THE CHARACTERISTICS OF CONSERVATIVE TREATMENT OF FRACTURES OF THE DISTAL RADIAL BONE IN ELDERLY PATIENTS
Gorbunova City Hospital No.1,
Kemerovo State medical Academy,
Kemerovo, Russia
A distal radius fracture is the most common injury with the rate of 40-50 % from all bone injuries in the upper extremities [1]. The main category of victims includes elderly people with active life style [2]. According to the WHO classification, the population at the age of 60-74 is considered as elderly, the age of 75-89 – as late life, and more than 90 – as long-livers.
At elderly age such injuries commonly happen at the background of osteoporosis. So, almost 10 % of American women at the age of 65 suffer from such fractures during the rest of their lives [3].
These injuries are traditionally treated with conservative techniques with use of reposition and plaster splint [4].
Conservative treatment of unstable intraarticular fractures of the distal radius in elderly patients causes osteopenia, collapse of bone fragments and incorrect consolidation [5-7].
Currently, elderly people are healthier, with higher life span, and they hope for more active recovery than previously. Unsuccessful reposition of fractures in elderly people causes dissatisfaction, pain syndrome, rigidity and lost functioning [8-12].
Despite of increasing rate, the epidemiology of distal radius fractures is poorly described, and treatment of elderly people is insufficiently described in the literature [13].
Objective – to study the results of conservative treatment of fractures of the distal radial bone and quality of life in elderly patients.
The tasks: to investigate the functional capability of the hand, the qualitative and quantitative values of hemodynamics, rate of complications and quality of life of patients with fractures of the distal radius.
All patients signed the informed consent for participation in the study.
MATERIALS AND METHODS
24 patients with fractures of the distal radius received treatment in Gorbunova City Clinical Hospital No.1 from January, 2012 till May, 2013.
All studies with participation of the patients corresponded to the ethical standards of the bioethical committee corresponding to Helsinki Declare – Ethical Principles for Medical Research with Human Subjects and the Rules for Clinical Practice in Russian Federation confirmed by Russian Ministry of Health, June 19, 2003, No.266.
All patients were female, the age of 60 and older (24 patients, 100 %).
All patients had bilateral injuries (10 %): on the right side – 13 (54 %) patients, on the left side – 11 (46 %).
The fractures of type A were in 8 (33 %) patients, type B – in 2 (9 %), type C – in 14 (58 %).
The professional occupation of the patients was as indicated below: retired persons – 14 (58 %), office staff – 9 (38 %), business person – 1 (4 %). 17 (71 %) patients requested medical aid in the winter, 7 (29 %) – in the spring.
8 (33 %) patients requested assistance within an hour after injury, 7 (29 %) – within 1-2 hours, 5 (21 %) – within 2-6 hours, 1 (4 %) – within 6-24 hours, 3 (13 %) after 24 hours.
The following examination techniques were used: clinical, radiologic, estimation of hand functioning, multispiral computer tomography, ultrasonic doppler, electromyography, dynamometry.
The clinical examination was conducted according to the conventional scheme including patient’s complaints, history of an injury, local examination. As a rule, upon admission the patients presented the complaints about pain in the region of the radiocarpal joint with limited motions in the fingers of the hand, presence of deformation in the distal one-third of the forearm. The main mechanism of injury was fall on outstretched arm.
The functional capacity of the hand was estimated with the standard angle meter. We estimated flexion of the hand, extension, radial abduction, ulnar abduction. The standard was flexion of 75°, extension of 65°, radial abduction of 20°, ulnar abduction of 40°. The insignificant limitations were flexion of 35°, extension of 30°, radial abduction of 10°, ulnar abduction of 20°. The moderate limitations were flexion of 20-25°, extension of 20-25°, radial abduction of 5°, ulnar abduction of 15°. The significant limitations were flexion of 15°, extension of 15°, radial abduction of 3°, ulnar abduction of 10° [Marks V.O., 1978].
The standard frontal and lateral radiography for injuries to the distal radius gives a possibility for investigating the length and direction of primary dislocation, as well as for finding out whether a fracture is intra- or extraarticular. All plain X-ray images of fractures of the distal radius includes estimation of shortening and lengthening of the radial bone, changes in the ulnar bone and flexure of the radial bone. X-ray examinations were conducted with RDK 56/2 and Philips Diagnost.
