Transcript مقاله آقای دکتر جاودان.ppt

IN THE NAME OF GOD
FRACTURE OF THE DISTAL
RADIUS AND ULNA
Common fracture encountered BY
orthopedic trauma surgeons
Low energy Trauma %80
high energy trauma %20
Men are significantly younger than
woman
AO BASE
CLASSIFICTION
EXTRA – ARTICULAR %60 AO T1
PARTIAL – ARTICULAR %12 AO T2
COMPLETE – ARTICULAR %28 AO T3
TRIANGULAR FIBROCARTILAGE
COMPLEX INJURY (TFCC)
IS MORE COMMON THAN INTERESSEOS
LIGAMENTS (%40- 80)
MAJORITY ARE SUPERFICIAL
AVULSION WITH ULNA STYLOID
FRACTURE
Who framwork of measurment
(internationnal classification of
- Impairment (abnormal physical activity)
ICIDH
- Disability (unable to perform daily
activity)
- Handicaps
Today emphasis on self reported
measurment (prwe)
Disablity that patient reported may has a
psychologic base that no need treatment
Pain
L-O-M
R-u joint unstable
Fingers stiffness
CTS
OA changes
Gartlant score:
Excellent : 0-2 points
Good : 3-8
Fair : 9-20
Poor: 21 <
Prwe overall is a valid – reliable &
responsive outcome measure
Treatment option
1- Splint
2- CR & plaster fixation
3- Fixator – extern
4- Pin & plaster
5- CR & CP
6- ORIF
Depend to prediction of
outcome and instability
functional
A:
prediction of stability
several factors are associated with re –
displacement following CR:
1- Age over 80
under 30
2- Initial displacement : radius shortening
3- Metaphyseal communition
4- Displacement following CR
repeated manipulation is unlikely to good x-ray
result outcome
B:
Prediction of function related to patient
12345-
Age
Work
Poor socioeconomic status
Lower education levels
Low bone density
C:
Fracture – factors
Some surgeon emphasis to influence of x-ray
position on outcome function
1- Metaphyseal alignment
2- Articular alignment
3- Radial Height (over 4mm has permanent
pain after 2-3 month)
4- Ulnar variance
In ulnar variance
shorthening has more effect alternation
in (DRUJ) function than radial inclination
palmar tilt
Radial inclination + shortening (Axial
compression)
A: DECREAS GRIP POWER
B: R-C JOINT DJD
C: DRUJ DJD
Dorsal – palmar tilt:
Incongruence of distal r-u joint Increase
A: tightness of interosseos
B: L-O-M
C: mid carpal instability
D: decreas grip power
E: worse dash score
Articular alingment :
Relation ship between cartilage damage and
residual incongruity & development of DJD
is not obvious
Outcome is related to
1- Age
2- Severity of trauma
3- Residual articular displacement
4- Difficulty in Obtaining accurate measurement
of the articular surface
5- Inter & intraobserver reliability
In one study 38 years After this fracture :
All treated non operativly
now average age are 64y
2/3 of fracture mal-united but patients are
sign free and no need treatment
In 64 cases with this fracture &
20 osteoprotic
44 osteo penia
Result in protic group was unaccepted
Indication of treatment related to:
1- patient
Age
Condition
demand
2- Type of fracture
The purpose of treatment is maintain:
Normal power
Mobility
Function in wrist & hand.
No differenc outcome between position of wrist
in cast
1- Palmar Flexion & Ulnar Deviation
2- Neutral position
patient & fracture factors are more effective
rather than
wrist position in cast.
Functional recovery is faster in limited
immobilization
removal splint than complete cast
 For
displace type 5-6 weeks casting
 Some
beleav that after 3 w remove
of cast and start mobilization has
better result.
Mackenney
%10 of minimmaly displace
%43 of displace fracture
Are unstable after 2 week. (re-manipulate)
Some follow-up for non – operative treatment
9 - 13 y
Age: 9-78 y
Dorsal angulation : 13 in > 60 y
18 in< 60y
But 52 of 66 cases had excellent clinical
outcome
Results in RTC study of non-operative treatment with
A: pc pining has no or minimal x-ray advantage
But no functional advantage
in patient < 60 years x-ray & clinical result
are better
B: with bridging EXT-fix
x-ray position good
function : no difference
C: with volar- locking plate:
94 case 65> age
X- ray : good
Clinical : accepted
High rate tendon complication has need
re-surgery
D: FIX-EXTRE + ORIF
X-ray & clinical result are better than
Non-operative treatment
THE END