Comparative analysis of treatment methods for patients with fractures of the distal metaepiphysis of the radius.

Fracture of the radius in a typical location

A fracture of the radius in a typical location (fracture of the distal metaepiphysis of the radius) is the most common fracture of the bones of the upper limb. This type of fracture occurs more often in older and older women and is associated with disorders of bone mineral density, against the background of hormonal changes in the body in the postmenopausal period. The epidemiology of a fracture of the radius in a typical location is associated with the anatomical and morphological structure of the distal end of the radius, which consists mainly of cancellous bone tissue and has the smallest thickness of the cortical layer compared to the diaphysis.

Mechanism of fracture of the radius in a typical location

The leading factor is falling on an outstretched arm. Most often occurs in winter, as a result of falls on ice (slipping).

In the summer, fractures of the radius in a typical location are more often suffered by young people leading an active lifestyle.

The direction of displacement of fragments during a fracture of the radius in a typical location is determined by the position of the hand at the time of injury. Based on this, there are two types of fracture of the distal metaepiphysis of the radius. Colles fracture (extensor) Fig. 1 A, B.

The fragment moves toward the rear and radial side. This is the most common option. Smith's fracture (flexion) Fig. 1 B, D. Occurs when the hand is bent. The fragment is displaced to the palmar side.

Picture 1

This type of fracture is characterized by a wide variety of bone tissue disorders. In this regard, a careful individual approach to the treatment of such patients is necessary, rejecting the opinion that the injuries are “typical”!

Clinical picture of a radius fracture in a typical location.

It is imperative to determine the mechanism of injury. As a rule, patients complain of pain, hemorrhage and swelling. A bayonet-like deformity may be observed when fragments in the lower third of the forearm are displaced. There is sharp pain on palpation. It cannot be done without dysfunction of the joint. A fracture of the radius in a typical location without displacement (impacted or incomplete fracture) often has poor clinical manifestations. Due to the possibility of damage to nerves and tendons, it is necessary to examine the sensitivity and mobility of the fingers. Damage to the carpal bones and rupture of the distal radioulnar joint are also possible.

Treatment of a radius fracture in a typical location.

The leading treatment method is conservative. It consists of restoring normal bone anatomy (closed manual reduction of fragments of the distal metaepiphysis of the radius) under local anesthesia. And this manipulation ends with fixation of the forearm and hand (and sometimes the elbow joint) with a dorsal plaster splint from the base of the fingers to the upper third of the forearm. The duration of therapeutic immobilization is from 4 to 8 weeks.

In this case, it is imperative to perform control radiographs 7-14 days after reposition, because Almost all fractures of the radius in a typical location are intra-articular, consisting of many fragments, which, after the swelling subsides, as well as under the influence of muscle and tendon traction, are displaced again, i.e. the so-called secondary displacement of the fragments occurs and the most interesting thing begins: the patient comes with repeated images to the doctor at the clinic, he sees that the fragments have shifted, and then, if he believes that it is necessary to operate on the patient, he tells him about it and the patients begin to look for a medical institution where they could get help.

Treatment tactics for a fracture of the radius in a typical location (distal metaepiphysis of the radius) in our Center for Traumatology and Orthopedics:

Figure 2. 23A-2 Figure 3. 23A-3
Only the two above fractures can and are subject to conservative treatment. In all other cases, closed reposition is only the first stage of treatment. Since in 80% of cases secondary displacement of fragments occurs.

An example of surgical treatment of a radius fracture in a typical location

Patient I is 46 years old. Open reduction, osteosynthesis of the distal metaepiphysis of the radius using a volar two-column plate with polyaxial locked screws

Figure 4.
Before surgery Figure 5. After surgery
Functional outcome 6 weeks after surgery:

A properly completed postoperative period almost always leads to such results. At the same time, the main advantage of surgical treatment is the early functional result, which is ahead of the time of bone fusion. Those. After such operations, patients do not need to wait for bone fusion, and can return to their normal activities in the early stages (on average 2-4 weeks).

This problem is dealt with by the 3rd traumatology department, Dr. Umnikov A.S.

Clinically Relevant Anatomy

Anatomy of the wrist joint

The carpal joint, often called the wrist joint, is a synovial joint located between the forearm and hand. Distally, the joint is formed by the proximal row of carpal bones (except for the pisiform):

• scaphoid;
• lunate bone;
• triangular bone.

The proximal wrist joint is formed by the DCL and the articular disc.

