 158 years later, after the advent of accepted modern modes of treatment. Prevention of these disfiguring and disabling deformities in the young and active middle-aged patient is the subject of this paper. Current conventional treatment consists of “disimpacting” the fracture, manipulating the fragments, and immobilizing the wrist in flexion, pronation, and ulnar deviation. In simple noncomminuted fractures, this method is routinely satisfactory, but the same method applied to a cornminuted fracture almost certainly produces an unsatisfactory result. In these fractures, the dorsal cortex of the radius is fragmented, destroying the buttress of bone essential to maintain the radial articular surface in its normal volar tilt. This loss of stability allows the radius to collapse and deviate radially, thrusting the ulnar head into prominence. Thus, cornminuted fractures often regress to a deformity practically identical to that present originally. The resultant loss of function and appearance may not be of clinical importance in the elderly, but for the young or active middle-aged patient, enough deformity and disability may result that the physician is faced with a discontented patient. Secondary surgical corrections, such as osteoFrom St. Francis Hospital, Wichita, Kansas. Reprint requests should be addressed to Dr. Marsh, Director, Orthopedic Residency Training Program, St. Francis Hospital, Wichita, Kansas 67214. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque. New Mexico, May l-4, 1972.
Volume 124, December 1972
tomy of the radius, resection of the ulnar head, or even wrist fusion may be necessary to decrease the disability. In 1929 Bohler [2] attempted to solve this problem by placing a Steinmann pin through the olecranon and a second pin through the bases of the metacarpals. Traction was applied, the fracture manipulated, and a cast applied, incorporating the pins while traction was continued. This immobilization was maintained for six weeks. Many modifications have since been suggested but the basic concept of selfcontained skeletal traction remains a reasonable solution for badly cornminuted fractures in carefully selected patients. We are therefore not the originators of the technic, but we believe that it merits being called to attention as a successful method of treating cornminuted fractures of the distal radius. Material and Methods Eight orthopedists provided twenty-six patients for this study. All original roentgenograms were reviewed and eighteen patients with twenty fractures were available for personal re-examination. Four patients could not be located and four completed a questionnaire which had been mailed to them. Twenty-nine fractures in twenty-six patients were treated between 1956 and 1972, indicating the high degree of selectivity exercised in choosing these patients since this was only a small percentage of the total number of patients with Colles’ fractures seen and treated by conventional methods. There were thirteen male and thirteen female patients. The average age was 43.1 years, with a range from twenty to eighty. The average follow-up -time was 16.7 months.
715
Marsh
and Teal
TABLE I
Criteria* for Subjective Evaluation of Results of Treatment of Comminuted Fractures of the Distal Radius with Self-Contained Skeletal Traction
Result
Description
Excellent
No pain,
Good
motion Occasional
no disability, pain,
no noticeable
no disability,
slight
limitation
Of
limitation
of
motion Occasional pain, no disability if careful, slight limitation of motion, slight restriction of activities Constant pain, limitation of motion, disability, and limitation of activities because of wrist problem
Fair Poor
* According
to Cole and Obletz [3].
Five variations of Bbhler’s 123 technic were used: (1) pins through the thumb metacarpal and the olecranon; (2) pins through the second and third metacarpal and midshaft of the radius; (3) pins through the second and third metacarpals and olecranon; (4) pins through the fourth and fifth metacarpal and midshaft of the radius; and (5) pins through the fourth and fifth metacarpals and olecranon. An above-elbow cast was used in twenty-two fractures and a short-arm cast or dorsal plaster slab was employed in seven. The procedure was carried out in the operating room, and did not require any special equipment. An axillary block or general anesthetic was administered, the hand, forearm, and elbow were scrubbed and draped, and Steinmann pins measuring 3/32 of an inch were drilled into place. The arm was then suspended with the elbow in 90 degrees of flexion and traction applied. After the fracture had been disimpacted, it was manipulated and reduced, and reduction was verified by x-ray studies. A plaster cast was applied, incorporating the pins, while the arm was still in traction. TABLE III
Objective Evaluation* of Results Based on X-Ray Appearance at Follow-up Study Degree or Millimeters
Result
la”-23” loo-1 7”
excellent good poor excellent good poor excellent good poor
Angle Radial
Radial
Volar
Range Over-all result
* According
716
to Scheck
excellent good fair poor [4].
