- Email: [email protected]
Unstable fractures of the distal end of the radius (Transfixion pins and a cast)
206
Injury,
15, 206-2
11
Printed
in Great Britain
Unstable fractures of the distal end of the radius (Transfixion pins and a cast) R. K. Suman Accident
and Orthopaedic
Division,
Glasgow
Royal lnfirmar y
Summary
Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster cast. Thirtyseven patients were personally reviewed and an analysis of the results are presented in this paper. Scheck’s point system was used to grade functional results: 8 1.I per cent, were classified as satisfactory (excellent and good) and 18.9 per cent unsatisfactory (poor) group. INTRODUCTION
fractures of the distal end of the radius, though easily improved by closed manipulation, prove difficult to maintain in satisfactory position. When the position is lost, recurrence of the deformity occurs with disappointing cosmetic and functional results. This paper describes the results of treating unstable fractures of the distal end of the radius by closed manipulation and transfixion with two Kirschner wires. UNSTABLE
Definition
A fracture was classified as unstable when it was difficult to maintain the position at the time of manipulation, in the presence of severe comminution, or with articular involvement. A fracture was also considered unstable if there was loss of the position in a plaster cast; a dorsal angulation of more than 5 degrees: or 5 mm. or more of shortening of the radius. PATIENTS
AND
METHODS
Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster casts between 1977 and 198 1. Thirty-seven patients were reviewed by the author and the results are presented in this paper. Follow-up ranged from nine months to four years. There were ten men and twentyseven women. The average age was fifty-nine (range thirty-one-sixty-five years). The dominant hand was involved in twenty-eight patients (75.8 per cent). Five patients had associated injuries: one fracture of the scaphoid, one fracture of the radial head. one fracture of the clavicle and two fractures of the surgical neck of the humerus. Three fractures were open. The distribution of the radiological types of the fractures is shown in Table I. Twenty-nine unstable fractures of the distal end of the radius were treated by transfixion pins as a primary
procedure, while in eight cases transfixion pins were used because of failure to maintain the position in a plaster cast alone. Under general anaesthesia, a Kirschner wire was inserted through the second and the third metacarpals and another through the proximal end of the ulna. A stirrup was applied to the distal Kirschner wire and the arm was suspended from the intravenous drip stand (Fig. 1). Gentle traction was applied to reduce the deformity. The limb was encased in a long arm plaster cast incorporating the Kirschner wires (Fig. 2). The forearm was held in pronation and the hand in line with the forearm but with slight ulnar deviation. The Kirschner wires were removed after four to six weeks and the splintage was continued in a carefully moulded forearm plaster cast until the fracture healed. Finger and shoulder movements were maintained throughout the period of splintage. RESULTS
The radiological and functional results were evaluated by comparing the injured with the normal wrist. Radiological assessment New radiographs were taken at the time of review.
Radial angle. volar angle and the distance between ulnar head and tip of the radial styloid process were measured. The point system as described by Scheck (Table Z) was used to grade the radiological appearances as excellent, good and poor. Satisfactory results (excellent and good) were achieved in 83.8 per cent of the cases (Table III). Functional
assessment
This included subjective evaluation, that is pain and restriction in occupation or exertional activity; objective assessment-any deformity of the wrist, grip
Table /. Radiological
types of fractures
Type of fracture
No. of cases
Colles’s fracture Smith’s fracture Barton’s fracture
26 8 3
Suman:
Unstable
fractures
207
of the radius
Fig. 1. Two Kirschner wires in situ. The arm is suspended with a stirrup attached to the Kirschner wire through the
Fig. 2. Both Kirschner plaster cast.
wires are incorporated
in a long
second and third metacarpals.
