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© Borgis - Postępy Nauk Medycznych 6/2013, s. 416-419
*Andrzej Boszczyk, Piotr Zakrzewski, Stanisław Pomianowski
Leczenie złamań końca dalszego kości promieniowej u osób w wieku podeszłym
Treatment of distal radial fractures in elderly patients
Department of Traumatology and Orthopaedics, The Medical Centre of Postgraduate Education, prof. Adam Gruca Hospital, Otwock
Head of Department: prof. Stanisław Pomianowski, MD, PhD
Streszczenie
Złamania dalszego końca kości promieniowej stanowią około 30% wszystkich złamań u pacjentów powyżej 50 roku życia. Pierwszorzędowym celem leczenia tych złamań jest zachowanie funkcji ręki i przedramienia. Agresywność leczenia należy dostosować do stanu i oczekiwań pacjenta. Priorytetem jest unikanie powikłań. Przy doborze metody leczenia należy brać pod uwagę niską wytrzymałość tkanki kostnej u tych pacjentów oraz łatwość, z jaką dochodzi do przemieszczeń wtórnych złamań i obluzowania zespoleń metalowych. Pacjenci w wieku podeszłym lepiej od pacjentów młodych tolerują natomiast deformacje w obrębie dalszego końca przedramienia. Podstawową metodą leczenia jest unieruchomienie w opatrunku gipsowym. Złamania wtórnie przemieszczone lub wykazujące pierwotnie cechy niestabilności wymagają leczenia operacyjnego. Stabilizacja operacyjna najczęściej ma postać przezskórnej stabilizacji drutami Kirschnera. Zastosowanie anatomicznych płyt blokowanych pozwala na uzyskanie stabilnego zespolenia nawet w kości zmienionej osteoporotycznie. W przypadkach znacznego zmiażdżenia tkanki kostnej stosuje się stabilizację zewnętrzną. Na wynik odległy wpływ ma także zachowanie ruchomości palców – należy unikać unieruchamiania stawów śródręczno-palcowych w opatrunku gipsowym i wcześnie wdrażać ćwiczenia zapobiegające przykurczom w stawach śródręczno-palcowych i stawach palców.
Summary
Fractures of distal radius make up to 30% of all fractures in patients over 50 years of age. Primary goal of treatment of these fractures is preservation of hand and forearm function. Aggressiveness of treatment regimen needs to be tailored to patients comorbidities and preferences. Avoiding complications is of utmost importance. Low mechanical strength of the bone needs to be taken into account. Secondary displacement and implant failure is not rare. Elderly patients, however, have higher tolerance to wrist deformation. Primary treatment method is closed reduction and immobilization in plaster cast. Unstable or displaced fractures require operative stabilization, most commonly with K-wires. Locked plates can provide stable fixation in osteoporotic bone. External fixation is used in the case of severe bone fragmentation. Late result depends on finger motion, therefore metacarpophalangeal joints should not be immobilized. Early range of motion exercises of metacarpophalangeal and interphalangeal joints should be instituted.
Fractures of the distal part of the radius constitute approximately 30% of all fractures in patients over 50 years of age (1). These fractures are rarely life threatening, but by leading to disability of the upper limb they may significantly influence the quality of life (2). The distal end of the radius participates in creating a complex system, which comprises the radiocarpal joint (divided into the radioscaphoid joint and the radiolunate joint) and the distal radioulnar joint (3). Together with the triangular cartilage complex, this connection ensures a broad range of movement, which is necessary for the function of the hand. In elderly persons, distal radial fractures are frequently classified as comminuted fractures. In this situation, reconstruction of the normal anatomical position is difficult, or even impossible. For this reason, the main purpose in this situation is to reconstruct the function, not the anatomical structure of the limb (4).
Purpose of the treatment
Ring and Jupiter distinguished the following treatment objectives for fractures of the distal part of the radius in elderly patients (5):
1. Maintaining function of the hand and fingers.
2. Maintaining function of the forearm.
3. Adapting the treatment method to the situation and the patient’s expectations.
4. Avoiding complications.
The authors emphasize that anatomical reconstruction of bone fragments in elderly patients is difficult to achieve, and even if it is successful, secondary displacements easily occur (6). Therefore, the main objective should be to maintain the function of the limb and to avoid treatment complications, while reconstructing anatomical structures should be the secondary objective. Such management is also justified by observation that elderly patients better tolerate deformation within the distal part of the forearm than younger patients do (4).
Overview of treatment methods
Immobilization in a plaster cast
The majority of fractures are immobilized in a plaster cast (7-9). This method is used in the case of undisplaced fractures and stable fractures after reduction. Due to the aforementioned comminuted bone tissue, the secondary displacement of bone fragments should be considered (4, 5).
Fixation with percutaneously inserted wires
Fixation with percutaneously inserted Kirschner wires is performed after obtaining closed reduction of the fracture (fig. 1). Wires measuring 1.4-1.8 mm in diameter are used, and they are maintained over the period of 6 weeks (10).
Fig. 1. Closed reduction and K-wire fixation of an unstable extra-articular fracture.