Multispiral computer tomography with 3D reconstruction (MSCT) is necessary estimation of degree of dislocation. MSCT simplifies examinations of intraarticular fractures, especially comminuted (with impacted articular surface in the center) fractures with impaction of scaphoid articular surface. 2 patients received MSCT with the device Somatom Emotion (Siemens, Germany).
Ultrasonic scanning was conducted with Sonoace R-7 (Medison) with the linear transducer L5-12/50 EP in the mode of pulse-wave spectral doppler (id). On the days 3-5 after plaster removing and one month after immobilization the standard parameters of blood flow were investigated in healthy and injured extremities. The qualitative values were estimated (blood velocity curve shape), as well as quantitative ones: peak velocity of blood flow (Vps), maximal end diastolic blood flow velocity (Ved), pulsation index (Pi), time-averaged maximal velocity of blood flow (TANx).
Electromyography was conducted for the patients with clinical course of neuropathy of the median nerve and clinical course of complex regional pain syndrome (CRPS) with the device Neuro MVP-4. It was conducted for 14 patients.
Dynamometry was conducted for all patients after plaster removing and one month after removal of plaster immobilization. The dynamometer DRP-90 was used. The control group included 30 healthy women at the age of 60.
The materials of the study were statistically analyzed with Microsoft Office Excel 2013 (the license No. 61524572) and Statistica 6.1 (the license agreement V092231FAN3). The examinations were conducted on the basis of the sufficient amount of observed cases. The study presents the statistically significant results. The median (Me) and interquartile range (25th and 75th percentiles) were used for description of the quantitative data. The data analysis was conducted with the methods of non-parametric statistics for two dependent samples (Wilcoxon’s test [T]) and Mann-Whitey test for two independent groups (U). P value of 0.05 was considered as critical level of significance. The null hypothesis was accepted in the case of exceeding the actual level of statistical significance over the critical level (p).
Upon admission all patients received anesthesia of a fracture region with use of 1 % novocaine (20 ml). For displaced fragments we used single-step manual closed reposition of fragments with plaster fixation from the metacarpophalangeal joints to the upper one-third of the forearm or to the middle one-third of the humerus in dependence on stability of a fracture. The indicated procedures included analgetic, anti-inflammatory therapy, physotherapeutic treatment (if contraindications were absent), remedial gymnastics for fingers in the plaster bar beginning from the days 3-4, extension and flexion in the ulnar joint, motions in the shoulder joint. X-ray control examination was conducted on 7th day after reposition with aim of excluding secondary displacement.
In 3 weeks after application of plaster bar the hand was brought into the physiological position (if necessary).
Prevention of complications was realized with non-steroidal anti-inflammatory drugs (Nise, 100 mg 2 times per day, Celebrex, 100 mg 1 time per day per os), vascular drugs (trental, 100 mg 3 times per day per os, vitamin C, 100 mg 3 times per day, milgamma, 2.0 i.m. No.10, proserin 0.05 %, 2.0 i.m. No.10). Remedial gymnastics was initiated from 3rd day.
The radiologic control examination was conducted in 4 weeks. If union was achieved, a plaster bar was removed. The patient received restorative treatment.
On the days 2-4 after removal of plaster immobilization the volume of motions in the radiocarpal joint was measured and dynamometry was conducted. The same examinations were conducted in a month after removal of plaster immobilization.
Functional capacity of the hand was conducted with DASH in 2-5 days after removal of plaster splint and in 1 month after removal of immobilization. The American Academy of Orthopedic Surgeons (USA) and Institute of Labour and Health (Canada) developed the valid English organ-specific questionnaire DASH (The Disabilities of the Arm, Shoulder and Hand) (1994). DASH estimates disability of an upper extremity from 0 (absent disability) till 100 (excessive disability).
Life quality was estimated with SF-36. All values of the questionnaire were combined in two summary measurements: the physical component of health (the scales 1-4) and the mental one (the scales 5-8).
