The Journal of Bone and Joint Surgery 79:1290-1302 (1997)
© 1997 The Journal of Bone and Joint Surgery, Inc.
Displaced Intra-Articular Fractures of the Distal Aspect of the Radius. Long-Term Results in Young Adults after Open Reduction and Internal Fixation*
LOUIS W. CATALANO III, M.D. ,
R. JEFFREY COLE, M.D. ,
RICHARD H. GELBERMAN, M.D.,
BRADLEY A. EVANOFF, M.D., M.P.H.,
LOUIS A. GILULA, M.D. and
JOSEPH BORRELLI, JR., M.D., ST. LOUIS, MISSOURI
Investigation performed at Washington University School of Medicine, St. Louis
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Abstract
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The purpose of this retrospective study was to determine the long-term functional and radiographic outcomes in a series of young adults (less than forty-five years old) in whom an acute displaced intra-articular fracture of the distal aspect of the radius had been treated with operative reduction and stabilization. Twenty-six fractures in twenty-six patients met the initial inclusion criteria for the study. Twenty-one patients returned for a physical examination, imaging (plain radiographs and computerized tomography scans), and completion of a validated musculoskeletal function assessment questionnaire at a minimum of 5.5 years. The physical examinations were performed by the same observer, who was not involved in the initial care of the patients. The plain radiographs and computerized tomography scans were assessed in a blinded fashion by two independent observers who measured the radiographic parameters with standardized methods.
At an average of 7.1 years, osteoarthrosis of the radiocarpal joint was evident on the plain radiographs and computerized tomography scans of sixteen (76 per cent) of the twenty-one wrists. A strong association was found between the development of osteoarthrosis of the radiocarpal joint and residual displacement of articular fragments at the time of osseous union (p < 0.01). However, the functional status at the time of the most recent follow-up, as determined by physical examination and on the basis of the responses on the questionnaire, did not correlate with the magnitude of the residual step and gap displacement at the time of fracture-healing. All patients had a good or excellent functional outcome irrespective of radiographic evidence of osteoarthrosis of the radiocarpal or the distal radio-ulnar joint or non-union of the ulnar styloid process. It appears prudent therefore to base the indications for salvage operative procedures on the presence of severe symptoms or a loss of function rather than on radiographic evidence of osteoarthrosis of the radiocarpal joint.
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Introduction
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A correlation has been noted between residual articular displacement of fractures of the distal aspect of the radius as measured on plain radiographs and the prevalence of post-traumatic osteoarthrosis4,11,20,28. In an effort to improve clinical outcomes after intra-articular fractures, several authors have recommended that distal radial fracture fragments be reduced operatively when articular incongruities exceed one5,29 or two2,5,12 millimeters. However, to our knowledge, no long-term follow-up study has addressed the relationship between the functional and radiographic outcomes after displaced intra-articular fractures of the distal aspect of the radius. Thus, it remains to be determined whether this clinical approach is effective in preventing degenerative osteoarthrosis and minimizing patient morbidity.
In order to evaluate the relationship between malunion of articular fracture fragments and functional outcome, post-traumatic articular changes such as narrowing of the joint space and incongruity of the articular surface were assessed on the computerized tomography scans and plain radiographs of a series of young patients who had had open reduction and internal fixation of a displaced intra-articular fracture of the distal aspect of the radius. We focused on establishing the correlation between the radiographic findings of articular step and gap deformity at the time of union and the objective (radiographic) and subjective (functional) outcomes at the long-term follow-up examination.
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Materials and Methods
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Study Design
The investigation was a retrospective study of consecutive patients at one institution who had been followed for at least five and one-half years after open reduction and internal fixation of a displaced intra-articular fracture of the distal aspect of the radius. The patients all were less than forty-five years old at the time of the operation. The study design included an evaluation of plain radiographs made at the time of union of the fracture (at seven to nine weeks) and an evaluation of plain radiographs and computerized tomography scans made at the time of the most recent evaluation. Patients were also assessed with traditional objective measurements of range of motion and strength and with a validated self-administered musculoskeletal function assessment questionnaire. This study was approved by the institutional review board of the hospital.