strength, movements of the wrist and fingers, and pronation and supination. The functional results were graded as excellent, good and poor; this was the sum of all points derived from all factors described in Table II. Eighty-one per cent were included in the satisfactory group (excellent and good) (Table IV’). Complications No pin track infection
occurred. The carpal tunnel syndrome was seen in three cases, but only one needed decompression. DISCUSSION
Gartland and Werley (195 1) reported 3 1.7 per cent unsatisfactory results in cornminuted fractures of the distal end of the radius treated by closed manipulation and splintage in plaster casts. Bacom and Kurtzke (1953) analysed the results of 2000 Colles’ fractures and it was observed that the poor functional results were directly related to the degree of radiological deformity due to loss of position of the fracture in the plaster cast. In order to maintain the length of the radius Bijhler advocated as early as 1929, the use of transfixion pins and plaster cast for unstable fractures of the distal end of the radius (Marsh and Teal, 1972). Transfixion pins incorporated in a plaster cast provide fixed traction and prevent shortening of the fractured radius. Many variations of this method have been described, but the
underlying principle remains the same. With the use of transfixion pins with cornminuted fractures of the distal end of the radius, there had been a noticeable increase in satisfactory (excellent and good) results; Hammond (1949) 8 1 per cent, Scheck (1962) 75 per cent, Cole and Obletz (1966) 94 per cent and Green (1975) 86 per cent. The author’s results (Table II/) with transfixion pins and plaster cast achieved 81 per cent satisfactory (excellent and good) functional results, comparable to results obtained by others using similar methods. Cooney et al. (1979) described external skeletal fixation of such fractures using Roger Anderson apparatus. These authors initially used a triangular method of fixation but later preferred a quadrilateral system for rigid immobilization. They reported 11 per cent unsatisfactory results using this elaborate system of splintage. It must also be pointed out that 12 per cent of fractures in their series were relatively stable types, Frykman Type I and II. (Frykmann, 1967). Cozen (195 1) reported excellent or good results in twenty one of twenty three patients treated by wedging the plaster cast in order to prevent loss of reduction. Sarmiento et al. (1975) advocated use of an orthoplast brace for Colles’ fractures. Initial splintage is carried out in an above elbow cast with the forearm in supination in order to eliminate the action of brachioradialis. This plaster cast is replaced by an orthoplast brace a few days later. The brace allows movements of the elbow and palmar flexion of the wrist but Sarmiento et al. (1975) accept that their method does not prevent
208
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 3
Table Il. Point system as described by Scheck (1962) Description
Table Ill. Radiological assessment
Points
1. Subjective evaluation Excellent - No pain, weakness or limitation of motion, no restriction in activity. Good - Occasional discomfort after exertion, slight limitation of motion, minor restriction in activity. Poor - Deformity, pain, weakness and limitation of motion, patient has not continued with former occupation and recreational activity.
0
1
Results
No. of cases
Excellent Good Poor
3 (8.1%) 28 (75.7%) 6 (16.2%)
Point ranges * 0 to 1 2 to 3 Over 3
“Point ranges: Represents sum of all points derived from all factors described in Table II.
2 Tab/e IV Functional results
2. Visual examination of the wrist Excellent - Normal appearance. Good - Just noticeable deformity because of some broadening of the wrist and slight prominence of ulnar styloid process. - Obvious deformity. Poor
0
3. Wrist, finger motion, pronation and supination Excellent - 0 to 15 degrees loss of movements. - 16 to 30 degrees loss of moveGood ments. - Over 30 degrees loss of movePoor ments 4. Grip (grip uninjured Excellent Good Poor
in percentage of grip strength of the hand) - 100% - 85 to 89% - Under 85%
0 1
2
3 mm Excellent (1 O-l 3 mm) (5-9 mm) Good Poor (<5mm) Final radiological assessment (Derived from sum points from all components) Excellent 0 to 1 point 2 to 3 points Good Over to 3 points Poor
6.
0 1 2
1’
Excellent (6-l 1”) (O-SO) Good (Negative volar angle) Poor
(4 Normal average radial length-l
0 1 2
0 1
2 of
Over all functional results (Were derived from sum of all points from all factors as described above) Excellent 0 to 3 points 4 to 8 points Good Over to 8 points Poor
of fragments in comminuted Colles’s fractures; they reported only 69.2 per cent excellent and good results. There appears to be a direct relationship between collapse
No. of cases
Excellent Good Poor
8 (21.6%) 22 (59.5%) 7 (18.9%)
Point ranges* 0 to 3 4 to 8 Over 8
*Point ranges: Represents sum of all points derived from all factors described in Table II.
