OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #71, 11:19 AM *Health Status after Wrist Arthrodesis for Posttraumatic Arthritis Lauren P. Adey, MD; David C. Ring, MD ; Jesse B. Jupiter, MD; Massachusetts General Hospital, Boston, Massachusetts, USA (a-AO Foundation) Background: Total wrist arthrodesis is regarded as the most predictable way to relieve the pain of posttraumatic wrist arthritis. Wrist arthrodesis is also believed to be compatible with a high level of upper extremity functioning. The upper-extremity-specific and general health status of patients with total wrist arthrodesis after trauma have not been evaluated. Methods: With use of an IRB-approved protocol, 22 patients were evaluated an average of 6 years after total wrist arthrodesis for posttraumatic arthritis. Upper-extremity-specific and general health status were measured by using the DASH and SF-36 instruments, respectively. Patient satisfaction and their interest in pursuing a wrist mobilizing procedure, should one become available, were also assessed. Objective assessment included grip strength, digit range of motion, and radiographic fusion. Results: The average DASH score was 25 (range, 4 to 57). The average physical component score of the SF-36 was 39 (range, 15 to 60), and the average mental component score was 52 (range, 44 to 64). Nineteen patients reported wrist pain, including severe pain in 5 patients. Two of the patients had ulnar nerve damage at the time of their original injury and continued to have nerve-related pain. Fifteen patients were satisfied or very satisfied with the result of the fusion, 5 patients were neutral, and 2 patients were mildly dissatisfied. Twenty patients would elect to have a motion-restoring procedure, should one become available. One patient required a second operation to obtain successful fusion. Subsequent procedures included neuroma excision in one patient, and hardware removal from six. Grip strength averaged 79% of that of the uninvolved wrist, and five of the patients had stiff digits. Conclusion: Substantial dysfunction was noted on both upper-extremity-specific and general health status measures after total wrist arthrodesis for posttraumatic conditions. Pain was improved but not eliminated. Although some of the pain and dysfunction were related to associated problems, the interest in motion-restoring procedures expressed by out patients reflects the residual pain and functional limitations associated with a wrist that has undergone arthrodesis.

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #65, 10:29 AM A Randomized Controlled Trial of Closed Reduction and Casting versus Closed Reduction and External Fixation for Distal Radius Fractures with Metaphyseal Displacement but Without Joint Incongruity Hans J. Kreder, MD, FRCS(C) ; Douglas P. Hanel, MD; Julie Agel, MA, ATC; Michael D. McKee, MD, FRCS(C); Thomas E. Trumble, MD; University of Toronto, Toronto, Ontario, Canada; Harborview Medical Center, Seattle, Washington, USA; University of Minnesota, Minneapolis, Minnesota, USA (-OREF Grant) Purpose: We compared closed reduction and casting with closed reduction and external fixation for repair of distal radius fractures with metaphyseal displacement but without joint incongruity in a multicenter randomized clinical trial. Methods: We randomized 113 eligible patients with distal radius fractures with metaphyseal displacement but without joint incongruity to repair with either closed reduction and casting ( N = 59) or closed reduction and external fixation ( N = 54). For five patients randomized to cast treatment, an open procedure was required within the first 3 weeks because of significant loss of correction. One patient randomized to external fixation underwent open reduction and internal fixation because of displacement of a previously undisplaced partial articular fracture. The patients were evaluated at 6 weeks, 6 months, and 1 and 2 years. Upper extremity function, as measured by using the upper extremity module of the Musculoskeletal Function Assessment, represented the primary endpoint. Pain, Jebsen Taylor functional test score, range of motion, and grip and pinch strength were evaluated as secondary outcomes. Repeated measures analysis of variance was used to compare outcome between the two study groups. We compared the results at each time interval by using the Student's t -test or chi square test to evaluate the outcome data. Results: By 2 years, Jebsen Taylor scores and pain scores were similar to population age- and sex-matched control scores in both study groups. At all evaluation time points, there was a trend toward better function in the external fixation group; however, this did not reach statistical significance ( P <0.05). The mean difference in upper extremity function scores at 2 years (the primary endpoint) was 5.5 in favor of external fixation (power = 0.161). Results of approximately 896 patients would have been required to obtain 80% statistical power. There were six pin site infections in the external fixation group (14%), with one deep infection requiring curettage (2%). One patient in the external fixation group (2%) and two in the cast group (6%) developed a reflex sympathetic dystrophy ( P = 0.585). There was no statistically significant difference in the radiographic restoration of anatomic parameters, although there was a trend toward better length and palmar tilt restoration with use of external fixation ( P >0.05). Discussion and Conclusions: Upper extremity function, Jebsen Taylor, and pain scores, and grip strength improved significantly the 1st year of the study for all patients. There was a trend toward better functional, clinical, and radiographic outcomes with use of immediate external fixation for distal radius fractures with metaphyseal displacement and a congruous joint.