RESULTS
The volume of flexion in the radiocarpal joint on the days 3-5 after plaster removal: the normal value – 1 (4 %), insignificant limitation – 10 (42 %), moderate limitation – 12 (50 %), significant limitation – 1 (4 %). The volume of extension in the radiocarpal joint after plaster removal on the days 3-5: the normal value – 1 (4 %), insignificant limitation – 3 (12.9 %), moderate limitation – 12 (50 %), significant limitation – 8 (33 %). The volume of radial abduction in the radiocarpal joint after plaster removal on the days 3-5: the normal value – 5 (21 %), insignificant limitation – 8 (33 %), moderate limitation – 11 (46 %), significant limitation – 0 (0 %). Ulnar abduction in the radiocarpal joint on the days 3-5 after plaster removal: the normal value – 1 (4 %), insignificant limitation – 4 (16 %), moderate limitation – 8 (33 %), significant limitation – 11 (46 %). Dynamometry of an injured extremity on the days 3-5 after plaster removal: 0 kg – 19 (79 %), 1-4 kg – 3 (13 %), 5-9 kg – 1 (4 %), 10-20 kg – 1 (4 %), > 20 kg – 0 (0 %).
The volume of flexion in the radiocarpal joint in 1 month after removal of immobilization: the normal value – 5 (29 %), insignificant limitation – 19 (71 %), moderate limitation – 0 (0 %), significant limitation – 0 (0 %). The volume of extension in the radiocarpal joint in a month after removal of immobilization: the normal value – 3 (13 %), insignificant limitation – 11 (46 %), moderate limitation – 8 (33 %), significant limitation – 0 (0 %). The volume of ulnar abduction in the radiocarpal joint in a month after removal of immobilization: the normal value – 3 (12 %), insignificant limitation – 12 (50 %), moderate limitation – 6 (25 %), significant limitation – 3 (13 %). Dynamometry of an injured extremity in a month after removal of immobilization: 0 kg – 12 (50 %), 1-4 kg – 4 (17 %), 5-9 kg – 4 (17 %), 10-20 kg – 2 (8 %).
Therefore, the days 3-5 after removal of plaster immobilization demonstrate moderate and significant limitation of ulnar abduction and extension in the radiocarpal joint and moderate limitation of flexion and radial abduction. The amount of normal values is extremely low. Dynamometry shows the absence of strength in overwhelming superiority of patients.
In a month after removal of plaster immobilization with insignificant positive time trends one can observe insignificant and moderate limitations of motions in the radiocarpal joint with insignificant limitations of radial abduction, moderate and significant limitations of ulnar abduction; half of cases is associated with insignificant limitation of ulnar abduction. The results of dynamometry showed the condition without dynamics in a half of cases.
The values of dynamometry before treatment were 0 (0; 0) kg, after – 0 (0; 5) kg; (T = 0; p = 0.007). Flexion before treatment – 30 (20; 35) degrees, after – 60 (40; 60) degrees; (T = 0; p = 0.001). Extension before treatment – 20 (15; 25) degrees, after – 35 (25; 50) degrees; (T = 0; p = 0.001). Radial abduction before treatment – 10 (5; 10) degrees, after – 15 (10; 25) degrees; (T = 0; p = 0.001). Ulnar abduction before treatment – 15 (10; 20) degrees, after – 20 (15; 30) degrees; (T = 0; p = 0.001). Therefore, the statistically significant differences were found between the values of the volume of motions before and after treatment.
The comparison of posttreatment values of dynamometry and volume of motions with the reference values found the statistically significant difference. The values of dynamometry in the group of the healthy women at the age of 60 were 28 (26; 28) kg, the values of dynamometry in the study group after treatment – 0 (0; 5) kg; (U = 23; p = 0.001). Flexion after treatment was 60 (40; 60) degrees, the reference value – 75 degrees; (U = 57.5; p = 0.001). Extension after treatment – 35 (25; 50) degrees, the reference – 65 degrees; (U = 34.5; p = 0.001). Ulnar abduction after treatment was 20 (15; 30) degrees, the reference – 40 degrees; (U = 23; p = 0.001). There were no statistically significant differences in comparison with the values of radial abduction (after treatment – 15 (10; 25) degrees, the reference – 20 degrees; (U = 218.5; p = 0.312)).It can be explained by optimal reposition of bone fragments.
