Comparative Analysis Of Colles' Fracture As Treated By
International Journal of Orthopaedics Sciences 2020; 6(2): 780-784E-ISSN: 2395-1958P-ISSN: 2706-6630IJOS 2020; 6(2): 780-784 2020 IJOSwww.orthopaper.comReceived: 01-02-2020Accepted: 03-03-2020Dr. Adarsh TAssistant professor, Departmentof Orthopaedics, JSS MedicalCollege and Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaDr. Ravishankar RenukaryaProfessor, Department ofOrthopaedics, JSS MedicalCollege and Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaDr. Purushotham SastryProfessor and HOD, Departmentof Orthopedics, JSS MedicalCollege & Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaDr. MruthyunjayaProfessor, Department ofOrthopaedics, JSS MedicalCollege and Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaDr. Mayur CJunior Resident, Department ofOrthopaedics, JSS MedicalCollege and Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaCorresponding Author:Dr. Mayur CJunior Resident, Department ofOrthopaedics, JSS MedicalCollege and Hospital, JSSAcademy of Higher Educationand Research, Mysuru,Karnataka, IndiaComparative analysis of Colles’ fracture as treated byclosed reduction and cast immobilization v/spercutaneous K wire fixationDr. Adarsh T, Dr. Ravishankar Renukarya, Dr. Purushotham Sastry,Dr. Mruthyunjaya and Dr. Mayur CDOI: tractBackground: In Colles’ fracture closed reduction and POP cast application has been the mainstay oftreatment, difficulty lies in predicting and maintaining the proper reduction due to dorsal communition offracture. Percutaneous K-wire stabilization is also a widely accepted treatment option for continuedmaintenance of reduction till fracture union. But there is no consensus on its outcome in comparison toclosed reduction and cast application.Objectives: To evaluate the results of closed reduction and cast application vs closed reduction withpercutaneous K-Wire fixation in the treatment of the distal radius extra-articular fractures.Materials and methods: The study was conducted on 60 patients from September 2017 to April 2019with extra-articular fractures of distal radius. The cases were randomly divided into two equal groups of30 patients, group A and B, the first group treated by closed reduction and below elbow cast,while thesecond group were treated by closed reduction percutaneous K-wire application. The results of bothgroups were evaluated radiologically and functionally as per our protocol.Results: At 6 months postoperatively, according to Gartland and Werley, Group A we had 13(43%)excellent results, 9(30%) good results, 7(23%) fair results and 1(3%) poor results. In group B, 11(36%)excellent results, 13(43%) good results, 5 (16%) fair results and 1(3%) poor results. Our studydemonstrates that there is no significant difference in the functional outcome obtained with closedreduction and cast versus closed reduction, K-wire fixation and cast. However, K-wire fixation plays arole in maintaining post-operative reduction and to achieve near normal anatomical union.Conclusion: Colles’ fracture treated by percutaneous K-wire fixation along with below elbow castprovided additional stability and good radiological outcome in comparison to patients treated with closedreduction and below elbow cast alone. However, closed reduction and cast application alone gives samefunctional outcome as K-wire fixation.Keywords: Extra articular, Colles’ fracture, K-wire fixation, below elbow castingIntroductionAbraham Colles of Dublin, Ireland back in 1814 was the one who first described what is nowcommonly known as Colles’ fracture, he had described it as being unique unlike otherfractures lacking the typical characteristic of crepitus and abnormal mobility. Distal radiusfracture in early days was most common in elderly population and in post menopausal ladieshowever of late the incidence has increased in younger population because of the high velocityinjuries and road traffic accidents [1, 2]In the late part of eighteenth century and early nineteenth century disability caused bymalunited distal radius fracture was considered acceptable. Patients would get acclimatised tothe residual deformity, limitation of range of movement, decreased grip strength. Howeverwith changing trends of management and better availability of newer treatment modalities andunacceptability of deformity by the patients a near normal function of wrist had to be achieved[3].Fractures involving the distal radius which is extra articular can be treated by variousmodalities like Internal fixation with plate and screws after open reduction, ligamentotaxisfollowing closed reduction of fracture, percutaneous K-wire fixation, closed reduction and 780