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #66, 10:35 AM The Aberdeen Colles-Fracture Brace: An Alternative Treatment for Colles Fracture: A Prospective Randomized Multicenter Study Nezar S. Tumia, FRCS 1 ; Douglas Wardlaw, FRCS 1 ; Jeffrey P. Hallett, FRCS 2 ; Robert Deutman, MD 3 ; Sten A. Mattsson, MD 4 ; Bengt Sandén, MD 4 ; 1 Department of Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; 2 Department of Orthopaedics, The Ipswich Hospital NHS Trust, Ipswich, Suffolk, England; 3 Department of Orthopaedics, Martini Hospital, Groningen, The Netherlands; 4 Department of Orthopaedics, University Hospital, Uppsala, Sweden Purpose: The morbidity associated with the Colles cast immobilization in treating Colles fracture includes stiffness and reduced strength and function of the hand and fingers, which has led to an increased interest in an alternative treatment using a functional brace. The Aberdeen Colles fracture brace (AFB) is a prefabricated brace that maintains fracture reduction by applying three-point loading and at the same time allowing movement at the wrist joint. We compared the outcome of the management of Colles fractures with use of the AFB and with use of a conventional plaster of Paris (POP) cast. Methods: A randomized prospective multicenter clinical trial was carried out; 339 patients with Colles fractures were treated at five different trauma centers. Patients were stratified into two groups: group 1, 151 patients who had minimally displaced fractures not requiring manipulation, and group 2, 188 patients who had displaced fractures requiring manipulation. Both groups were treated with either a conventional POP cast or the AFB. The functional and anatomical assessments were made using the modified Gartland and Werley scoring system and the radiological displacement method (Bunger et al., 1984), respectively. The relative grip strength of the injured hand was calculated for each patient. Pain and discomfort assessment was made according to pain scores: 0, no pain; 1, occasional pain on heavy activity; 2, often pain on heavy activity; 3, often pain on normal activity; and 4, often pain at rest. Results: Both the AFB and POP treatment groups gave similar anatomical scores and pain scores. Hand grip strength was better among patients in the AFB group than in the POP cast group. However, there was no statistically significant difference in the functional scores. Discussion: There was no significant difference in the anatomical scores between either treatment. The AFB was as effective as the POP cast in maintaining fracture reduction in treating both manipulated and non-manipulated fractures. In addition, there was no significant difference overall in the pain scores between treatments in both groups. The handgrip strength was better in patients who used the AFB than in those who had a POP cast because of the free movement at the wrist joint permitted by the AFB (P < 0.05 at week 5). Conclusion: The AFB can be used effectively in treating both manipulated and non-manipulated Colles fractures. The AFB gave better handgrip strength, perhaps due to the free movement at the wrist joint in the AFB. This feature may play a role in early rehabilitation, especially in elderly patients.

