RESUMEN
BACKGROUND: Severely comminuted AO type-C3 intra-articular fractures of the distal end of the radius are difficult to treat. Failure to achieve and maintain nearly anatomic restoration can result in pain, instability, and poor function. We report the results of a retrospective study of the use of a standard protocol of open reduction and combined internal and external fixation of these fractures. METHODS: Seventeen of twenty-five patients treated with the protocol were available for follow-up evaluation. Six had an AO type-C3.1 fracture; eight, type-C3.2; and three, type-C3.3. Eleven fractures required a dorsal buttress plate and/or a volar buttress plate, and eleven required bone-grafting. The mean time until the external fixator was removed was seven weeks. RESULTS: At a mean of thirty months postoperatively, the mean arc of flexion-extension was 72% of that on the uninjured side and the mean grip strength was 73% of that on the uninjured side. The mean articular step-off was 1 mm, the total articular incongruity (the gap plus the step-off) averaged 2 mm, and the radial length was restored to a mean of 11 mm. Thirteen patients had less than 3 mm of total articular incongruity. Arthritis was graded as none in three patients, mild in ten, moderate in three, and severe in one. According to the Gartland and Werley demerit-point system, ten of the patients had a good or excellent result. According to the modified Green and O'Brien clinical rating system, five had a good or excellent result. One patient had a fracture collapse requiring wrist fusion, one had reflex sympathetic dystrophy, and three had minor Kirschner-wire-related problems. Total articular incongruity immediately postoperatively had a moderately strong correlation with the outcome as assessed with both clinical rating systems (r = 0.70 and 0.74 for the Gartland and Werley system and the Green and O'Brien system, respectively; p<0.05). CONCLUSIONS: Open reduction and combined internal and external fixation of AO type-C3 fractures can restore radiographic parameters to nearly normal values, maintain reduction throughout the period of fracture-healing, and provide satisfactory functional results.
Asunto(s)
Fijación Interna de Fracturas , Fijación de Fractura , Fracturas Conminutas/cirugía , Fracturas del Radio/cirugía , Traumatismos de la Muñeca/cirugía , Adulto , Fijadores Externos , Femenino , Estudios de Seguimiento , Fracturas Conminutas/diagnóstico por imagen , Humanos , Masculino , Satisfacción del Paciente , Radiografía , Fracturas del Radio/diagnóstico por imagen , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Traumatismos de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugíaRESUMEN
OBJECTIVE: To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury. DESIGN AND PATIENTS: Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation. RESULTS: Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears. CONCLUSION: MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.
Asunto(s)
Imagen por Resonancia Magnética , Fracturas del Radio/diagnóstico , Adulto , Huesos del Carpo/diagnóstico por imagen , Huesos del Carpo/lesiones , Huesos del Carpo/patología , Cartílago Articular/diagnóstico por imagen , Cartílago Articular/lesiones , Cartílago Articular/patología , Femenino , Estudios de Seguimiento , Fracturas Óseas/diagnóstico , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Fracturas del Cartílago , Fracturas Cerradas/diagnóstico , Fracturas Cerradas/diagnóstico por imagen , Fracturas Cerradas/cirugía , Humanos , Luxaciones Articulares/diagnóstico , Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/cirugía , Ligamentos Articulares/diagnóstico por imagen , Ligamentos Articulares/lesiones , Ligamentos Articulares/patología , Hueso Semilunar/diagnóstico por imagen , Hueso Semilunar/lesiones , Hueso Semilunar/patología , Masculino , Metacarpo/diagnóstico por imagen , Metacarpo/lesiones , Metacarpo/patología , Persona de Mediana Edad , Radiografía , Fracturas del Radio/diagnóstico por imagen , Fracturas del Radio/cirugía , Rotura , Traumatismos de los Tejidos Blandos/diagnóstico , Traumatismos de los Tejidos Blandos/diagnóstico por imagen , Traumatismos de los Tejidos Blandos/cirugía , Tenosinovitis/diagnóstico , Tenosinovitis/diagnóstico por imagen , Cúbito/diagnóstico por imagen , Cúbito/lesiones , Cúbito/patologíaRESUMEN
The preoperative angiogram is widely used as a means of assessing peripheral vascular runoff before bypass grafting, but the correlation between preoperative angiographic findings and actual measurements of peripheral vascular resistance has not been adequately examined. To test this correlation, we first devised a simple technique for measuring peripheral resistance and validated it in five dogs. Increases in peripheral resistance were artificially produced by temporarily occluding either the deep or superficial femoral artery or by intravenous administration of phenylephrine hydrochloride, a vasoconstrictor. In each instance, significant increases in resistance could be measured. We then used a similar technique to measure resistance in 23 patients undergoing peripheral bypass surgery. In addition, preoperative angiograms for these 23 patients were independently scored by four readers as 0, 1, 2, or 3 based on the number of patent vessels seen below the knee. Variations in scoring from reader to reader suggested that the present criteria for grading angiograms on this basis are unclear. Moreover, the correlation between angiographic score and measured resistance was poor for three of the four scorers (-0.21 to -0.29, p greater than 0.05). The angiographic scores of one reader, however, correlated reasonably well with the peripheral resistance measured at surgery (-0.59, p = 0.01). These findings demonstrate that current criteria for grading the preoperative angiogram are not sufficiently standardized to reliably predict runoff from a preoperative angiogram. However, these findings also suggest that it may be possible to identify angiographic findings that correlate well with changes in measured resistance.