Views: 16 Author: Site Editor Publish Time: 2022-08-05 Origin: Site
Fractures of the distal radius are among the most common fractures in the elderly. People between the ages of 50 and 75 are currently defined as the elderly. The incidence of distal radius fractures increases year by year as the range of motion in older adults increases. The hot issue in the debate about distal radius fractures remains: Is surgery necessary?
Fractures of the distal radius account for approximately 18% of all body fractures in older adults. Caucasian population, female patients, and osteoporosis are major risk factors for distal radius fractures. In addition, it also includes seasonal factors, such as the elderly slip-to-fall prone to fractures of the distal radius in winter. Some studies have reported that elderly patients with intact cognitive ability and neuromuscular system are at high risk of distal radius fractures (because patients have strong reflexes, they will reflexively stretch their hands to support the ground when they fall, resulting in fractures). .
According to statistics, in the United States, the medical cost of distal radius fractures in 2007 was about 170 million US dollars (about 1983 US dollars / person). Although most elderly patients with distal radius fractures are treated conservatively, the number of patients opting for surgical internal fixation is increasing year by year. The medical cost of intraoperative fixation is three times that of conservative treatment, and it also increases the cost of hospital stay and other related costs.
There are also regional and ethnic differences in the use of internal fixation for distal radius fractures. A study on Medicare indicated that women and Caucasians were more likely to have surgery, and the range of choice for internal fixation was 4.6% to 42.1%. And found that doctors trained in hand surgery were more likely to choose surgery.
The patient's injury mechanism and main complaints should be noted in the clinical history, including the location of pain, functional activity, and degree of deformity. At the same time, it is also necessary to understand the patient's dominant hand, usual hobbies, and the patient's occupation. In addition, it is more important to know whether the patient has osteoarthritis or sequelae that affect the functional activities of the affected limb before the injury. Among them, asking elderly patients whether they need to use crutches when walking and whether they can take care of themselves in daily life is very important for understanding the needs of patients and formulating diagnosis and treatment plans.
During the clinical physical examination, a systematic and comprehensive examination of the patient's wrist from far to near is required. The blood supply of the wrist is known by the capillary refill test and the radial and ulnar pulse. The sensory conditions of the median nerve, ulnar nerve and radial nerve were obtained by two-point discrimination test and light touch test. The incidence of acute carpal tunnel syndrome in distal radius fractures is 5.4% to 8.6%, so special attention should be paid to paresthesia and numbness in the distribution area of the median nerve. The patient's motor function was examined by examining the anterior and posterior interosseous, radial, median, and ulnar nerves. In addition, the examiner also needs to pay attention to the condition of the patient's skin wound (such as ecchymosis, edema, fork-like angulation, etc.) to determine whether it is an open fracture. Due to the poor soft tissue conditions and thin skin in the elderly, distal radius fractures are often accompanied by skin lacerations. When closed traction reduction is used, careful operation is especially required to avoid additional soft tissue damage.
Radiographic evaluation of distal radius fractures typically includes anteroposterior, lateral, and oblique radiographs. The angulation and rotation of the fracture can be understood by imaging examinations to determine whether there is shortening, whether the fracture fragment is comminuted, and whether the joint line is complete. Other specific imaging parameters included: ulnar declination (mean 22°, range: 19°-29°), height of the distal radius (11-12 mm), and palmar inclination of the distal radius (mean 11°, range: 11 °-14.5°). X-rays of the forearm and elbow are also taken to check for forearm damage or elbow instability. After closed reduction and splint immobilization, another X-ray film is required to assess whether the parameters of the distal radius have improved. Clinically, CT examination is often used to assist in diagnosis and classification of fractures (eg, whether there is an intra-articular fracture, whether there is a compression or shear fracture), so as to further determine the surgical treatment plan. At the same time, CT examination is also required for further evaluation when performing osteotomy and orthopedic treatment of malunion.
According to the AAOS treatment guidelines, there is no consensus on the use of conservative or surgical management of distal radius fractures. There is no consensus on whether to use volar locking plate fixation or percutaneous Kirschner wire fixation in surgical treatment. Kodama et al recommend the use of a fracture scoring system to determine whether a patient needs surgery. And for elderly patients ≥50 years old, the type of fracture, changes in radiographic parameters of the wrist joint, age, dominant hand, and the occupation of the patient should be used to further determine the treatment plan. In a multiple regression analysis, the degree of comminution of the volar or dorsal distal radius fragment after reduction, whether the fracture involved the ulnar neck, palmar inclination, and variability in the distal ulna were strongly associated with clinical outcomes.
At our center, minimally displaced distal radius fractures are usually immobilized with a Sugar tong plaster splint over the elbow to limit pronation and supination of the elbow (see Figure 1). If the displacement of the fracture is large, a Sugar tong splint should be performed after closed reduction. Note that when performing plaster splint immobilization, the scope of immobilization should stop at the proximal end of the finger, so as to facilitate the movement of the finger and prevent stiffness. The use of elastic bandages for limited compression fixation can assist in splinting. The type of fracture determines the method of closed reduction. If necessary, local hematoma anesthesia of the distal radius can be selected, and then traction reduction is performed by pulling the fingers (index and middle fingers) to correct the deformity and restore the radiocarpal joint alignment. Traction reduction is usually performed using the inverse fracture mechanism. Traction reduction in different planes is required to complete the ligament restoration and restore the alignment of the fracture fragments, the capitulum and the lunate. On the coronal plane, restore the anatomical alignment of the ulna and radius, the distal bone fragment and the radial shaft. The reduction of a typical Colles fracture requires the assistant to hold the patient's thumb in one hand and the patient's 4 fingers in the other hand, applying countertraction to separate the fracture fragment from the metaphysis of the radius, continuing longitudinal traction, and then palmar. Flexion and ulnar deviation to help reduce the fracture fragment. For elderly patients with surrounding soft tissue damage, careful manipulation is required during the reduction process to prevent skin tearing (a cotton pad can be used during reduction). After repositioning, a neurovascular examination was performed.
Figure 1. (A) A patient with distal radius fracture was immobilized in a slightly neutral palmar position with Sugar tong plaster splint to prevent redisplacement; (B) and (C) anteroposterior and lateral radiographs showing the patient's wrist fixation good. The plaster splint does not extend beyond the metacarpal head so that the fingers can move normally.
Surgical treatment options for elderly patients with distal radius fractures include: closed reduction and external fixation, percutaneous Kirschner wire fixation, open reduction, volar/dorsal locking plate fixation, and dorsal bridging plate fixation (see shown in Figure 2).
The other type of open reduction and dorsal plate fixation is mainly used for the treatment of intra-articular fractures. It can reduce the articular surface under direct vision without stripping the ligament tissue on the volar side of the wrist joint, reducing the risk of later radiocarpal joint instability. If a volar lunate fracture is involved, it needs to be immobilized. For patients with radial shaft fracture or multiple injuries, the built-in traction plate can be used to achieve reduction through ligament restoration. At the same time, the traction plate is also suitable for the reduction and fixation of comminuted and osteoporotic distal radius fractures. The plate was removed 12 weeks after the operation, and a good clinical therapeutic effect could be achieved.
Volar locking plate can improve radial shortening and volar tilt, and the incidence of complications is low. Compared with the dorsal plate, the grip strength of the affected limb can be significantly improved within 6 months after surgery, and the function and pain can be improved. Complications such as redisplacement of dorsal plate fixation and irritation of the extensor digitorum tendon occur in up to 30% of cases. And the fixation effect of the volar plate is also better than that of Kirschner wire or external fixator.
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