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #67, 10:41 AM A Randomized Controlled Trial of Indirect Reduction and Percutaneous Fixation versus Open Reduction and Internal Fixation for Displaced Intraarticular Distal Radius Fractures Hans J. Kreder, MD, FRCS(C); Douglas P. Hanel, MD ; Julie Agel, MA, ATC; Michael D. McKee, MD, FRCS(C); Thomas E. Trumble, MD; University of Toronto, Toronto, Ontario, Canada; Harborview Medical Center, Seattle, Washington, USA; University of Minnesota, Minneapolis, Minnesota, USA (-OREF Grant) Purpose: We compared indirect reduction and percutaneous fixation with open reduction and internal fixation for repair of displaced intraarticular distal radius fractures in a multicenter randomized clinical trial. Methods: A total of 179 skeletally mature patients 16 to 75 years of age who had displaced intraarticular distal radius fractures received either indirect percutaneous reduction and external fixation ( N = 88) or open reduction internal fixation (ORIF) ( N = 91). Each fracture was reduced to a standard of acceptable radiographic parameters. Patients were evaluated at 6 weeks, 6 months, and 1 and 2 years. Function was measured by using the upper extremity module of the Musculoskeletal Function Assessment to represent the primary endpoint. Pain, the Jebsen-Taylor functional test score, range of motion, and grip and pinch strength were secondary outcomes. Repeated measures analysis of variance was used to compare outcomes between the two study groups over time. Results: Primary and secondary outcome measures improved significantly the 1st year. By 2 years, the mean Jebsen Taylor and pain scores were within half a standard deviation of the control population scores for both study groups. Upper extremity function improved more rapidly after indirect reduction as compared with ORIF; a 13-point score difference was noted in favor of indirect reduction at the 6-month evaluation ( P = 0.037). After adjusting for repeated measures over the 2-year study period, indirect reduction resulted in significantly better upper extremity function compared with ORIF ( P = 0.014). Pinch strength was also significantly better after indirect reduction ( P = 0.020), with similar trends for grip strength ( P = 0.448) and Jebsen Taylor scores ( P = 0.059). There was no statistically significant difference in the radiographic restoration of anatomic parameters ( P >0.05). Twelve patients (14%) healed with residual intraarticular step deformity in the indirect reduction group compared with 13 patients (14%) in the open reduction group ( P = 1.0). Only three patients (3%) in the indirect group and two patients (2%) in the ORIF group had step deformity of more than 2 mm at union ( P = 0.679). Residual step and gap deformity were associated with development of radiographic osteoarthritis and also with poor function scores ( P <0.05). Discussion: Indirect reduction and percutaneous fixation results in more rapid return to function and superior functional outcome within 2 years from injury as compared with ORIF for repair of displaced intraarticular distal radius fractures, provided that intraarticular step and gap deformity is minimized. Conclusion: This is the first study with results showing that ORIF of intraarticular distal radius fractures should be preceded by attempts at closed reduction, percutaneous stabilization, and external fixation. Only if the reduction cannot be obtained with closed percutaneous methods should the fracture be opened and internally secured.