Patients
Fifty-two intra-articular fractures of the distal aspect of the radius in fifty-one patients who were less than forty-five years old were treated operatively in the Department of Orthopaedic Surgery at Barnes Hospital of Washington University School of Medicine between 1986 and 1990. Patients who had an isolated fracture of the dorsal or palmar articular margin involving less than 20 per cent of the joint surface, an isolated fracture of the radial styloid process distal to the scaphoid facet, or ipsilateral injuries of the hand or wrist were excluded from the study. Patients were also excluded if either the posteroanterior or the lateral perioperative radiograph was unavailable. Twenty-five patients (twenty-six fractures) were excluded from the study on the basis of these criteria. Twenty-one of the twenty-six eligible patients agreed to return for a personal interview and evaluation performed by one of us (L. W. C., III), at an average of 7.1 years (range, 5.5 to 10.9 years) after the injury. Of the five patients who did not return for follow-up, two could not be located, one had moved to a foreign country, one had been incarcerated, and one refused to participate in the study despite living in the area.
There were fourteen male and seven female patients (Table I). The average age at the time of the injury was thirty years (range, seventeen to forty-two years). At the time of the injury, eighteen patients were employed outside the home, one was a full-time student, one was a homemaker, and one was unemployed because of mild mental retardation. Of the eighteen patients who were employed outside the home, four performed managerial, professional, or business tasks; four performed clerical or technical support tasks; and ten performed manual labor. Four patients had a work-related injury. No patient was receiving Workers' Compensation benefits at the time of the injury.
The mechanism of injury was a fall for fourteen patients, a direct blow for three, a motor-vehicle accident for two, and a pedestrian-motor-vehicle accident for two. Ten patients had involvement of the dominant extremity. The injury was a Gustilo type-II open fracture8 in two patients. In fourteen patients, the injury was confined to the wrist, and the remaining seven patients had associated musculoskeletal injuries. In two wrists, associated acute compression of the median nerve was treated with early carpal tunnel release. Three of the associated musculoskeletal injuries were in the ipsilateral upper extremity: an open fracture of the olecranon that was treated with open reduction and internal fixation in two patients and a non-displaced fracture of the olecranon that was treated with immobilization in one patient. Four patients had an injury of the contralateral extremity or the axial skeleton: one had compression fractures of the second and third lumbar vertebrae, one had a joint depression fracture of the calcaneus, one had displaced fractures of the ankle and the midfoot, and one had a fracture of the contralateral thumb metacarpal (Table I).
Classification of the Fractures
All fractures were classified according to the Frykman6, Melone17, and AO/ASIF20 systems with use of posteroanterior and lateral radiographs of the wrist made at the time of the initial injury and after the reduction (Table I). There were ten Frykman type-VII and eleven Frykman type-VIII fractures. There were seven Melone type-2A, two Melone type-2B, two Melone type-3, and ten Melone type-4 fractures. According to the AO/ASIF classification, one fracture was type B2, three were type B3, two were type C1, thirteen were type C2, and two were type C3. The number of articular fragments ranged from two to six (average, four; median, five). Six wrists had at least two millimeters of depression of either the scaphoid or the lunate facet. We found the AO/ASIF system to be the most useful for classification of this series of fractures and used that methodology to describe the results of treatment at the most recent follow-up evaluation.
Operative Treatment
At the time that these patients were managed, the approach of the upper extremity service was to perform open reduction and internal fixation for at least one millimeter of residual incongruity of the articular surface after closed reduction. Eighteen patients were initially managed in the emergency department with closed reduction followed by immobilization in an above-the-elbow plaster cast. Three patients, who were referred from another hospital after the application of a plaster cast, were managed with primary open reduction for severe depression of articular fracture fragments. For the series as a whole, open reduction and internal fixation was performed at an average of 5.2 days (range, zero to sixteen days) after the injury. Fixation with a plate or screw, or both, was used when there was a cleavage-type fracture pattern with minimum comminution. A palmar approach was used in three wrists: two wrists in which a type-B3 fracture was fixed with a plate and one in which a type-B2 fracture was fixed with an isolated screw. In the remainder of the wrists, open reduction was performed through a dorsal approach. Fixation with Kirschner wire was used in eighteen wrists (one type B3, two type C1, thirteen type C2, and two type C3) that had a greater degree of comminution. In seven wrists (one type B3 and six type C2) with severe metaphyseal comminution, autogenous bone graft was used in the metaphyseal defects to support the reduced articular surface. External fixation, with or without bone-grafting, was used to improve the axial stability of six wrists (five type C2 and one type C3) that had not been stabilized adequately by fixation with Kirschner wire. The external fixation was removed at five to six weeks. All patients in the study began protected mobilization of the wrist no later than nine weeks after the initial injuries.