5. Radiological assessment (4 Normal average Radial angle-22” Excellent (18-22”) (1 o-1 7”) Good Poor (
U-4 Normal average volar angle-l
Results
the radiological appearance and the functional results. Radiologically satisfactory (excellent and good) results in 83.8 per cent gave 81 per cent functional satisfactory (excellent and good) results (Tables II/ and IV). This observation is in keeping.with the statements of Bacorn and Kurtzke (195 1) and Green (I 975) that poor functional results are directly related to the degree of radiological deformity. The author agrees with Green (1975) that failure to restore the radial length will result in unsatisfactory appearance and function. Restoring the normal volar tilt of the distal articular surface of the radius is difficult. In thirty cases (8 1 per cent) the radial articular surface was neutral on the lateral X-ray film (Fig. 3 a to.fi; 3 1 cases (83 per cent) had virtually normal wrist functions. Arthrotic changes were noted in six intra-articular fractures. Objective analysis of the cases with poor functional results revealed that in six out of seven cases, the cause was inadequate reduction of the deformity. In one case the poor result was due to painful non-union of the associated fracture of the scaphoid. Cole and Obletz (1966) and Green (1975) suggested that encasement in a plaster cast with transfixion pins should be continued for eight to ten weeks to prevent loss of position. In this study the transfixion pins were removed at four to six weeks. Splintage was continued by a carefully moulded forearm plaster cast until the fracture had healed. Only 2-3 mm of shortening of the radius was found in 11 cases (30 per cent) after removal of the transfixion pins. It seems there is no advantage in retaining transfixion pins for longer than six weeks; it prolongs the period of rehabilitation and may increase the risk of pin track infection. Green (1975) reported such infection in 33 per cent of the cases. None occurred in this series, perhaps because of the earlier removal of the pins.
a
b
C
Fig. 3. a and b Initial films of a comminuted volar angulation is not fully corrected. e andJ
Smith’s fracture. c and d Immediately after manipulation Fracture healed in good alignment (fourteen months later).
the
d
c
211
Suman: Unstable fractures of the radius
CONCLUSIONS
Unstable fractures of the distal end of the radius are difficult to treat and functional results can be disappointing. Even a complex external fixation method yields 11 per cent of unsatisfactory results. This study reports 8 1 per cent satisfactory functional results with transfixion pins and plaster cast. This is a simple and effective method to maintain reduction of these unstable fractures. It does not require special instruments. It is not necessary to retain transfixion pins for more than six weeks. It is suggested that transfixion pins should be used in unstable fractures of the distal end of the radius whenever possible in this difficult injury, but it is acknowledged that some ugly looking wrists work well and are tolerated by their owners. Acknowledgements
My sincere thanks are due to the Consultant allowing me to study their cases.
staff for
REFERENCES Bacorn
R. W. and Kirtzke J. F. (1953) Colles’ Fracture. .I.
Bone Joint Surg. 35A, 643.
Cole J. M. and Obletz B. E. (1966) Cornminuted Fractures of the Distal End of the Radius Treated by Skeletal Transfixation in Plaster Cast. J. Bone Joint Surg. 48A, 93 1. Cooney W. P., Linscheid R. L. and Dobyns J. H. (1979) External Pin Fixation For Unstable Colles’ Fractures. J. Bone Joint Surg. 61 A, 840. Cozen L. (195 1) Colles’ Fractures. A Method of Maintaining Reduction. California Med. J. 75,921. Frykman G. (1967) Fracture of the Distal Radius Including Sequlae. Acta Orthop. Stand. Suppl. 108. Gartland J. J. jun. and Werley C. W. (1951) Evaluation of Healed Colles’ Fractures. J. Bone Joint Surg. 33A, 895. Green D. P. (1975) Pins and Plaster Treatment of Comminuted Fractures of the distal end of the Radius. J. Bone Joint Surg. 57A, 304.
Hammond
G. (1949) Cornminuted
Colles’ Fracture. Am. J.
Surg. 78,6 17.
Marsh H. 0. and Teal S. W. (1972) Treatment of Comminuted Fractures of the Distal Radius with Self-Contained Skeletal Traction. Am. J. Surg. 124, 715. Sarmiento A., Pratt G. W., Berry N. C. et al. (1975) Colles’ Fracture. Functional bracing in Supination. J. Bone Joint Surg. 57A, 3 11. Scheck M. (1962) Long Term Follow-up of Cornminuted Fractures of the Distal End of the Radius by Transfixion with Kirschner Wires and Cast. J. Bone Joint Surg. 44A, 337.
Paper accepted 23 March 1983.
Requests for reprints should be addressed to: R. K. Suman, Accident and Orthopaedic Division, The Royal Infirmary, Glasgow G4 OSF.
