Research articles
 

By Dr. M K Mam , Dr. Sharad Prabhakar , Dr. J S Prakash , Dr. Kamal Bali
Corresponding Author Dr. Sharad Prabhakar
PGIMER, Chandigarh, India, - India
Submitting Author Dr. Kamal Bali
Other Authors Dr. M K Mam
Orthopaedics, CMC, Chandigarh, - India

Dr. J S Prakash
Orthopaedics, CMC, Chandigarh, - India

Dr. Kamal Bali
Orthopedics, PGIMER, Chandigarh, India, - India

TRAUMA

Colles, fracture, distal radius, closed reduction, K-wire fixation, open reduction, conservative

Mam MK, Prabhakar S, Prakash JS, Bali K. Functional Outcome Following Treatment Of Colles Fracture: A Comparative Study Of Closed Reduction And Plaster Cast Application Versus Kirschner Wire Fixation. WebmedCentral TRAUMA 2011;2(1):WMC001472
doi: 10.9754/journal.wmc.2011.001472
No
Submitted on: 14 Jan 2011 01:46:24 PM GMT
Published on: 16 Jan 2011 03:39:24 AM GMT

Abstract


Colles’ fracture is the most common of the distal radial fractures. There are many classifications and varied treatment options, with variable results. Various studies with short-term and long-term results of treatment of Colles’ fracture have correlated deformities with loss of function. This prompted us to undertake a comparative study to determine the functional outcome with clinico-radiological analysis of patients with Colles’ fractures treated with closed reduction and cast alone versus closed reduction, Kirschner wire fixation and cast. At the last follow up, no significant difference in the functional outcome was obtained with closed reduction and cast versus closed reduction, K-wire fixation and cast

Introduction


Fractures near the wrist joint due to fall on the out stretched hand constitute one of the largest of all groups of bone injuries and are estimated to account for one-sixth of all fractures seen and treated in the emergency room1. With the passage of time, the epidemiological pattern of fractures has evolved from a non-comminuted extra-articular fracture as classically described by Colles to a comminuted articular fracture associated with high velocity trauma. Middle aged or elderly women often sustain this fracture following low velocity trauma while in the young it is caused by high velocity trauma2.
The treatment modalities for this fracture have also evolved over time as understanding of this injury has changed1. The concept of ligamentotaxis to reduce the fracture with the help of external fixation was introduced by Vaughan in 19853. However, closed reduction and immobilization in a plaster cast remains the accepted method of treatment for 75% to 80% of fractures of the distal radius1. Various K-wire fixation techniques have been described but Azzopardi et al state that biomechanically a crossed K–wire construct provides the greatest stability and supplementary K-wires do not provide a better clinical outcome4. Some authors believed that no special treatment was needed as the resulting deformity barely resulted in loss of function5. However this concept has been challenged and the restoration of normal anatomy is now considered essential for normal function2. Various studies6,7,8 with short-term and long-term results of treatment of Colles’ fracture have correlated deformities with loss of function.
This prompted us to undertake a comparative study to determine the functional outcome with clinico-radiological analysis of patients with Colles’ fractures treated with closed reduction and cast alone versus closed reduction, Kirschner wire fixation and cast.

Methods


The study was conducted at the Department of Orthopaedics, Christian Medical College & Hospital, Ludhiana, Punjab. All patients with Colles’ fracture between June 2004 and June 2005 were studied. The patients were followed up at 3 weeks, 6 weeks, 3 months and 9 months. A complete clinicoradiological assessment was performed at each visit. Patients with fused epiphysis, sustaining distal radius fracture were included in the study. Patients with open fractures, additional major fractures in the ipsilateral upper limb, associated neuro-vascular deficit and with bilateral Colles’ fractures were excluded from the study. Initial anteroposterior and lateral radiographs of both the injured and uninjured side were taken. The “Universal Classification” modified from the classifications of Gartland (1951)9 and Sarmiento (1975)10 was used in the study. The fractures were divided into - Extra-articular fractures: Type - I, non-displaced and stable, Type – II, displaced and unstable. Intra-articular fractures: Type – III, non-displaced; Type – IV, displaced.
23 cases were manipulated under general anaesthesia. 7 cases were manipulated under regional anaesthesia. Fracture stability was assessed intra-operatively after reduction under C-arm. Patients with stable fractures underwent closed reduction and cast. Those with unstable fractures underwent closed reduction, K-wire fixation and cast application.
For patients undergoing closed reduction and cast application (Fig 1), the patient was positioned supine on the operating table. The surgeon grasped the injured hand and disimpacted the fragments by firm longitudinal traction. An assistant provided counter-traction by grasping the arm above the flexed elbow. Steady traction corrected the dorsal displacement. This was followed by palmar flexion and ulnar deviation of the wrist with the forearm in pronation. Reduction was confirmed using an image intensifier. Three point fixation was obtained in a well moulded plaster cast which was applied to maintain the wrist in the desired position. For comminuted fractures an above elbow cast was given. Stable fractures were given a below elbow cast. Active finger mobilization, shoulder exercises and elbow mobilization (in patients with short arm casts) were started immediately postoperatively. A long arm cast was converted to short arm cast at 3 weeks which was continued for another 3 weeks. Total duration of casting was 6 weeks.
In the percutaneous pinning group (Fig 2), the limb was prepared and draped before closed reduction. The fracture was reduced in the manner described above and then fixed using two smooth Kirschner wires. The wires were inserted through small stab incisions under fluoroscopic control. One wire was inserted from the styloid process of the radius directed proximally and medially through the fracture site . The other wire was passed from the lateral border of the radius in a proximal to distal direction to engage the ulnar aspect of the distal fragment. Both wires engaged the opposite cortex. In 2 cases the second wire was passed through the dorso-ulnar border of the distal fragment in a distal to proximal direction. Damage to the superficial branch of the radial nerve and the extensor tendons was minimized by blunt dissection to the bone. The pins were left protruding percutaneously, dressed and the fracture was then immobilized in a well moulded long arm cast. It was converted to a short arm cast at 3 weeks. The wires and cast were removed after 6 weeks. Active finger mobilization and shoulder exercises were begun immediately postoperatively.
Patients treated were followed up at 3 weeks, 6 weeks, 3 months and 9 months in the Orthopaedics OPD. Clinico-radiological assessment of the patients was performed at each follow-up visit. Functional scoring was done using the Gartland and Werley 9 scoring scale (Table 1). The radiographs of the wrist joint of the patients were evaluated and the anatomical scoring method of Stewart et al 11 (Table 2) was used to assess the fracture reduction.