Numeric Value 0 1 2 0 1 2 0 1 2 6-6 O-4 5-8 9-12 13-18
The hospitalization period varied from two to five days. Traction should be maintained for a minimum of six weeks, but occasionally the pins were removed earlier because of pin tract infection or migration, This usually resulted when below-elbow plaster immobilization was used. The period of immobilization varied from three to ten weeks. Results
Our mailed questionnaire did not permit an accurate assessment of results; therefore the final evaluation will be limited to the eighteen patients with twenty fractures who were seen for examination. Evaluation was threefold: (1) subjective, according to the criteria of Cole and Obletz [3]; (2) objective, according to the criteria of Scheck [4]; and (4) overall assessment, combining these two criteria. The subjective criteria of Cole and Obletz are based on pain, disability, and the active range of motion. TABLE II
Criteria* for Objective Evaluation Based on Wrist Motion
Motion Compared with That of Normal Wrist Amount of Loss O”-15” 16”-30” 31 O-45” 45O+
* According
Rating
Numeric Value
excellent good fair poor
0 1 2 3
to Scheck
Motions Tested
Motion Flexion Extension Pronation Supination Range
Range of Numeric Value o-3 o-3 o-3 o-3 o-12
[4]
(Table I.) The subjective results were excellent in two, good in eleven, fair in six, and poor in one. The objective results were evaluated by measuring the active and passive joint motion (Table II) and measurements from the x-ray film. The latter is based on radial shortening, loss of volar tilt of the articular surface of the radius, and loss of the normal radial articular angulation towards the ulnar head. (Table III.) Objective results were excellent in fourteen cases, good in four, fair in one, and poor in one. In order to determine the over-all results in each case from the subjective and objective data, a final point scale was established. The subjective result, taken from the criteria of Cole and Obletz, was assigned a specific number of points and these were added to the points which gave the objective result which were determined by the criteria of Scheck. The final total number of points was then used to assign the over-all result as noted in Figure 1.
The Amerlcan Journal of Surgery
Comminuted
Fractures
of Distal Radius
good, the objective result excellent, and the over-all excellent at four month follow-up study. (Figure 4.) COLE & OBLETZ CRITERlA
SCHECK CRITERIA I E..CELLENT 0-4 GOOD 5-8 9-12 FAIR POOR 13-18
GOOD FAlR POOR I ASSIGN POINTS FOR EACHPeSCILT EXCELL$N'T - 0 POINTS 4 -GOOD 8 " FAIR 12 ,' POOR
I l
POINTS'ASSIGNED TO RESULT
+
/ POINTS GIVING RESULT /
\ Q
EXCELLENT GOOD FAIR POOR
Figure 1. Determination ive and objective results.