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #68, 10:54 AM *The Role of Distal Radial Osteotomy in the Restoration of Wrist and Hand Function Margaret M. McQueen, MD, FRCS; Alison Wakefield, MSc, MCSP; Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (a-Stryker Howmedica Osteonics) Purpose: Malunion is a common complication of distal radial fracture that may result in pain, loss of function, and posttraumatic arthritis. Distal radial osteotomy with bone graft and external fixation is an accepted corrective technique for the treatment of this complication. This prospective study examined functional outcome after treatment with a novel less-invasive surgical technique. Methods: Twenty-three patients with malunion after distal radial fracture underwent distal radial osteotomy with use of a dorsal opening wedge with cancellous bone grafting through a 3-cm transverse dorsal incision. The position was maintained by using the Hoffman II nonbridging external fixator for 6 weeks. The range of movement, grip strength, wrist and hand function, and radiographs were examined at 6 weeks, 3 months, and 6 months postoperatively and compared with preoperative values. Quality of life measurements were assessed with the SF-36 questionnaire. Data (mean ± SEM) were compared with use of the Wilcoxon signed-rank test, with significance set at 5%. Results : Surgery improved dorsal angulation from 19.5 (2.22) to ­6.4 (1.4) P <0.001. All components of wrist movement were significantly improved from the 3-month examination ( P <0.05). Grip strength increased from 27% of the unaffected side to 56% at 6 months ( P <0.05), and the functional score improved from 72% to 92% of the unaffected hand ( P <0.001). Patients reported a significant reduction in pain and were much more satisfied with the cosmetic appearance of their wrist; quality of life also improved significantly. Surgical morbidity included 13 minor pin tract infections, two patients had a spontaneous rupture of the extensor pollicis longus tendon, and two needed further ulnar procedures for distal radioulnar joint symptoms. Conclusion : The minimally invasive distal radial osteotomy with nonbridging fixation was successful in restoring anatomic position, decreasing pain, and improving wrist and hand function in patients with malunion of distal radial fractures. Early functional improvement provided evidence for the efficacy of this technique.

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #69, 11:00 AM *Corrective Osteotomy of Dorsally Malunited Fractures of the Distal Radius via the Extended Flexor Carpi Radialis Approach Jorge L. Orbay, MD (d-Hand Innovations, Inc.); Alejandro Badia, MD; Roger K. Khouri, MD; Eduardo González, MD; Diego L. Fernandez, MD; Igor R. Indriago, MD; Miami Hand Center, Miami, Florida, USA; Lindenhof Hospital, Berne, Switzerland Introduction: We were encouraged by the observation that volar surgical approaches to the distal radius are better tolerated than dorsal; therefore, we decided to treat symptomatic malunions of dorsally displaced distal radius fractures with a corrective osteotomy performed through the extended flexor carpi radialis (FCR) approach and stabilized with the DVR fixed-angle plate. Here we present our experience with this technique. Methods: We reviewed retrospectively the records of all patients who underwent corrective osteotomy of dorsally malunited distal radius fractures at our center between October 1997 and October 1991 with use of the DVR plate applied through the extended FCR approach. Indications for the procedure were persistent pain, limitation of motion, and deformity more than 4 months after union of dorsally displaced distal radius fractures. Standard radiographic anatomical parameters were measured, and final functional results were assessed by measuring digital motion, wrist motion, and grip strength. Results: All 26 patients (mean age, 42 years) that underwent this procedure at an average of 9 months after their original injury were accounted for and followed for an average of 70 weeks. Preoperative deformity averaged 20° of dorsal inclination, 9° of radial tilt, and 4 mm of radial shortening. All the osteotomies healed with the following radiographic and functional results. The final volar tilt averaged 8°; radial inclination, 20°; and radial shortening, 0 mm. The final average wrist flexion increased 23°, dorsiflexion increased 12°, forearm supination increased 18°, and pronation increased 11°. Grip strength increased from 51% to 72% of the contralateral side. There were 12 opening, 7 closing wedge, and 7 intrafocal osteotomies. Additional procedures consisted of 5 ulnar-shortening osteotomies, 2 distal ulna resection arthroplasties, and 22 carpal tunnel releases. Bone grafting was used in 19 patients. There were no tendon ruptures or tenosynovitis, and no plate needed removal. Discussion and Conclusion: The use of a fixed-angle plate permits corrective osteotomies for malunion of dorsally displaced distal radius fractures through a volar approach. This technique avoids extensor tendon complications and reduces the incidence of re-operation for plate removal.

Volar Versus Dorsal Plating in the Management of Intra-Articular Distal Radius Fractures David S. Ruch MD, and Anastasios Papadonikolakis MD Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC Received 16 February 2005; accepted 7 September 2005. Available online 25 January 2006. Purpose To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures. Methods This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score. Results Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score.Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one. Conclusions Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group. Type of study/level of evidence Therapeutic, Level III. Full Text available