Injury,
15, 206-2
11
Printed
in Great Britain
Unstable fractures of the distal end of the radius (Transfixion pins and a cast) R. K. Suman Accident
and Orthopaedic
Division,
Glasgow
Royal lnfirmar y
Summary
Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster cast. Thirtyseven patients were personally reviewed and an analysis of the results are presented in this paper. Scheck’s point system was used to grade functional results: 8 1.I per cent, were classified as satisfactory (excellent and good) and 18.9 per cent unsatisfactory (poor) group. INTRODUCTION
fractures of the distal end of the radius, though easily improved by closed manipulation, prove difficult to maintain in satisfactory position. When the position is lost, recurrence of the deformity occurs with disappointing cosmetic and functional results. This paper describes the results of treating unstable fractures of the distal end of the radius by closed manipulation and transfixion with two Kirschner wires. UNSTABLE
Definition
A fracture was classified as unstable when it was difficult to maintain the position at the time of manipulation, in the presence of severe comminution, or with articular involvement. A fracture was also considered unstable if there was loss of the position in a plaster cast; a dorsal angulation of more than 5 degrees: or 5 mm. or more of shortening of the radius. PATIENTS
AND
METHODS
Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster casts between 1977 and 198 1. Thirty-seven patients were reviewed by the author and the results are presented in this paper. Follow-up ranged from nine months to four years. There were ten men and twentyseven women. The average age was fifty-nine (range thirty-one-sixty-five years). The dominant hand was involved in twenty-eight patients (75.8 per cent). Five patients had associated injuries: one fracture of the scaphoid, one fracture of the radial head. one fracture of the clavicle and two fractures of the surgical neck of the humerus. Three fractures were open. The distribution of the radiological types of the fractures is shown in Table I. Twenty-nine unstable fractures of the distal end of the radius were treated by transfixion pins as a primary
procedure, while in eight cases transfixion pins were used because of failure to maintain the position in a plaster cast alone. Under general anaesthesia, a Kirschner wire was inserted through the second and the third metacarpals and another through the proximal end of the ulna. A stirrup was applied to the distal Kirschner wire and the arm was suspended from the intravenous drip stand (Fig. 1). Gentle traction was applied to reduce the deformity. The limb was encased in a long arm plaster cast incorporating the Kirschner wires (Fig. 2). The forearm was held in pronation and the hand in line with the forearm but with slight ulnar deviation. The Kirschner wires were removed after four to six weeks and the splintage was continued in a carefully moulded forearm plaster cast until the fracture healed. Finger and shoulder movements were maintained throughout the period of splintage. RESULTS
The radiological and functional results were evaluated by comparing the injured with the normal wrist. Radiological assessment New radiographs were taken at the time of review.
Radial angle. volar angle and the distance between ulnar head and tip of the radial styloid process were measured. The point system as described by Scheck (Table Z) was used to grade the radiological appearances as excellent, good and poor. Satisfactory results (excellent and good) were achieved in 83.8 per cent of the cases (Table III). Functional
assessment
This included subjective evaluation, that is pain and restriction in occupation or exertional activity; objective assessment-any deformity of the wrist, grip
Table /. Radiological
types of fractures
Type of fracture
No. of cases
Colles’s fracture Smith’s fracture Barton’s fracture
26 8 3
Suman:
Unstable
fractures
207
of the radius
Fig. 1. Two Kirschner wires in situ. The arm is suspended with a stirrup attached to the Kirschner wire through the
Fig. 2. Both Kirschner plaster cast.
wires are incorporated
in a long
second and third metacarpals.