Beginning on the day that the cast was removed, each wrist was placed in a removable splint and the patient was taught active and active-assisted range-of-motion exercises in three planes. The home-therapy program was monitored by a trained occupational therapist at least once a week and included tissue massage and grip-strengthening.
Subjective Follow-up Evaluation
At the time of the most recent follow-up evaluation, all patients completed the Musculoskeletal Function Assessment instrument (MFA)16, which is a 100-item self-administered health status questionnaire intended to assess self-perception of physical, psychological, and social well-being among patients who have an injury of the upper or lower extremity. Studies have shown that this instrument has good reliability and good criterion and construct validity4. Specific functional domains assessed by the MFA include self-care, sleep and rest, hand and fine motor skills, mobility, housework, employment and work activities, leisure and recreational activities, family relationships, cognition and thinking, and emotional adjustment. The questionnaire provides a summary score as well as a separate score for each domain. The outcome measures used in the present study included the total score as well as the score for the hand and fine motor skills domain.
Objective Follow-up Evaluation
The physical examination of all patients was performed by one of us (L. W. C., III), who was not involved in the initial care. Areas of tenderness or deformity were noted. The range of motion of both wrists was measured in three planes (flexion-extension, radio-ulnar deviation, and pronation-supination) with a goniometer placed along the axis of rotation of the respective joints. Grip strength was assessed with use of a Jamar dynamometer (Asimow Engineering, Los Angeles, California). Lateral-key-pinch strength and three-point-pinch strength were also measured (Therapeutic Instruments, Clifton, New Jersey). For the strength measurements, the patient was seated and then asked to relax the shoulder and position the upper extremity with the elbow flexed 90 degrees, the forearm in neutral rotation, and the wrist slightly extended. The strength of the involved hand was compared with that of the uninvolved one by averaging two consecutive measurements. A third measurement was made for two patients because there was a discrepancy of more than 20 per cent between the first two measurements. For these patients, strength was calculated as the average of three measurements. The scaphoid shift test31 and the ulnocarpal impaction test28 were performed, and the stability of the distal radio-ulnar joint was assessed.
Imaging Evaluation
All imaging studies were assessed in a blinded fashion by two independent observers (L. W. C., III, and R. J. C.), and the two measurements were averaged. When measurements varied by more than 50 per cent, the two observers simultaneously re-evaluated the imaging study and a third, consensus measurement was made. Radial length18,23,30, radial inclination18,23,25,30, volar tilt18,23,30, and ulnar variance22,25 were measured on the initial and post-reduction radiographs of the wrist. These radiographs were not specifically standardized with regard to the position of the forearm and wrist. However, all of the follow-up radiographs were so standardized. Articular incongruity (step and gap displacement) was quantified with use of the arc method of measurement3 (Figs. 1, 2-A, and 2-B). Data collection forms, which were printed on transparency overlays, were completed by placing the templates directly over the radiographs or computerized tomography scans on a horizontal viewbox. Length measurements were recorded to the closest 0.1 millimeter with use of a permanent marker with a fine (0.2-millimeter) tip (Sakura Color Products, Hayward, California) and a ten-times magnifying loupe with an incorporated millimeter scale (B and H Specialties, Syracuse, New York). Angular measurements were made with a commercially available goniometer (Helix, Medford, New York). The same goniometer, series of arcs, and magnifying loupe were used for all measurements. The extent of comminution and the presence or absence of a fracture of the ulnar styloid process were also recorded on each radiograph made at the time of the initial injury.
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FIG1: Fig. 1 Illustration of the arc method of measurement of gap and step displacement. On the lateral radiograph, gap displacement is measured with use of a template to trace a circle that matches the arc of curvature of the greatest remaining articular surface of the distal aspect of the radius. Two points (A and B) are marked at the subchondral fracture margin of the two primary fragments between which displacement is to be measured. A line (Line I) is drawn through the geometric center of the circle to pass through the subchondral margin of the most displaced fragment (B). The intersection of Line I with the arc of the circle is noted as D. Step displacement is the component of displacement measured along Line I between B and D. Gap displacement is the component of displacement measured between A and C.
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FIG2-A: Figs. 2-A and 2-B: Case 15. Measurement, with the arc method, of proximal displacement of the scaphoid or lunate facet on posteroanterior radiographs of an involved and an uninvolved wrist.