O-4 S-11 - 12-20 20 OR ABOVE
of over-all results from subject-
The over-all results improved as the length of the follow-up period increased, and as the pain, swelling, inflammation about the wrist, and the fears of the patient subsided. The following are three illustrative cases. Case Reports
Case I. The patient, a forty-four year old woman, fell down the stairs at home on November 20, 1971. (Figure 2.) On the following day, pins were placed through the second and third metacarpals and the radius, and a dorsal plaster slab was applied. (Figure 3.) Immobilization was discontinued after eight weeks. The subjective result was
result
Case II. The patient, a twenty-six year old man, injured his wrist at work on June 6, 1970. (Figure 5.) Pins were placed through the fourth and fifth metacarpals and the olecranon. (Figure 6.) Immobilization was discontinued at six weeks. The subjective result was good, the objective result excellent, and the over-all result good at eight month follow-up study. (Figure 7.) Case III. The patient, a sixty-six year old man, injured his wrist in an automobile accident on January 2, 1970. (Figure 8.) Pins were placed through the second and third metacarpals and the olecranon and a cast was applied. The pins and plaster cast were removed after six weeks. The subjective result was good, objective result excellent, and the over-all result was good at twenty-six month follow-up study. (Figure 9.) Complications
Complications were related to four factors: (1) the pins; (2) nerve compression from bony fragments; (3) improper application of plaster; and (4) the patient’s age and motivation. One case of transient superficial radial nerve paresthesia developed after insertion of a pin through the second and third metacarpals, and one case of transient ulnar nerve paresthesia occurred after insertion of a pin through the fourth and fifth metacarpals. Careful insertion of the pin should avoid these complications. One case of carpal tunnel nerve compression syndrome subsided after the fractured extremity had
Figure 2. Case 1. Roenfgenogram of forty-four year old woman immediately after injury on November 20, 1971. Figure 3. Case I. Roenfgenogram on November 21, 1971 showing treatment with pins through second and third mefacarpals and radius. Dorsal plaster slab was applied. Figure 4. Case I. Roentgenogram a1 four month follow-up study. Subjective result was good, ob/ective result excellent, and over-all result excellent
Volume 124, December
1972
Figure 5. Case Ii. Roentgenogram taken immediately after injury in a twenty-six year old man. Figure 6. Case II. Roentgenogram showing treatment on June 7, 1971 wifh pins through the fourth and fifth mefacarpals and olecranon. A short-arm casf was ap-
plied.
717
Marsh and Teal
Figure 7. Case II. Roentgenogram taken at eight month follow-up study. Subjective result was good, objective result excellent, and over-all result good.
been immobilized for several weeks. Thumb web space atrophy was noted in one elderly patient. Two cases of pin tract infection occurred. The pins were removed at three weeks in one patient and the original deformity recurred. These pin tract infecttions were superficial and healed promptly after pin removal. Aseptic surgical technic and careful application of the plaster to properly incorporate the pins should avoid this complication. Relatively stiff wrists developed in two patients. One, a twenty year old man, was uncooperative and would not adequately attempt to move his fingers while they were in plaster or after the cast was removed.
Figure 8. Case Ill. Roentgenogram taken on January 2, 1970 in sixty-six year old man immediately after he was injured in an automobile accident. Figure 9. Case Ill. Roentgenogram taken twenty-six months after treatment with pins through the second and third metacarpals and olecranon with long-arm cast. Subjective result was good, objective result excellent, and over-all result good.
718
An elderly woman with osteoporosis who sustained a grossly cornminuted fracture also developed a relatively stiff wrist. In retrospect, this patient should have been treated by conventional methods. In twelve patients there was some loss of supination. This loss was usually minimal and was evident only to the examiner, but in two patients there was a significant loss. The severity of the fractures plus the immobilization of the forearm in pronation combined to produce this loss of supination. One patient, aged twenty, sustained a fracture of the cervical spine and all extremities. Several days passed before the badly cornminuted distal radial fracture could be treated since the other severe injuries demanded priority. Proper early joint motion could not be started and the final result was poor.
Comments
We have presented the final results in eighteen patients with twenty ‘severely cornminuted fractures of the distal radius who were treated utilizing self-contained skeletal traction. The results are not ideal, but it must be remembered we are dealing with a select group of grossly comminuted, unstable fractures. These are difficult problems and the surgeon who treats all patients without consideration of vanity, age, sex, and occupation is doomed to a confrontation with some disgruntled individuals. We believe that self-contained skeletal traction merits consideration when one is faced with a grossly cornminuted fracture in certain classes of patients. The method is not technically difficult, but complications do occur. Almost all complications were of short duration and most patients at final examination had good or excellent results. Five variations of self-contained skeletal traction technic were utilized, but the preferred method places the distal pin through the base of the second and third metacarpals and the proximal pin through the olecranon or the midshaft of the radius. The selection of patients is critical and the treat /ment should be reserved for the young or active mid dle-aged patient with a severely cornminuted frac ture. The pins should remain in place for a minimum af six weeks since early removal results in loss of position as the soft callus permits the bony fragments to settle back into the original deformity. Leaving the pins in place for longer than eight weeks may result in stiffness of the affected joints. Use of this method in a poorly motivated, elderly, or osteoporotic patient, or the improper application of the technic may result in some stiffness of the
The American Journal of Surgery
Comminuted
joints. The cast must be trimmed back to allow full finger motion at the metacarpophalangeal joint. Joint motion must be started when the patient recovers from anesthesia and continued until normal motion is obtained. Do not forget that the shoulder must be exercised several times a day.