Multiplanar wrist movement is based on three joints:

• Radioscaphoid joint.
• Radial-lunate articulation.
• Distal radioulnar joint.

The ulna is not part of the radiocarpal joint; it articulates with the radius in two places, the superior and inferior radioulnar joint. Eighty percent of the axial load is on the DOCL and twenty percent on the ulna.

Between the ulna and the wrist bones is a fibrocartilaginous disc, also called an articular disc. Together, the carpal bones form a convex surface that articulates with the concave surface of the radius and articular disc.

Friends, on July 17 in Moscow, as part of the #RehabTeam project, Anna Ovsyannikova’s seminar “Rehabilitation of the hand after a fracture of the distal radius (fracture of the “radius in a typical place”)” will take place.” Find out more... In addition, on July 18, she will conduct a seminar “Rehabilitation of the hand after fractures of the metacarpal bones (Boxer fracture).” Find out more...

There are several ligaments attached to the DOLK. The volar ligaments are stronger than the dorsal ligaments. They provide greater stability to the wrist joint. In case of DCL fractures, the ligaments often remain intact.

Recovery

Because DOL fractures are so varied and treatment options are so wide, recovery is different for each person. Consultation with the treating surgeon may be required to determine timing of return to various activities.

During the first two months after surgery, patients report severe pain with movement and significant disability in performing activities of daily living, as assessed by valid and reliable outcome measures such as the Patient Rating of the Wrist Evaluation (PRWE) and the Arm Shoulder Disability Questionnaire. and brushes (DASH). These self-reported deficiencies are reflected in decreased range of motion and decreased grip strength, with strength being more correlated with function. Most patients achieve full recovery within the first six months. A small number of patients continue to have pain and disability for up to one year after injury regardless of treatment protocol, especially with sit-to-stand push-ups and heavy lifting. Patients with atypical recovery from distal radial joint fractures require modified treatment programs aimed at increasing levels of function.

Rehabilitation

Kay et al. found that a rehabilitation program consisting of consultation and exercises under the guidance of a physical therapist provided some additional benefits compared with no physical therapy intervention for adults following casting and/or pinning for a DCL fracture. These benefits included decreased pain compared to the control group at weeks 3 and 6, increased activity compared to the control group at week 3, and greater satisfaction with treatment compared to the control group. The two groups did not differ in recovery of active wrist range of motion or grip strength.

Michlovitz et al. published the results of a survey of physical therapists, occupational therapists, and certified hand care therapists to determine common rehabilitation practices for patients with a DCL fracture.

During immobilization

At this stage, less than 10% of patients with a DCL fracture are referred for rehabilitation treatment. Priorities during immobilization include managing finger swelling and stiffness and patient education. Home exercise programs are commonly offered to increase the range of motion of the shoulder, elbow, and fingers. Heat/cold treatments may be used to reduce pain. Compression wraps and massage can be used to relieve swelling. In 50% of cases splints were used for support and protection.

After immobilization

Ninety percent of therapists surveyed include heat/cold treatments and range of motion exercises at this stage. Eighty percent use compression wraps with massage, agility exercises, and joint and soft tissue mobilization. Nearly 90% also use strengthening exercises to improve strength and function. Static or dynamic splints (or both) can be used to relieve joint stiffness.

Smith et al. provided the following brief description of postoperative rehabilitation methods.

External fixation

• Control pain and swelling early.
• Caring for the damaged area.
• Maintaining active range of motion in non-involved joints, rotation of the forearm is difficult, active range of motion in the wrist is impossible.
• Desensitization of affected nerves, elimination of complex regional pain syndrome.
• After removal of the fixation equipment: active/active-assistive/passive range of motion of the wrist and forearm; focus on wrist flexion and extension, ulnar deviation and supination; static progressive tires; progressive activity and activities of daily living.

Dorsal plate

• Control swelling early.
• Static splint on the wrist.
• Maintaining active amplitude is not
• involved joints.
• Graduated early active range of motion at the wrist.
• After bone healing: active/active-assistive/passive range of motion of the wrist with emphasis on active wrist flexion; preload and relaxation program for the extensor tendons; static progressive tires.
• Progressive activity and activities of daily living.

Volar fixed-angle plate

• Swelling control, active range of motion of the wrist and non-involved joints.
• Static splint for the wrist in a resting position with 30° extension.
• After bone healing: progressive active/active-assistive/passive restoration of wrist amplitude; protective static splint on the wrist; Static progressive splinting is rarely indicated.
• Progressive activity and activities of daily living.