Results


A total of 41 patients with Colles’ fracture managed at the Dept. of Orthopaedics from June 2004 to June 2005 were studied. Of these, 3 cases were excluded from the study. (1 had bilateral Colles’ fracture, 1 had associated ipsilateral humerus fracture and 1 was a compound injury). Group I, which included patients who underwent closed reduction and cast application, had 20 patients. Group II (closed reduction, K-wire fixation and cast) had 18 patients. The patients were followed up immediately post-op, at 3 weeks, 6 weeks, 3 months and 9 months. 5 patients from group I and 3 patients from group II were lost to follow-up. These patients were also excluded from the study. The final analysis was performed on 30 patients, closed reduction and cast (Group I) with 15 patients and K-wire and cast (Group II), also with 15 patients.
The mean age at injury was 38.5 ± 13.75 yrs for males and 46.70 ± 8.37 yrs for females. The age ranged from 21 to 59 years for the whole group and 21 yrs to 58 yrs for males and 32 yrs to 59 yrs for females. There was no statistically significant difference in age between the patients with different types of distal radius fractures according to the Universal Classification (p> 0.503). The female to male ratio was 2:1 with 20 females and 10 males. The dominant side was involved in 17/30 (56.6%) patients whereas the non dominant side was involved in 13/30 (43.3%) patients. The distribution of the injuries according to the Universal Classification System is shown in Table 3. Majority of patients in both the groups were in Universal Classification type 4.
The post-op functional scores in both groups showed improvement over time (Table 4). There was however no statistically significant difference in the post-op function scores between the two groups (p=0.267). In Group I ( closed reduction and cast) , the anatomical scores showed worsening in 5 out of 15 cases (Table 5). The anatomical scores improved after surgery and remained the same post operatively in all but 2 cases in Group II. There was worsening after 3 weeks in one and after 3 months in the other. However, the difference between the two groups was not statistically significant (p= 0.412). The correlation between pre-operative anatomical score and post-operative functional scores at 6 weeks, 3 weeks and 9 months was investigated. However, there was no statistically significant correlation between pre-operative anatomical score and post-operative functional scores (p=0.398).