Fractures
of Distal Radius
through the midradius or olecranon (the proximal pin). 5. A long-arm cast provides better immobilization with less pin irritation. 6. Pin traction should be maintained for six weeks. 7. Early active joint motion of the fingers and shoulder should be demanded of the patient.
Conclusions
1. Twenty-nine cornminuted fractures of the distal radius in twenty-six patients were treated using self-contained skeletal traction. 2. The method is designed for severely comminuted fractures. 3. This technic should be employed in young and active middle-aged patients. 4. The preferred placement of pins is through the second and third metacarpals (the distal pin) and
Volume 124, December 1972
References I. Colles A: On the fracture of the distal extremity of the radius. Edin Med Surg J 10: 182, 1814. 2. Bohler L: The Treatment of Fractures, 4th ed. Bristol, England, John Wright 8 Son, 1929. 3. Cole JM, Obletz BE: Comminuted fractures of the distal end of the radius treated by skeletal transfixion in plaster cast. J Bone Joint Surg 48A: 931, 1966. 4. Scheck M: Long-term followup of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg 44A: 337, 1962.
719
Henry 0. Marsh, MD, Wichita,
Kansas
Stephen W. Teal, MD, Wichita,
Kansas
In 1814, Colles [I] described the fracture of the distal radius that bears his name and he outlined a course of treatment. Colles also described the residual permanent deformities after this injury which are seen today, 158 years later, after the advent of accepted modern modes of treatment. Prevention of these disfiguring and disabling deformities in the young and active middle-aged patient is the subject of this paper. Current conventional treatment consists of “disimpacting” the fracture, manipulating the fragments, and immobilizing the wrist in flexion, pronation, and ulnar deviation. In simple noncomminuted fractures, this method is routinely satisfactory, but the same method applied to a cornminuted fracture almost certainly produces an unsatisfactory result. In these fractures, the dorsal cortex of the radius is fragmented, destroying the buttress of bone essential to maintain the radial articular surface in its normal volar tilt. This loss of stability allows the radius to collapse and deviate radially, thrusting the ulnar head into prominence. Thus, cornminuted fractures often regress to a deformity practically identical to that present originally. The resultant loss of function and appearance may not be of clinical importance in the elderly, but for the young or active middle-aged patient, enough deformity and disability may result that the physician is faced with a discontented patient. Secondary surgical corrections, such as osteoFrom St. Francis Hospital, Wichita, Kansas. Reprint requests should be addressed to Dr. Marsh, Director, Orthopedic Residency Training Program, St. Francis Hospital, Wichita, Kansas 67214. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque. New Mexico, May l-4, 1972.