strength, movements of the wrist and fingers, and pronation and supination. The functional results were graded as excellent, good and poor; this was the sum of all points derived from all factors described in Table II. Eighty-one per cent were included in the satisfactory group (excellent and good) (Table IV’). Complications No pin track infection
occurred. The carpal tunnel syndrome was seen in three cases, but only one needed decompression. DISCUSSION
Gartland and Werley (195 1) reported 3 1.7 per cent unsatisfactory results in cornminuted fractures of the distal end of the radius treated by closed manipulation and splintage in plaster casts. Bacom and Kurtzke (1953) analysed the results of 2000 Colles’ fractures and it was observed that the poor functional results were directly related to the degree of radiological deformity due to loss of position of the fracture in the plaster cast. In order to maintain the length of the radius Bijhler advocated as early as 1929, the use of transfixion pins and plaster cast for unstable fractures of the distal end of the radius (Marsh and Teal, 1972). Transfixion pins incorporated in a plaster cast provide fixed traction and prevent shortening of the fractured radius. Many variations of this method have been described, but the
underlying principle remains the same. With the use of transfixion pins with cornminuted fractures of the distal end of the radius, there had been a noticeable increase in satisfactory (excellent and good) results; Hammond (1949) 8 1 per cent, Scheck (1962) 75 per cent, Cole and Obletz (1966) 94 per cent and Green (1975) 86 per cent. The author’s results (Table II/) with transfixion pins and plaster cast achieved 81 per cent satisfactory (excellent and good) functional results, comparable to results obtained by others using similar methods. Cooney et al. (1979) described external skeletal fixation of such fractures using Roger Anderson apparatus. These authors initially used a triangular method of fixation but later preferred a quadrilateral system for rigid immobilization. They reported 11 per cent unsatisfactory results using this elaborate system of splintage. It must also be pointed out that 12 per cent of fractures in their series were relatively stable types, Frykman Type I and II. (Frykmann, 1967). Cozen (195 1) reported excellent or good results in twenty one of twenty three patients treated by wedging the plaster cast in order to prevent loss of reduction. Sarmiento et al. (1975) advocated use of an orthoplast brace for Colles’ fractures. Initial splintage is carried out in an above elbow cast with the forearm in supination in order to eliminate the action of brachioradialis. This plaster cast is replaced by an orthoplast brace a few days later. The brace allows movements of the elbow and palmar flexion of the wrist but Sarmiento et al. (1975) accept that their method does not prevent
208
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 3
Table Il. Point system as described by Scheck (1962) Description
Table Ill. Radiological assessment
Points
1. Subjective evaluation Excellent - No pain, weakness or limitation of motion, no restriction in activity. Good - Occasional discomfort after exertion, slight limitation of motion, minor restriction in activity. Poor - Deformity, pain, weakness and limitation of motion, patient has not continued with former occupation and recreational activity.
0
1
Results
No. of cases
Excellent Good Poor
3 (8.1%) 28 (75.7%) 6 (16.2%)
Point ranges * 0 to 1 2 to 3 Over 3
“Point ranges: Represents sum of all points derived from all factors described in Table II.
2 Tab/e IV Functional results
2. Visual examination of the wrist Excellent - Normal appearance. Good - Just noticeable deformity because of some broadening of the wrist and slight prominence of ulnar styloid process. - Obvious deformity. Poor
0
3. Wrist, finger motion, pronation and supination Excellent - 0 to 15 degrees loss of movements. - 16 to 30 degrees loss of moveGood ments. - Over 30 degrees loss of movePoor ments 4. Grip (grip uninjured Excellent Good Poor
in percentage of grip strength of the hand) - 100% - 85 to 89% - Under 85%
0 1
2
3 mm Excellent (1 O-l 3 mm) (5-9 mm) Good Poor (<5mm) Final radiological assessment (Derived from sum points from all components) Excellent 0 to 1 point 2 to 3 points Good Over to 3 points Poor
6.
0 1 2
1’
Excellent (6-l 1”) (O-SO) Good (Negative volar angle) Poor
(4 Normal average radial length-l
0 1 2
0 1
2 of
Over all functional results (Were derived from sum of all points from all factors as described above) Excellent 0 to 3 points 4 to 8 points Good Over to 8 points Poor
of fragments in comminuted Colles’s fractures; they reported only 69.2 per cent excellent and good results. There appears to be a direct relationship between collapse
No. of cases
Excellent Good Poor
8 (21.6%) 22 (59.5%) 7 (18.9%)
Point ranges* 0 to 3 4 to 8 Over 8
*Point ranges: Represents sum of all points derived from all factors described in Table II.