Discussion


Fractures of the distal radius are one of the commonest skeletal injuries treated by orthopaedic surgeons and account for approximately one sixth of all fractures seen and treated in emergency rooms5. Majority of the patients in the present study had intra-articular fractures (Table 3). A similar observation was made by Altissimi et al6 and Sandhu et al 12. Jupiter 1 reported that the epidemiological pattern of fractures has evolved from a non-comminuted extra-articular fracture as classically described by Colles to a comminuted articular fracture . In various studies there is still no consensus regarding the management and assessment of outcomes of distal radius fracture. This has made it difficult to evaluate various methods of treatment4.
The functional scores at 6 weeks, 3 months and 9 months for treatment Groups I and II in the present study showed that there was no statistically significant difference in the functional outcome. Azzopardi et al4 reported similar findings. However our findings are different from those of Sandhu et al12 who reported a higher percentage of excellent and good results with K-wire fixation as compared to closed reduction and cast alone.
In the anatomical scores of Group I (closed reduction and cast) worsening was seen in 5 out of 15 cases. In Group II (K-wire and cast) worsening was seen in only two cases. However, the data was not statistically significant. Our findings are comparable with those of Azzopardi et al4 who reported that the differences in the radiological parameters between K-wire fixation and cast immobilization in their study were within errors of measurement. They concluded that functionally K-wire fixation was marginally superior to cast immobilization in maintaining fracture reduction after closed manipulation.
In our study the functional scores did not correlate with anatomical scores. Our findings are comparable with those of Smaill13, Stewart et al11, Dias et al14 and Gaur et al7. Gaur et al7 reported that despite a high deformity rate with cast alone there were no patients with poor functional results at 5 year follow up. Smaill’s13 and Dias et al’s14 reported that good function may be present in spite of residual bony deformity. Stewart et al11 reported that there was no correlation between anatomical and functional results at 6 months follow up.
Azzopardi et al4 reported that only 1/30 patients (3.3%) in the K-wire group required removal of the K-wires at 2 weeks due to pin tract infection. In our study none of the patients required removal of K-wires due to infection. The mean age in our study was 43.3 yrs which is less as compared to 59 yrs in the study by Azzopardi et al4. Therefore, probably there were less chances of pin loosening and infection in younger individuals with normal bone quality versus elderly patients with osteopenic bone.
In our study 1 patient out of 30 patients (3.3%) sustained a rupture of the extensor pollicis longus tendon. Our observations are similar to those of Frykman15. The patient, however, recovered by 9 months with excellent functional scores. Our observations are comparable with those of Benjamin16. He reported that patients with extensor pollicis longus tendon rupture left untreated for an year had no functional disability from the tendon rupture.
In our study 3/30 (10%) patients developed reflex sympathetic dystrophy. 2 patients had been treated with cast alone and 1 patient with K-wire fixation. The patients showed recovery of their functional scores by 9 months after physiotherapy. Our findings are comparable to those of Frykman15.
Our study demonstrates that there is no significant difference in the functional outcome obtained with closed reduction and cast versus closed reduction, K-wire fixation and cast. However, K-wire fixation may play a role in maintaining post operative reduction and anatomical score. This is evident by the fact that loss of reduction post operatively was seen in fewer cases with K-wire fixation as compared to cast alone, even though the difference was not statistically significant. Possibly a study with a larger number of cases and a longer follow up is required to elucidate this difference.

References


1.Jupiter JB: Fractures of the distal end of the radius. Current concepts review, J Bone Joint Surg 1991 73(3):461-9.
2.Nagi ON, Dhillon MS, Aggarwal S, Deogaonakar KJ. External fixators for intra articular distal radius fractures. Indian J  Orthop 2004  38:19-22.
3.Vaughan PA, Lui SM, IJ Harrington IJ, Maistrelli GL. Treatment of unstable fractures of the distal radius by external fixation. J Bone Joint Surg Br 1985 67-B: 385-389.
4.Azzopardi T, Ehrendorfer S, Coulton T, Abela M : Unstable extra-articular fractures of the distal radius : A prospective, randomized study of immobilization in a cast versus supplementary percutaneous pining. J Bone Joint Surg 2005 87-B(6): 837-840.
5.Ark J,  Jupiter JB : The rationale for precise management of distal radius fractures. Orthop Clin North Am 1993 24(2): 205-210.
6.Altissimi M, Antenucci R, Fiacco C et al : Long term results of conservative treatment of fractures of the distal radius. Clin Orthop  1986  206:202-210.
7.Gaur SC, Swarup A, Singh HP : Long-term results of Colles’ fracture treated by conventional methods. Indian Journal of Orthopaedics 1992 25: 150-152.
8.Sander RA, Keppel FL, Waldrop JL. External fixation of distal radius fracture.  Results and complications. J Hand Surg  16(A): 1991,385-389.
9.Gartland JJ, Werley CW : Evaluation of healed colles fractures. J Bone Joint Surg 1951 33(A): 895-907.
10.Sarmiento A, Pratt GW, Berry NC, Sinclair WP : Colles’ fracture – Functional bracing in supination. J Bone Joint Surg 1975 57(A): 311-316.
11.Stewart HD, Innes AR, Burke FD : Functional cast bracing for Colles’ fractures- A comparison between cast-bracing and conventional plaster casts. J Bone Joint Surg 1984 66(B): 749-753.
12.Sandhu HS, Singh M, Bajaj AS, Singh S : Closed reduction and percutaneous Kirschner wire fixation in Colles’ fracture. Indian Journal of Orthopaedics 1986 20: 198-203.
13.Smaill G : Long term follow-up of Colles’ fracture. J Bone Joint Surg 1965 47(B): 80-85.
14.Dias JJ, Wray CC, Jones JM, Gregg PP : The value of early mobilization in the treatment of Colles’ fractures. J Bone Joint Surg 1987 69(B): 463-467.
15.Frykman G. Fracture of the distal radius including sequele shoulder-hand –syndrome, disturbance of the distal radioulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand  (Supplementum)  1967 108: 1-153.
16.Benjamin A : Injuries of the forearm. In : Wilson JN editor, Watson Jones Fractures and Joint Injuries, 6th ed, Churchill Livingstone 1982: 650-709.

Source(s) of Funding


The Authors did not receive any funding for this study.

Competing Interests


The authors do not have any competing interests

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