Fig. 2-A: Posteroanterior radiograph of the uninvolved wrist. The radius and the center of the superimposed circle template are determined by defining a congruent relationship between the perimeter of the circle and the arc formed by the scaphoid and lunate facets of the distal aspect of the radius.
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FIG2-B: Fig. 2-B: Posteroanterior radiograph of the involved wrist with a superimposed circle template of identical radius and center as that determined on the posteroanterior radiograph of the contralateral wrist. The arrows indicate the magnitude of the articular proximal displacement along the distal aspect of the articular surface of the radius. In this wrist, the displacement involved the scaphoid facet.
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Posteroanterior, lateral, oblique, and ulnar deviation radiographs; computerized tomography scans of the involved wrist; and comparison posteroanterior and lateral radiographs of the uninvolved wrist were made for all patients at the time of the most recent evaluation. In order to maximize reproducibility of the measurements, standardized posteroanterior and lateral radiographs of the wrist were made. A true posteroanterior radiograph was made with the elbow abducted to shoulder height and flexed 90 degrees and the forearm and wrist in neutral rotation. Adequate positioning of the extremity with the forearm in neutral rotation was verified by identification of the extensor carpi ulnaris groove radial to the base of the ulnar styloid process on the posteroanterior radiograph10. A true lateral radiograph was ensured by identification of the volar margin of the pisiform lying between the palmar margins of the head of the capitate and the distal pole of the scaphoid (scaphoid-pisiform-capitate lateral)19,32. The previously noted measurements made on the initial and post-reduction radiographs were repeated with the addition of the scapholunate and capitolunate angles7,14,15 on the postoperative and most recent follow-up radiographs of the involved and uninvolved wrists. The presence or absence of non-union of the ulnar styloid process9 was documented. Residual articular incongruity (step and gap displacement) was determined on radiographs for all fractures after they had progressed to osseous union, at seven to nine weeks (which coincided with the initiation of active mobilization of the wrist). Residual articular incongruity was also determined from computerized tomography scans made at the most recent evaluation.
Computerized tomography scans were made for all twenty-one patients with a Siemens Somatome Plus scanner (Iselin, New Jersey). The upper extremity was positioned such that two-millimeter-thick continuous axial, sagittal, and coronal images were made by direct scanning24,27. Conversion factors for magnification were calculated for each computerized tomography scan with the five-centimeter scale included with each study. Correction for magnification was done automatically as these measurements were entered into the database.
At the time of the most recent evaluation, post-traumatic osteoarthrosis of the radiocarpal joint and the distal radio-ulnar joint was graded, on the basis of objective findings on the plain radiographs and the computerized tomography scans, with use of a modification of the four-grade system described by Knirk and Jupiter12 (Table II). Increased scalloping or proximal displacement of the scaphoid or lunate facet due to residual depression of the articular fracture fragments or advanced osteoarthrosis was included in this grading system (Figs. 2-A and 2-B). In addition, the minimum thickness of the remaining joint space was measured, with a ten-times magnifying loupe, within the scaphoid and lunate facets of the distal aspect of the radius on computerized tomography scans. This measurement was used to grade the osteoarthrosis (Table II).
Initial Radiographic Results
As the focus of this study was the correlation of residual radiographic abnormalities of the distal aspect of the radius with long-term functional and radiographic outcomes, data on intra-articular and extra-articular abnormalities were obtained after the fractures had progressed to osseous union. All fractures healed without the need for secondary operative procedures. One patient who had osteoarthrosis of the distal radio-ulnar joint had a Darrach resection of the distal aspect of the ulna eight years and eleven months after the injury and six months before the most recent evaluation (Table III).
Analysis of the Data
The data were analyzed with the SAS program (SAS Institute, Cary, North Carolina). Testing for significance was performed with the paired t test for paired continuous variables. Spearman rank correlations were calculated for comparisons of two-scaled variables. The level of significance was set at p < 0.05.
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Results
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Subjective Follow-up
At the time of the most recent follow-up evaluation, only one patient stated that the injury had necessitated a change of jobs. This patient (Case 14) stated that she was unable to work as a nurse and had returned to school. No disability claims were made with regard to the four work-related injuries.