External fixation
The secondary displacement inevitably occurs after reduction if the bone tissue is severely comminuted and the bone fragments do not have suitable support. Applying an external fixation (fig. 2) protects against the occurrence of theses secondary displacements of the bone fragments, while the bone is healing (11-13).
Fig. 2. External fixation of the distal radial fracture with significantly comminuted cortical layers.
Internal fixation
Unstable fractures of the distal end of the radius may be treated with an internal fixation method (fig. 3). Anatomically modelled plates, which support the angular locking of the screws, have been available for a few years (14, 15). The plate with the locked screws is similar to a comb, which holds the bone fragments together (16). For this reason, weight bearing is transferred through the fusion, not through the cortical layers, which were comminuted as a result of the fracture. Locking the screws in the plate significantly increases fusion durability and protects it from the occurrence of secondary displacements. This method facilitates early rehabilitation of the patient, which is an advantage over other methods, which require longer immobilization (17-20).
Fig. 3. Internal fixation of an unstable intra-articular fracture.
Management during treatment
Antiedema therapy
As it was mentioned before, regardless of the selected treatment method, maintaining the function of the hand and fingers significantly influences the final outcome. Therefore, it is necessary to act in order to limit increase of limb edema – it is recommended to keep the limb elevated. The frequently used arm sling does not have any anti-edematous effect! Gravitation drainage of edematous fluid is ensured by placing the limb according to the following rule: “fingers above the elbow, and the elbow above the heart”. Such position should be necessarily used at night and, if possible, during the day.
Rehabilitation of fingers
Besides antiedema therapy, maintaining the mobility of the fingers is equally important. This objective is achieved by a few simple exercises performed from the first day following the fracture (fig. 4).
Fig. 4. Finger exercises in the metacarpophalangeal joints, the proximal interphalangeal joints and the distal interphalangeal joints (a), abduction exercises and the adduction of fingers (b), exercises of the thumb and the fingers opposition (c). (Author of the drawing – Agata Boszczyk).
Summary
The primary objective in the treatment of distal radial fractures in elderly patients is to maintain the function of the hand and the forearm. The treatment method should be adapted to the patient’s condition and expectations. It is of major importance to avoid treatment related complications.
Piśmiennictwo
1. Lippuner K, Johansson H, Kanis JA, Rizzoli R: Remaining lifetime and absolute 10-year probabilities of osteoporotic fracture in Swiss men and women. Osteoporos Int 2009; 20: 1131-1140.
2. Lichtman D, Bindra R, Boyer M et al.: American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011; 93: 775-778.
3. Komura S, Yokoi T, Nonomura H et al.: Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures. J Hand Surg Am 2012; 37: 469-476.
4. Arora R, Gabl M, Gschwentner M et al.: A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma 2009; 23: 237-242.
5. Ring D, Jupiter J: Treatment of osteoporotic distal radius fractures. Osteoporos Int 2005; 16: 80-84.
6. Arora R, Roth T, Kralinger F, Blauth M: A representative case of osteoporotic distal radius fracture. J Orthop Trauma 2008; 22: 116-120.
7. Chung KC, Shauver MJ, Birkmeyer JD: Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am 2009; 91: 1868-1873.
8. Laino DK, Tejwani N: Indications for operative fixation of distal radius fractures – a review of the evidence. Bull NYU Hosp Jt Dis 2012; 70: 35-40.
9. Liporace FA, Adams MR, Capo JT, Koval KJ: Distal radius fractures. J Orthop Trauma 2009; 23: 739-748.
10. McFadyen I, Field J, McCann P et al.: Should unstable extra- -articular distal radial fractures be treated with fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial. Injury 2011; 42: 162-166.
11. Aktekin C, Altay M, Gursoy Z et al.: Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 2010; 35: 736-742.
12. Capo JT, Swan KG Jr, Tan V: External fixation techniques for distal radius fractures. Clin Orthop Relat Res 2006 Apr; 445: 30-41.
13. Arora R, Lutz M, Hennerbichler A et al.: Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma 2007; 21: 316-322.
14. Miranda MA: Locking plate technology and its role in osteoporotic fractures. Injury 2007; 38: 35-39.
15. Rozental TD, Blazar PE: Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am 2006; 31: 359-365.
16. Perren S: Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002; 84: 1093-1110.
17. Orbay J, Fernandez D: Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am 2004; 29: 96-102.
18. Jupiter J, Marent-Huber M: Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter prospective case series. J Bone Joint Surg Am 2009; 91: 55-65.
19. Meier R, Krettek C, Probst C: Treatment of distal radius fractures: Percutaneous Kirschner-wires or palmar locking plates? Unfallchirurg 2012; 115: 598-607.
20. Hull P, Baraza N, Gohil M et al.: Volar locking plates versus K-wire fixation of dorsally displaced distal radius fractures – a functional outcome study. J Trauma 2011; 70: 125-128.
otrzymano: 2013-03-25
zaakceptowano do druku: 2013-05-08

Adres do korespondencji:
*Andrzej Boszczyk
Department of Traumatology and Orthopaedics Medical Centre of Postgraduate Education
ul. Konarskiego 13, 05-400 Otwock
tel.: +48 (22) 779-40-31
e-mail: boszczyk@gazeta.pl

Postępy Nauk Medycznych 6/2013
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