International Journal of Orthopaedics Scienceswww.orthopaper.complaster cast application. However latter two are mostfrequently done by orthopaedic surgeons for Colles’ fracture[3-5].We have take into consideration lot of things before decidingon the treatment modality. In those patients with lowfunctional demand, advanced age, injury of non-dominanthand, extra-articular fracture along metaphyseal region,fracture can be immobilized in plaster of Paris cast afterclosed reduction [6, 7].Pin and plaster technique wherein, the K-wire providesadditional stability after closed reduction of fracture whiletreating this fracture involving distal radius fracture. (8,9)However due to poor bone quality of bone and due to highchance of fracture losing the reduction once edema subsidesin elderly patients ,percutaneous K-wire pinning gives theadditional support which is needed to maintain the fracture indesired alignment and position [7, 10].Apart from the fracture, the dorsal communition, beyond midaxial plane of radius, the pattern of fracture, intra-articularextension of fracture, association with ulnar fracture, theamount of primary displacement of fracture which includesdorsal tilt more than 20 degrees, radial shortening more than 5mm, which are the main risk factors for causing instabilityand these complicated fractures will need more aggressivetreatment [11-13]. The variable results obtained by closedreduction methods prompted us to evaluate and to comparethe results of extra articular distal radius fracturesThe purpose of study undertaken is to determine whichamong these two methods for management of extra-articulardistal radius fracture is statistically better with respect tofunctional and radiological outcome as assessed by Gartlandand Werley demerit scoring systemthoroughly for general condition, vitals and associatedsystemic diseases. All routine hematological and radiologicalinvestigations were carried out. In our study, patients wereallocated randomly into two equal groups, one treated byclosed reduction and cast application and the second treatedby closed reduction percutaneous K-wire fixation and castapplication under brachial or local hematoma block.Fig 1: Closed reduction with B/E cast in palmar flexion and ulnardeviationObjectives Primary objective: Functional evaluation of Colles’Fracture as treated by cast immobilization vsPercutaneous K-wire fixation by Gartland and Werleydemerit scoring system with Sarmeinto et al.modification Secondary objective: To assess anatomical andradiological congruity of treated cases of Extra-articulardistal radius fractureMaterials and methodsThe prospective randomized control study was conducted on60 patients attending as out-patient or in-patient atDepartment of Orthopaedics at JSS Medical College andHospital, Mysuru from September 2017 to April 2019 whohave been found to have extra-articular fractures of distalradius and fulfil all the inclusion and exclusion criteria.All patients with radiologically confirmed extra-articularfractures of distal radius (Colles’), patients who are medicallyfit, willing for the procedure and consented to be part of thestudy, patients above the age of 18 years and patientspresenting with injuries not older than 2 weeks were includedin the study. Patients with intra-articular fractures involvingradio-carpal joint, patients with open fractures of distal radiusand with neurovascular deficit, fractures in children, patientswith previous fractures of the wrist and patients withpathological fractures were excluded from the study.After getting IEC clearance and informed written consentfrom patients, history regarding the mode of injury andseverity of trauma were noted. Sampling was done by simplerandomization of the cases done according to a computerizedrandomization protocol. All patients were examinedFig 2: Closed reduction with percutaneous K wire fixationImmediate post operative check x-rays were taken in both PAand Lateral, the reduction of fracture was confirmed and anydisplacements were noted. Patients were discharged afterthree days with routine POP instructions with active finger,elbow and shoulder exercises. All cases were followed up atthe end of 2nd, 4th and 6th weeks. After 6 weeks K-wires andcast were removed and patient was assessed clinically forfracture union, range of movements and radiologicalparameters, physiotherapy was advised. After 6 weeks,regular follow up was done at an interval of three months andsix months respectively.The data obtained from the two groups shall be analyzed byusing unpaired student’s t- test for continuous variables. Theresults will be analyzed by SPSS version 24.0ResultsOut of the 60 patients included in the study, 30 patients weredivided randomly into 2 different groups. In Group 1, patientswere treated with closed reduction and below elbow POP cast 781