Volume 124, December 1972
tomy of the radius, resection of the ulnar head, or even wrist fusion may be necessary to decrease the disability. In 1929 Bohler [2] attempted to solve this problem by placing a Steinmann pin through the olecranon and a second pin through the bases of the metacarpals. Traction was applied, the fracture manipulated, and a cast applied, incorporating the pins while traction was continued. This immobilization was maintained for six weeks. Many modifications have since been suggested but the basic concept of selfcontained skeletal traction remains a reasonable solution for badly cornminuted fractures in carefully selected patients. We are therefore not the originators of the technic, but we believe that it merits being called to attention as a successful method of treating cornminuted fractures of the distal radius. Material and Methods Eight orthopedists provided twenty-six patients for this study. All original roentgenograms were reviewed and eighteen patients with twenty fractures were available for personal re-examination. Four patients could not be located and four completed a questionnaire which had been mailed to them. Twenty-nine fractures in twenty-six patients were treated between 1956 and 1972, indicating the high degree of selectivity exercised in choosing these patients since this was only a small percentage of the total number of patients with Colles’ fractures seen and treated by conventional methods. There were thirteen male and thirteen female patients. The average age was 43.1 years, with a range from twenty to eighty. The average follow-up -time was 16.7 months.
715
Marsh
and Teal
TABLE I
Criteria* for Subjective Evaluation of Results of Treatment of Comminuted Fractures of the Distal Radius with Self-Contained Skeletal Traction
Result
Description
Excellent
No pain,
Good
motion Occasional
no disability, pain,
no noticeable
no disability,
slight
limitation
Of
limitation
of
motion Occasional pain, no disability if careful, slight limitation of motion, slight restriction of activities Constant pain, limitation of motion, disability, and limitation of activities because of wrist problem
Fair Poor
* According
to Cole and Obletz [3].
Five variations of Bbhler’s 123 technic were used: (1) pins through the thumb metacarpal and the olecranon; (2) pins through the second and third metacarpal and midshaft of the radius; (3) pins through the second and third metacarpals and olecranon; (4) pins through the fourth and fifth metacarpal and midshaft of the radius; and (5) pins through the fourth and fifth metacarpals and olecranon. An above-elbow cast was used in twenty-two fractures and a short-arm cast or dorsal plaster slab was employed in seven. The procedure was carried out in the operating room, and did not require any special equipment. An axillary block or general anesthetic was administered, the hand, forearm, and elbow were scrubbed and draped, and Steinmann pins measuring 3/32 of an inch were drilled into place. The arm was then suspended with the elbow in 90 degrees of flexion and traction applied. After the fracture had been disimpacted, it was manipulated and reduced, and reduction was verified by x-ray studies. A plaster cast was applied, incorporating the pins, while the arm was still in traction. TABLE III
Objective Evaluation* of Results Based on X-Ray Appearance at Follow-up Study Degree or Millimeters
Result
la”-23” loo-1 7”
excellent good poor excellent good poor excellent good poor
Angle Radial
Radial
Volar
Range Over-all result
* According
716
to Scheck
excellent good fair poor [4].
Numeric Value 0 1 2 0 1 2 0 1 2 6-6 O-4 5-8 9-12 13-18
The hospitalization period varied from two to five days. Traction should be maintained for a minimum of six weeks, but occasionally the pins were removed earlier because of pin tract infection or migration, This usually resulted when below-elbow plaster immobilization was used. The period of immobilization varied from three to ten weeks. Results
Our mailed questionnaire did not permit an accurate assessment of results; therefore the final evaluation will be limited to the eighteen patients with twenty fractures who were seen for examination. Evaluation was threefold: (1) subjective, according to the criteria of Cole and Obletz [3]; (2) objective, according to the criteria of Scheck [4]; and (4) overall assessment, combining these two criteria. The subjective criteria of Cole and Obletz are based on pain, disability, and the active range of motion. TABLE II
Criteria* for Objective Evaluation Based on Wrist Motion
Motion Compared with That of Normal Wrist Amount of Loss O”-15” 16”-30” 31 O-45” 45O+
* According
Rating
Numeric Value
excellent good fair poor
0 1 2 3
to Scheck
Motions Tested
Motion Flexion Extension Pronation Supination Range
Range of Numeric Value o-3 o-3 o-3 o-3 o-12
[4]
(Table I.) The subjective results were excellent in two, good in eleven, fair in six, and poor in one. The objective results were evaluated by measuring the active and passive joint motion (Table II) and measurements from the x-ray film. The latter is based on radial shortening, loss of volar tilt of the articular surface of the radius, and loss of the normal radial articular angulation towards the ulnar head. (Table III.) Objective results were excellent in fourteen cases, good in four, fair in one, and poor in one. In order to determine the over-all results in each case from the subjective and objective data, a final point scale was established. The subjective result, taken from the criteria of Cole and Obletz, was assigned a specific number of points and these were added to the points which gave the objective result which were determined by the criteria of Scheck. The final total number of points was then used to assign the over-all result as noted in Figure 1.