The ultrasonic examination was conducted with Sonoace R-7 (Medison) with the linear transducer L5-12/50 ER in the mode of pulse wave spectral doppler (ID). The blood flow parameters in the radial and ulnar arteries were examined in the health injured extremities with use of the common points on the days 3-5 after plaster removal and in a month after immobilization removal. The qualitative (the wave of blood rate) and quantitative values (peak blood flow rate [Vps], maximal end diastolic rate of blood flow [Ved], pulsation index [Pi], time-averaged maximal blood flow rate [TANx]).
In 80 % of the cases the blood rate waveforms showed the shape which was common for vessels with low peripheral resistance. Considering the absence of difference between healthy and injured extremities it can be referred to systemic disorders of hemodynamics common for the studied age group.
The extension of systolic wave was noted in 66 % of the cases, but this difference was absent in use of the declared qualitative values. iHATLE value (it could objectify the identified phenomenon) was not used.
The recurrent examination (after the course of restorative treatment with wide systolic wave) showed the decreasing blood flow rate that testified the improvement in peripheral hemodynamics in an injured extremity.
The estimation of the qualitative and quantitative hemodynamic values of Vps, Ved, Pi and TMAx did not find any difference between the ulnar and radial arteries of the injured and healthy extremities (the table).
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Table The quantitative values of hemodynamics |
| Extremities |
3-5 days after removal of plaster |
A month after removal of plaster |
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| Vps | Ved | Ði | TAMx | Vpx | Ved | Ði | AMx | |
| A healthy extremity | 27.2 | 4.6 | 3.1 | 12 | 22 | 3.2 | 2.6 | 8.3 |
| An injured extremity | 27.2 | 4.6 | 3.1 | 13 | 22 | 3.2 | 2.6 | 8.5 |
The level of life quality was studied in the follow up groups. The level of life quality was 46.3 (35; 64.5) for fractures of type C after plaster removal, 50.8 (39.5; 69.5; p = 0.0779) (Fig. 1) for fractures of type A and B. The statistically significant differences were found in a month after plaster removal. For the type C the level of life quality was 46 (35.5; 66), for the types A and B – 57.3 (41; 71.5; p = 0.017) that can be explained by severity of a fracture (Fig. 2).
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Figure 1 Estimation of patients’ quality of life on the days 2-5 after removal of plaster
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Figure 2 Estimation of patients’ quality of life one month after removal of plaster
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Figure 3 Estimation of hand functional capacity
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The functional capacity of the hand was estimated with DASH. The questionnaire survey was conducted on the days 2-4 and in a month after plaster removal. The results are presented in the figure 3. The functional capacity of the hand is higher in type C fractures in comparison with fractures of type A and B both in 2-5 days and in a month after plaster removal.
The mean DASH was 65.9 (51.7; 72.5) for a fracture of type C, 43.9 (34; 40.8; p = 0.04) for fractures of types A and B. A month later the mean DASH was 58.4 (46.7; 64.2) for type C, 36.1 (25.1; 44.5; ð = 0.048) for types A and B. It is explained by severity of a fracture and high rate of complications in the group with type C fractures.
The examination of the complications showed that CRPS developed in 9 (37.5 %) persons, malunion – in 4 (16.6 %), median nerve neuropathy – in 5 (20.83 %).
The clinical case (Fig. 4-7)
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Figure 4 The X-ray image upon admission
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Figure 5 X-ray control after reposition
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Figure 6 X-ray control on 7th day
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Figure 7 Clinical course of regional pain syndrome
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The patient B., age of 60, a home injury. She fell on her left hand. She requested medical treatment in 24 hours after the injury. The diagnosis was: “A closed fracture of the distal radius with displacement of bone fragments. A closed fracture of the styloid process of the left ulnar bone”.
The procedures included radiological examination, anesthesia of a fracture site, closed manual single-step reposition of bone fragments, plaster immobilization, X-ray control after reposition.
Radiologic control examination was conducted after 7 days.
The patient received the treatment: vitamins of B group (B6, B12, C), vascular therapy (trental, 100 mg 3 times per day) for 7 days, spasmolytic therapy (drotaverine, 40 mg 3 times per day).
Edema increased after 3 and half weeks. Night time pain and CRPS appeared.
CONCLUSION
Conservative treatment of fractures of the distal radius in older patients causes unsatisfactory results and is accompanied by high rate of complications, functional insufficiency and decreasing life quality, particularly in type C fractures.
If closed reposition fails, a method of choice is locked angle stability plate fixation unless the contraindications exist.