International Journal of Orthopaedics Scienceswww.orthopaper.comalone and in group 2, patients were treated with closedreduction of the fracture, percutaneous K-wire fixation andbelow elbow POP cast.The mean age of the patients in the two groups combined was51.27 years. The maximum cases were seen between 51 to 60years of age in both the groups. The total number of males inthe POP cast application and in the percutaneous pinning withcast application were 10 and 19 respectively and the numberof female patients in both groups were 12 and 11 respectively.Chi square test among sex difference was 5.406 with p valueof 0.02 (statistically significant). The distribution of fractureswere classified based on Frykmann classification of distalradius fractures which was shown in table 1.assault leading to fracture in POP cast group. The sidedistribution in both groups were 14 and 18 right sidedfractures in the cast and k wiring groups respectively & 16and 12 left sided fractures in the two groups respectively.The complications were encountered in both groups, residualpain was the most common with 4 patients in the casting and5 in the k-wiring group. Stiffness of wrist was the nextcommon complication with 6 and 7 cases in both groupsrespectively. One patient in each group had reduced hand gripand one patient in casting group had sudeck’s osteodystrophyand one patient in k-wiring group had reduced grip. Theparameters analysed with radiological outcome were shown intable 2.Table 1: Fracture classification distributionTable 2: Radiological outcomeFracturetypeIIIK-wiring and %2273.3%Chi square 0.89 p 0.766Casting GroupRadiologicalparametersOut of 60 cases, self fall was the most common cause of thefractures with 23 cases in the casting group and 19 cases inthe k-wiring and cast group. Road traffic accident was thenext most common cause with 6 cases in the cast group and10 cases in the k wiring and cast group. There was 1 case ofPre-reduction X rayK-wiring andCasting ting GroupRadial height5.06(mm)Radial inclination9.16(degrees)Volar tilt2.86(degrees)Post-reduction and cast X .50.730.00016 month post-op X rayFig 3: Radiographs of colle’s fractures treated with closed reduction and B/E POP castingPre-reduction X rayPost-reduction, K wire fixation and cast X ray6 month post-op X rayFig 4: Radiographs of colle’s fractures treated with closed reduction and percutaneous K wire fixationFunctional outcome grading were done according to Gartlandand Werley demerit scoring system with Sarmientomodification (as shown in graph 1). In group treated by closedreduction and POP cast alone had 13 excellent, 9 good, 7 fairand 1 poor outcome while in group treated by closedreduction, percutaneous K-wire fixation and POP cast had 11excellent, 13 good, 5 fair and 1 poor outcome. ‘P’ valueobtained as assessed by unpaired students t-test was 0.746which is statistically insignificant with respect to functionaloutcome amongst the two groups. 782
International Journal of Orthopaedics Scienceswww.orthopaper.comGraph 1: Functional outcome with Gartland and Werley demerit scoring system with Sarmiento modificationDorsi flexionPalmar flexionSupinationPronationFig 5: Functional range of movements with closed reduction and B/E POP castingPalmar flexionDorsi flexionPronationSupinationFig 6: Functional range of movements with closed reduction and percutaneous K wire fixationDiscussionFracture of distal end of radius is most common upperextremity fracture accounting for 17.5% of all fractures inadults. Previously the incidence of the fracture was morecommon in elderly population due to poor bone qualityhowever due to high velocity injuries and road trafficaccidents the mean age group of the patients has reduced [4]. Instudy by Young et al. [10], he noted that due to increase in thelife expectancy in general, orthopedics residents have to dealwith these fractures focusing on treatment of theseosteoporotic fractures especially in woman post menopause.There have been various studies like the ones by Jupiter et al.[3], Ericson et al. [14], Porter et al. [15], Cooney et al. [5] whichhave suggested anatomical result and functional outcome aredirectly related, but most number of patients end up doingwell even though they have obvious deformity.In most of the cases anatomical congruity can be attained byclosed reduction of the fracture however problem lies inmaintaining the reduction till the fracture union. Clancy [16],Atkinson [17], Shankar [18] and Waltan [11] conducted variousstudies on heterogeneous group of people belonging todifferent age groups and different modalities of treatment.Jupiter et al. [3] in their study had given overview about theextra articular distal radius fracture treated by K-wire fixation. 783