The Amerlcan Journal of Surgery
Comminuted
Fractures
of Distal Radius
good, the objective result excellent, and the over-all excellent at four month follow-up study. (Figure 4.) COLE & OBLETZ CRITERlA
SCHECK CRITERIA I E..CELLENT 0-4 GOOD 5-8 9-12 FAIR POOR 13-18
GOOD FAlR POOR I ASSIGN POINTS FOR EACHPeSCILT EXCELL$N'T - 0 POINTS 4 -GOOD 8 " FAIR 12 ,' POOR
I l
POINTS'ASSIGNED TO RESULT
+
/ POINTS GIVING RESULT /
\ Q
EXCELLENT GOOD FAIR POOR
Figure 1. Determination ive and objective results.
O-4 S-11 - 12-20 20 OR ABOVE
of over-all results from subject-
The over-all results improved as the length of the follow-up period increased, and as the pain, swelling, inflammation about the wrist, and the fears of the patient subsided. The following are three illustrative cases. Case Reports
Case I. The patient, a forty-four year old woman, fell down the stairs at home on November 20, 1971. (Figure 2.) On the following day, pins were placed through the second and third metacarpals and the radius, and a dorsal plaster slab was applied. (Figure 3.) Immobilization was discontinued after eight weeks. The subjective result was
result
Case II. The patient, a twenty-six year old man, injured his wrist at work on June 6, 1970. (Figure 5.) Pins were placed through the fourth and fifth metacarpals and the olecranon. (Figure 6.) Immobilization was discontinued at six weeks. The subjective result was good, the objective result excellent, and the over-all result good at eight month follow-up study. (Figure 7.) Case III. The patient, a sixty-six year old man, injured his wrist in an automobile accident on January 2, 1970. (Figure 8.) Pins were placed through the second and third metacarpals and the olecranon and a cast was applied. The pins and plaster cast were removed after six weeks. The subjective result was good, objective result excellent, and the over-all result was good at twenty-six month follow-up study. (Figure 9.) Complications
Complications were related to four factors: (1) the pins; (2) nerve compression from bony fragments; (3) improper application of plaster; and (4) the patient’s age and motivation. One case of transient superficial radial nerve paresthesia developed after insertion of a pin through the second and third metacarpals, and one case of transient ulnar nerve paresthesia occurred after insertion of a pin through the fourth and fifth metacarpals. Careful insertion of the pin should avoid these complications. One case of carpal tunnel nerve compression syndrome subsided after the fractured extremity had
Figure 2. Case 1. Roenfgenogram of forty-four year old woman immediately after injury on November 20, 1971. Figure 3. Case I. Roenfgenogram on November 21, 1971 showing treatment with pins through second and third mefacarpals and radius. Dorsal plaster slab was applied. Figure 4. Case I. Roentgenogram a1 four month follow-up study. Subjective result was good, ob/ective result excellent, and over-all result excellent
Volume 124, December
1972
Figure 5. Case Ii. Roentgenogram taken immediately after injury in a twenty-six year old man. Figure 6. Case II. Roentgenogram showing treatment on June 7, 1971 wifh pins through the fourth and fifth mefacarpals and olecranon. A short-arm casf was ap-
plied.