5. Radiological assessment (4 Normal average Radial angle-22” Excellent (18-22”) (1 o-1 7”) Good Poor (
U-4 Normal average volar angle-l
Results
the radiological appearance and the functional results. Radiologically satisfactory (excellent and good) results in 83.8 per cent gave 81 per cent functional satisfactory (excellent and good) results (Tables II/ and IV). This observation is in keeping.with the statements of Bacorn and Kurtzke (195 1) and Green (I 975) that poor functional results are directly related to the degree of radiological deformity. The author agrees with Green (1975) that failure to restore the radial length will result in unsatisfactory appearance and function. Restoring the normal volar tilt of the distal articular surface of the radius is difficult. In thirty cases (8 1 per cent) the radial articular surface was neutral on the lateral X-ray film (Fig. 3 a to.fi; 3 1 cases (83 per cent) had virtually normal wrist functions. Arthrotic changes were noted in six intra-articular fractures. Objective analysis of the cases with poor functional results revealed that in six out of seven cases, the cause was inadequate reduction of the deformity. In one case the poor result was due to painful non-union of the associated fracture of the scaphoid. Cole and Obletz (1966) and Green (1975) suggested that encasement in a plaster cast with transfixion pins should be continued for eight to ten weeks to prevent loss of position. In this study the transfixion pins were removed at four to six weeks. Splintage was continued by a carefully moulded forearm plaster cast until the fracture had healed. Only 2-3 mm of shortening of the radius was found in 11 cases (30 per cent) after removal of the transfixion pins. It seems there is no advantage in retaining transfixion pins for longer than six weeks; it prolongs the period of rehabilitation and may increase the risk of pin track infection. Green (1975) reported such infection in 33 per cent of the cases. None occurred in this series, perhaps because of the earlier removal of the pins.
a
b
C
Fig. 3. a and b Initial films of a comminuted volar angulation is not fully corrected. e andJ
Smith’s fracture. c and d Immediately after manipulation Fracture healed in good alignment (fourteen months later).
the
d
c
211
Suman: Unstable fractures of the radius
CONCLUSIONS
Unstable fractures of the distal end of the radius are difficult to treat and functional results can be disappointing. Even a complex external fixation method yields 11 per cent of unsatisfactory results. This study reports 8 1 per cent satisfactory functional results with transfixion pins and plaster cast. This is a simple and effective method to maintain reduction of these unstable fractures. It does not require special instruments. It is not necessary to retain transfixion pins for more than six weeks. It is suggested that transfixion pins should be used in unstable fractures of the distal end of the radius whenever possible in this difficult injury, but it is acknowledged that some ugly looking wrists work well and are tolerated by their owners. Acknowledgements
My sincere thanks are due to the Consultant allowing me to study their cases.
staff for
REFERENCES Bacorn
R. W. and Kirtzke J. F. (1953) Colles’ Fracture. .I.
Bone Joint Surg. 35A, 643.
Cole J. M. and Obletz B. E. (1966) Cornminuted Fractures of the Distal End of the Radius Treated by Skeletal Transfixation in Plaster Cast. J. Bone Joint Surg. 48A, 93 1. Cooney W. P., Linscheid R. L. and Dobyns J. H. (1979) External Pin Fixation For Unstable Colles’ Fractures. J. Bone Joint Surg. 61 A, 840. Cozen L. (195 1) Colles’ Fractures. A Method of Maintaining Reduction. California Med. J. 75,921. Frykman G. (1967) Fracture of the Distal Radius Including Sequlae. Acta Orthop. Stand. Suppl. 108. Gartland J. J. jun. and Werley C. W. (1951) Evaluation of Healed Colles’ Fractures. J. Bone Joint Surg. 33A, 895. Green D. P. (1975) Pins and Plaster Treatment of Comminuted Fractures of the distal end of the Radius. J. Bone Joint Surg. 57A, 304.
Hammond
G. (1949) Cornminuted
Colles’ Fracture. Am. J.
Surg. 78,6 17.
Marsh H. 0. and Teal S. W. (1972) Treatment of Comminuted Fractures of the Distal Radius with Self-Contained Skeletal Traction. Am. J. Surg. 124, 715. Sarmiento A., Pratt G. W., Berry N. C. et al. (1975) Colles’ Fracture. Functional bracing in Supination. J. Bone Joint Surg. 57A, 3 11. Scheck M. (1962) Long Term Follow-up of Cornminuted Fractures of the Distal End of the Radius by Transfixion with Kirschner Wires and Cast. J. Bone Joint Surg. 44A, 337.
Paper accepted 23 March 1983.
Requests for reprints should be addressed to: R. K. Suman, Accident and Orthopaedic Division, The Royal Infirmary, Glasgow G4 OSF.