International Journal of Orthopaedics Scienceswww.orthopaper.comClancey et al, Atkinson et al. and Rodrigues et al. further intheir studies on distal radius fracture compared between thetreatment modalities for extra articular fractures [16, 17, 19] All ofthem claimed good results however with the lack ofcontrolled trials no clear consensus could be drawn.Kurup et al. [20] studies regarding late collapse of the fractureafter removal of the K-wire after 6 weeks, result showed thatthere was late collapse after K-wire was removed after 6weeks. Stoffelen et al. [21] conducted a prospectiverandomized trial of closed reduction versus intrafocal pinningfor extra articular fracture claiming no difference in outcomebetween the two groups.In the study conducted by us, we compared two differenttreatment modalities for extra articular distal radius fractures.In both the groups, fractures was immobilized in below elbowPOP cast for 6 weeks. Jupiter et al. [3] and Sahin et al. [22] havefound that there is no significant difference in the outcome offracture while treating the fractures by above or below elbowPOP castIn our study we found that radiological parameters were betterin group treated by closed reduction and percutaneous K-wirefixation group. Our study result was comparable to studiesdone by Azzopardi et al., [6] Abhishek et al., [23] and R RBagul et al. [24]. The p value obtained by unpaired student’s ttest in all radiological parameters was found to be 0.0001which is considered statistically significant.Functional outcome analysis was done by Gartland andWerley Demerit scoring system. Azzopardi et al. [6] andWong et al. [7] used Mayo wrist scoring system and activitiesof daily living respectively. In our study we found that thefunctional outcome as per demerit score system of Gartlandand Werley obtained amongst the two groups was notstatistically significant with the student’s unpaired t testyielding a p value of 0.746.Limitations in the study were relatively small sample size,interobserver variability & error in subjective evaluation byGartland and Werley demerit scoring system, insufficient datato analyse the intra-articular extension of fracture andvariability in the type of anaesthesia used for fixation offracture in different groups might alter fracture reduction.ConclusionWe conclude that extra-articular distal radius fractures(Colles’) as treated by percutaneous K-wire fixation alongwith below elbow cast provided additional stability and goodradiological outcome in comparison to patients treated withclosed reduction and below elbow cast ferences1. Porter M, Stockley I. Fractures of distal radius:intermediate and end results in relation to radiographicparameters. Clin Orthop. 1987; 220:241-52.2. Cooney WP, Dobyns JH, Linscheid RL. Complicationsof Colles fractures fractures. J Bone Joint Surg (Am).1980; 62-A:613-19.3. Jupiter JB. Fractures of distal end of radius. J Bone JointSurg (Am). 1991; 73-A:461-9.4. Ring D, Jupiter JB. Percutaneous and limited openfixation of fractures of distal end of radius. ClinicalOrthop. 2000; 375:105-15.5. Cooney WP, Lindscheid R, Dobyns J. External pinfixation for unstable Colles fracture. J Bone Joint Surg(Br). 1979; 61-B:840-5.6. Azzopardi T, Coultan T. A prospective randomized studyof immobilization in cast versus supplementary22.23.24. 784 percutaneous pinning. J Bone Joint Surg. 2005; 87:837.Wong TC, Chiu CY. Casting versus percutaneouspinning for extra-articular fractures of distal radius in anelderly Chinese population. J Hand Surg Eur. 2010;35(3);202-8.Rayhack JM. The history and evolution of percutaneouspinning of distal radius fractures. Orthop Clin North Am.1993; 24:287-300.Simic PM, Weiland AJ. Fractures of the distal radius:changes in treatment over past two decades. J Bone JointSurg (Am). 2003; 85:552-64.Young BT, Ryan GM. Outcome following non operativetreatment of displaced distal radius fractures in lowdemand patients older than 60 years. J Hand Surg (Am).2000; 25:19-28.Walton NP, Brammar TJ. Treatment of unstable distalradius fractures by intrafocal, intramedullary K-wires.Injury. 2001; 32:383-9.Kurup HV, Madalia V. Variables affecting stability ofdistal radius fractures fixed with K-wires ; a radiologicalstudy. Eur J Orthop Surg Traumatol. 