717
Marsh and Teal
Figure 7. Case II. Roentgenogram taken at eight month follow-up study. Subjective result was good, objective result excellent, and over-all result good.
been immobilized for several weeks. Thumb web space atrophy was noted in one elderly patient. Two cases of pin tract infection occurred. The pins were removed at three weeks in one patient and the original deformity recurred. These pin tract infecttions were superficial and healed promptly after pin removal. Aseptic surgical technic and careful application of the plaster to properly incorporate the pins should avoid this complication. Relatively stiff wrists developed in two patients. One, a twenty year old man, was uncooperative and would not adequately attempt to move his fingers while they were in plaster or after the cast was removed.
Figure 8. Case Ill. Roentgenogram taken on January 2, 1970 in sixty-six year old man immediately after he was injured in an automobile accident. Figure 9. Case Ill. Roentgenogram taken twenty-six months after treatment with pins through the second and third metacarpals and olecranon with long-arm cast. Subjective result was good, objective result excellent, and over-all result good.
718
An elderly woman with osteoporosis who sustained a grossly cornminuted fracture also developed a relatively stiff wrist. In retrospect, this patient should have been treated by conventional methods. In twelve patients there was some loss of supination. This loss was usually minimal and was evident only to the examiner, but in two patients there was a significant loss. The severity of the fractures plus the immobilization of the forearm in pronation combined to produce this loss of supination. One patient, aged twenty, sustained a fracture of the cervical spine and all extremities. Several days passed before the badly cornminuted distal radial fracture could be treated since the other severe injuries demanded priority. Proper early joint motion could not be started and the final result was poor.
Comments
We have presented the final results in eighteen patients with twenty ‘severely cornminuted fractures of the distal radius who were treated utilizing self-contained skeletal traction. The results are not ideal, but it must be remembered we are dealing with a select group of grossly comminuted, unstable fractures. These are difficult problems and the surgeon who treats all patients without consideration of vanity, age, sex, and occupation is doomed to a confrontation with some disgruntled individuals. We believe that self-contained skeletal traction merits consideration when one is faced with a grossly cornminuted fracture in certain classes of patients. The method is not technically difficult, but complications do occur. Almost all complications were of short duration and most patients at final examination had good or excellent results. Five variations of self-contained skeletal traction technic were utilized, but the preferred method places the distal pin through the base of the second and third metacarpals and the proximal pin through the olecranon or the midshaft of the radius. The selection of patients is critical and the treat /ment should be reserved for the young or active mid dle-aged patient with a severely cornminuted frac ture. The pins should remain in place for a minimum af six weeks since early removal results in loss of position as the soft callus permits the bony fragments to settle back into the original deformity. Leaving the pins in place for longer than eight weeks may result in stiffness of the affected joints. Use of this method in a poorly motivated, elderly, or osteoporotic patient, or the improper application of the technic may result in some stiffness of the
The American Journal of Surgery
Comminuted
joints. The cast must be trimmed back to allow full finger motion at the metacarpophalangeal joint. Joint motion must be started when the patient recovers from anesthesia and continued until normal motion is obtained. Do not forget that the shoulder must be exercised several times a day.
Fractures
of Distal Radius
through the midradius or olecranon (the proximal pin). 5. A long-arm cast provides better immobilization with less pin irritation. 6. Pin traction should be maintained for six weeks. 7. Early active joint motion of the fingers and shoulder should be demanded of the patient.
Conclusions
1. Twenty-nine cornminuted fractures of the distal radius in twenty-six patients were treated using self-contained skeletal traction. 2. The method is designed for severely comminuted fractures. 3. This technic should be employed in young and active middle-aged patients. 4. The preferred placement of pins is through the second and third metacarpals (the distal pin) and
Volume 124, December 1972
References I. Colles A: On the fracture of the distal extremity of the radius. Edin Med Surg J 10: 182, 1814. 2. Bohler L: The Treatment of Fractures, 4th ed. Bristol, England, John Wright 8 Son, 1929. 3. Cole JM, Obletz BE: Comminuted fractures of the distal end of the radius treated by skeletal transfixion in plaster cast. J Bone Joint Surg 48A: 931, 1966. 4. Scheck M: Long-term followup of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg 44A: 337, 1962.
719