Ligamentotaxis principle in the treatment of intra articular fractures of distal end of radius

LIGAMENTOTAXIS PRINCIPLE IN THE LIGAMENTOTAXIS PRINCIPLE IN THE TREATMENT OF INTRA ARTICULAR TREATMENT OF INTRA ARTICULAR

FRACTURES OF DISTAL END OF FRACTURES OF DISTAL END OF RADIUSRADIUS

-- -- A PROSPECTIVE STUDY TO ASSESS A PROSPECTIVE STUDY TO ASSESS CORRELATION BETWEEN RADIOLOGY AND CORRELATION BETWEEN RADIOLOGY AND

FUNCTIONFUNCTION

Dr. Manoj kumar P.N. ( PG Trainee )Dr. Manoj kumar P.N. ( PG Trainee )

Dr. Vinod kumar B.P. ( Asst. Prof )Dr. Vinod kumar B.P. ( Asst. Prof )

Dept of Orthopaedics, MCH TrivandrumDept of Orthopaedics, MCH Trivandrum

ABRAHAM COLLE [ 1773- 1843 ]ABRAHAM COLLE [ 1773- 1843 ]

# DISTAL END OF RADIUS# DISTAL END OF RADIUS

• 1/6th of all trauma cases

• 3/4th of all fractures of forearm

• Occurs in all age groups

• Results from low energy trauma

• No broad consensus regarding the treatment and the anticipated outcome

# DISTAL END OF RADIUS# DISTAL END OF RADIUS

• Numerous classification systems

• Various treatment modalities have been proposed

• What finally matters is the function rather than surgical precision

# DISTAL END OF RADIUS# DISTAL END OF RADIUS

External skeletal fixation has been increasingly popular in the treatment of complex fractures of the distal end of radius

AIMAIM

• To assess the correlation between radiology and function in the treatment of intra-articular fractures of distal end of radius treated by external fixation ( JESS )

WHY THIS STUDY ?WHY THIS STUDY ?

• The functional outcome studied in detail in various other studies

• Few and conflicting reports regarding correlation between radiology and function

• Treatment decisions are taken based on X-rays

• So study assumes significance

MATERIALS AND METHODSMATERIALS AND METHODS

• Design of the study – Prospective study

• Time period – Aug 2006 to Dec 2007

• Site of study – Department of Orthopaedics, Medical College, Trivandrum

MATERIALS AND METHODSMATERIALS AND METHODS

• Reference population – Southern districts of Kerala and Tamilnadu

• Sample size -- 45 cases

• Inclusion criteria -- Intra-articular fractures of the distal end of radius in the age group of 20- 50 yrs treated by JESS fixator

MATERIALS AND METHODSMATERIALS AND METHODS

• Exclusion criteria -- a) Undisplaced fractures of distal end of radius with intra-articular extension treated by plaster cast immobilization.

• b) Displaced intra-articular fractures treated with JESS fixator which subsequently got displaced and needed open reduction and internal fixation

• c) Compound fractures of the distal end or radius

• d) Displaced intra-articular fractures of distal end of radius in patients below 20yrs and above 50 yrs

MATERIALS AND METHODSMATERIALS AND METHODS

• Methodology -- Patients satisfying the inclusion criteria were enrolled into the study after obtaining due consent and explaining the alternative treatment modalities available.

• • After pre-operative X-rays , JESS fixator was

applied and follow up X-rays were taken immediate post op and at 3 weeks.

MATERIALS AND METHODSMATERIALS AND METHODS

• At 3 weeks JESS fixator was removed in stable cases and a short arm cast given. Cast was removed at 6 wks and follow up X rays are taken at 6 weeks, 6 months and 1 year

• In unstable cases ( Types 3 and 4 ), the JESS fixator was retained for 6 wks

THE FIXATORTHE FIXATOR

Developed by Dr, B B Joshi from Mumbai

• Two 3.5mm Schanz pins on the radius and two 2.5mm pins on the 2nd metacarpal.

JESSJESS

JESSJESS

Mc Murtry and Jupiter types 1 and Mc Murtry and Jupiter types 1 and 22

Mc Murtry and Jupiter Types 3 and Mc Murtry and Jupiter Types 3 and 44

RADIOGRAPHIC ASSESSMENTRADIOGRAPHIC ASSESSMENT

• The standard radiographic measurements :

radial inclination

radial length

radial width or shift

palmar slope

Acceptable radiographic parameters for Acceptable radiographic parameters for

healed radius fracturehealed radius fracture::

• (Rockwood and Green’s Fractures in adults Vol 1 p 919 Table 26-2)

Radial inclination Less than 5 degree loss

Radial length - Within 2-3mm of contra lateral wrist

Palmar slope - No angulation past neutral

Intraarticular step off - Less than 2mm

FUNCTIONAL EVALUATIONFUNCTIONAL EVALUATION

• We used Gartland and Werely’s functional evaluation scores modified by Stewart (1984 )

• Functional evaluation was done at 1year follow-up

• Both subjective and objective evaluation was done

SUBJECTIVE EVALUATIONSUBJECTIVE EVALUATION

• As per the scoring system, the following subjective complaints were considered:

1) Pain 2) Limitation of movement

3)Disability 4) Restriction of activity

The results were graded as excellent( 0 points ), good( 2 points ), fair( 4 points ), and poor( 6 points )

OBJECTIVEOBJECTIVE EVALUATIONEVALUATION

• Dorsiflexion <45degrees 5

• Palmar flexion <30degrees 1

• Ulnar deviation <25degrees 3

• Radial deviation <15degrees 1

• Supination <50degrees 2

• Pronation <50degrees 2

• Circumduction Loss 1

• Finger flexion Not to the distal crease 1-2

• Grip Loss of strength 1

• Radial or median Neuritis Mild-Severe 1-3

• The total objective evaluation score was obtained by adding the evaluation scores for each parameter

• The total functional assessment score is the sum of the subjective and objective evaluation scores and is graded into four categories as follows:

FUNCTIONAL SCOREFUNCTIONAL SCORE

• 0-2 Excellent

• 3-8 Good

• 9-14 Fair

• >15 Poor

CORRELATIONCORRELATION

• The correlation between radiology and function was done using standard statistical variables including the Pearson’s correlation coefficient

OBSERVATIONSOBSERVATIONS

• Age• The youngest patient

in our series was 22 years old and the oldest was 50 years old . The average age of the patients at the time of operation was around

AGE

20 to 30 yrs

30 to 40 yrs

40 to 50 yrs

No. of patients

12 17 16

OBSERVATIONSOBSERVATIONS

• Gender• The gender

distribution of patients was as follows:

M F %M %F

32 13 72% 28%

OBSERVATIONSOBSERVATIONS

• Mechanism of injury

• Fourteen patients sustained injury in road traffic accidents and the remaining thirty-one injured themselves during a fall

RTA FALL

No. of patients

14 31

OBSERVATIONSOBSERVATIONS

• Dominant / Non dominant side involved

• Twenty nine fractures involved the dominant wrist and sixteen the non-dominant side. For all our patients the right side was the dominant one

Dominant

Non dominant

% R %L

29 16 64% 36%

OBSERVATIONSOBSERVATIONS

Type - 1 20 (44%)

Type - 2 15 (33%)

Type - 3 06 (13%)

Type - 4 04 (10%)

FRACTURE TYPEFRACTURE TYPE

Type -1Type -2Type - 3Type - 4

OBSERVATIONSOBSERVATIONS

• Delay in surgery:

• 40 patients had their surgery ( JESS fixator application ) done within 6 hours of presentation in our casualty. Five patients had preliminary cast application and so fixator application was delayed by 24 to 48 hours.

OBSERVATIONSOBSERVATIONS

• Associated injuries:• Fifteen of our 45 patients ( 33% ) had an

associated ulnar styloid fracture. Other associated injuries included extra-articular fracture of lower end radius on the other extremity (1 patient ) , medial malleolus and pubic rami fracture ( 1 patient ) , and a lower thoracic spine fracture without neurological deficits ( 1 patient ).

OBSERVATIONSOBSERVATIONS

• Hospital stay:

• Most of our patients were treated as day case surgeries and were sent home the same evening or next day morning. Patients with associated injuries were however admitted.

Type -1 # follow upType -1 # follow up

Case follow up-1Case follow up-1

Case follow up -1Case follow up -1

Case follow up 2Case follow up 2

Case follow up - 2Case follow up - 2

Case follow up 2Case follow up 2

ComplicationsComplications

• Finger stiffness or pain dysfunction syndrome– 22/45

• Pin tract infection 4/45

• Loss of reduction – 2/45

• No nerve or tendon injuries

ResultsResults

• JESS is an rewarding method for the treatment of intra articular fractures of distal end of radius as 26 out of 45 cases ( 57.8 % )produced excellent results with this technique

• Good results were obtained in 13 out of 45 ( 28.9 % )

• So overall 85% patients had good to excellent function in the end.

RESULTSRESULTS

• Good or acceptable radiology at 1 yr produced good to excellent function regardless of the fracture type.

RESULTSRESULTS

Radial length was the most significant radiological parameter that affected the functional scores.( Cumulative score of 66.7 at p< 0.05 )

In case No: 5, 6 and 26, in spite of other radiological parameters being acceptable, a deficiency of radial length spoiled an otherwise good result

Similarly, in case no: 1, 14 41 and 45, accurate restoration of radial length alone produced good functional scores

RESULTSRESULTS

• Bad radiology does not invariably produce a bad functional outcome ( Ref: Case No.8 where scores of 10/04/07/00 produced a functional score of 07 indicating good outcome

• A negative palmar slope consistently gives bad functional results ( Ref: Case No. 10, 22 and 33 )

• Correction of palmar slope with JESS fixator is difficult and may require additional fixations like K wires.

To sum upTo sum up

• Good radiology = good function whatever be the fracture type

• During reduction, correct and maintain the radial length ( AP view ) and palmar slope ( lat view ). No further manipulations for radiological finesse.

• Bad radiology may give reasonably good function in the end

• Palmar slope correction with a JESS fixator is difficult