2005; 15:135-139.Egol KA, Walsh M. Distal radius fractures in operativeversus non operative treatment. J Bone Joint Surg. 2010;92:1851-7.Van Der Linden W, Ericson R. Colles fracture: howshould its displacement be measured and how should itbe immobilized. J Bone Joint Surg. 1981; 63:1285-8.Porter M, Stockley I. Fractures of distal radius:intermediate and end results in relation to radiographicparameters. Clin Orthop. 1987; 220:241-52.Clancey G. Percutaneous K-Wire fixation of collesfractures, a prospective study of thirty cases. J Bone JointSurg (Am). 1984; 66-A:1008-14.Mah ET, Atkinson RN. Percutaneous K-Wirestabilization following closed reduction of collesfractures. J hand Surg (Am). 1992; 17:55-62.Shankar NS, Craxford AD. Comminuted colles fracture:a prospective trial of management. J R Coll Surg Edin.1992; 37:199-202.Rodriguez Merchen EC. Plaster cast versus percutaneouspin fixation for comminuted fractures of distal end radiusin patients between 46 to 65 years of age. J OrthoTrauma. 1997; 11:212-17.Kurup HV, Mandalia VM, Shaju KA, Singh B,Beaumont AR. Late collapse of distal radius fracturesafter K-wire removal: is it significant? J OrthopTraumatol. 2008; 9:69-72.Stoffelen DV, BroosPL. Closed reduction versusKapandji-pinning for Extraarticular distal radiusfractures. J Hand Surg (Br).1999; 24:89-91.Shain M, Tasbas BA. The effect of long and short termcasting on stability of reduction and bone mineral densityin conservative treatment of colles fracture. Acta orthopTraumatol Truc. 2005; 38:30-4.Das AK, Sundaram N. Percutaneous pinning for noncomminuted extra articular fractures of distal radius.Indian J Orthop. 2011; 45:422-6.Sandhu HS, Singh M. Closed reduction and percutaneousK-wire fixation in Colles fracture Indian J Orthop. 1986;20:197-203.
hand, extra-articular fracture along metaphyseal region, fracture can be immobilized in plaster of Paris cast after closed reduction [6, 7]. Pin and plaster technique wherein, the K-wire provides additional stability after closed reduction of fracture while treating this fracture involving distal radius fracture.
Fig. 2: Colles’ fracture (A dinner fork deformity) X-ray of the Wrist: Your doctor orders for an X-ray of the wrist, which is a must. The X-rays help to study the fracture pattern. (Fig 3) In the fortunate ones there m
A.2 ASTM fracture toughness values 76 A.3 HDPE fracture toughness results by razor cut depth 77 A.4 PC fracture toughness results by razor cut depth 78 A.5 Fracture toughness values, with 4-point bend fixture and toughness tool. . 79 A.6 Fracture toughness values by fracture surface, .020" RC 80 A.7 Fracture toughness values by fracture surface .
Colles, William Morris, 1855-1926. Papers, 1888-1928. 2.5 linear ft (ca. 2,400 items in 6 boxes). Biography: English literary agent. Colles was the founder and managing director of The Authors' Syndicate, Ltd. Summary: Files dealing with publishers, the editing of m
Fracture Liaison/ investigation, treatment and follow-up- prevents further fracture Glasgow FLS 2000-2010 Patients with fragility fracture assessed 50,000 Hip fracture rates -7.3% England hip fracture rates 17% Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services: National Osteoporosis .
This article shows how the fracture energy of concrete, as well as other fracture parameters such as the effective length of the fracture process zone, critical crack-tip opening displacement and the fracture toughness, can be approximately predicted from the standard . Asymptotic analysis further showed that the fracture model based on the .
6.4 Fracture of zinc 166 6.5 River lines on calcite 171 6.6 Interpretation of interference patterns on fracture surfaces 175 6.6.1 Interference at blisters and wedges 176 6.6.2 Interference at fracture surfaces of polymers that have crazed 178 6.6.3 Transient fracture surface features 180 6.7 Block fracture of gallium arsenide 180
Fracture is defined as the separation of a material into pieces due to an applied stress. Based on the ability of materials to undergo plastic deformation before the fracture, two types of fracture can be observed: ductile and brittle fracture.1,2 In ductile fracture, materials have extensive plastic
Agile software development with Scrum is first introduced with its elements. Next, we use three development process lenses (communication, coordination, and control) to study how Scrum supports each of development processes, how they are related each other, and how they affect the performance of Scrum. In the following section, we analyze Scrum practices from social factor theories (social .