Inverse correlations were observed between the health-related quality of life as measured with the MFA and the maximum step and gap displacements as measured both at the time of osseous union and on computerized tomography scans made at the most recent evaluation. Thus, the patients who reported the worst health-related quality of life and function of the hand were among those who had the least incongruity of the joint at the time of fracture-healing. The inverse correlation between the total MFA score and the maximum gap displacement at the time of fracture-healing was significant (r = -0.48, p = 0.03), and the inverse correlations between the total MFA score and the maximum step displacement and between the score for hand and fine motor skills and both the maximum step and the maximum gap displacement approached significance. The relationship between the total MFA score and the maximum step displacement on the computerized tomography scans was found to be significant (r = -0.53, p = 0.01) as was the relationship between the score for hand and fine motor skills and maximum step displacement on the scans (r = -0.63, p = 0.002). The correlation between the total MFA score and the maximum gap displacement on the computerized tomography scans approached significance, whereas we could not detect a significant correlation, with the numbers available, between the score for hand and fine motor skills and the maximum gap displacement on the scans (Table IV).
Objective Follow-up
Range of motion: The average ranges of motion and standard deviations, as measured on the involved and uninvolved sides, were 70 ± 10.9 and 79 ± 2.8 degrees, respectively, of flexion; 56 ± 13.4 and 67 ± 4.3 degrees of extension; 13 ± 2.6 and 15 ± 1.7 degrees of radial deviation; 20 ± 3.1 and 22 ± 3.2 degrees of ulnar deviation; 81 ± 7.5 and 85 ± 4.4 degrees of pronation; and 83 ± 6.6 and 86 ± 4.8 degrees of supination (Table V). All range-of-motion measurements showed a significant difference between the involved and uninvolved sides (p < 0.05 for each comparison). When the maximum step and gap displacements at the time of osseous union were correlated with the range of motion at the most recent follow-up examination, only the correlation between flexion of the wrist and the maximum gap displacement (r = -0.66, p = 0.001) was found to be significant (Table IV).
Strength assessment: The average grip strength of the involved hands was 43 ± 14.4 kilograms and that of the uninvolved hands was 49 ± 13.0 kilograms; the average lateral-key-pinch strength was 22 ± 4.4 and 24 ± 5.3 kilograms, respectively; and the average three-point-pinch strength was 21 ± 6.1 and 22 ± 6.2 kilograms (Table V). A significant difference was noted between the two sides with regard to grip strength, lateral-key-pinch strength, and three-point-pinch strength (p < 0.05 for each comparison). However, with the numbers available for study, we could not detect any significant correlations between the maximum step and gap displacements and the measures of strength at the most recent follow-up evaluation (Table IV).
Imaging Evaluation
Osseous Deformity of the Distal Aspect of the Radius
Deformity of the distal aspect of the radius was assessed by measurement of radial length, radial angle, volar tilt, and ulnar variance on plain radiographs (Table VI). Radial length improved from an average of 9.2 ± 2.0 millimeters before the reduction to an average of 11.3 ± 3.2 millimeters at the most recent follow-up evaluation. The average radial length of the contralateral wrists was 13.6 ± 2.7 millimeters. The radial angle improved from an average of 17 ± 3.5 degrees to an average of 22 ± 4.5 degrees; the average radial angle of the contralateral wrists was 25 ± 2.0 degrees. The volar tilt improved from an average of -6 ± 15.5 degrees of dorsal tilt to an average of 4 ± 12.2 degrees of volar tilt; the volar tilt of the contralateral wrists was 10 ± 5.1 degrees. Ulnar variance was an average of 0.2 ± 2.3 millimeters before the reduction and an average of 0.8 ± 2.4 millimeters at the most recent follow-up evaluation. The average ulnar variance of the contralateral wrists was -0.6 ± 2.1 millimeters. A significant difference was noted between the involved and uninvolved sides for radial length, radial angle, and ulnar variance (p < 0.05 for each comparison).
Residual Incongruity of the Radiocarpal Joint
Articular incongruity (step and gap displacement) was measured on the plain radiographs made at the time of union, which was also when active mobilization was initiated (Table III). The average maximum step displacement was 1.6 ± 1.2 millimeters, and the average maximum gap displacement was 1.5 ± 1.6 millimeters. One patient (Case 3) had had an increase in the maximum step displacement of more than two millimeters from the post-reduction period to the time of osseous union. No wrist had had an increase of more than two millimeters in the maximum gap displacement. The step and gap displacements were also measured on the most recent plain radiographs and computerized tomography scans. On the most recent radiographs, the average maximum step displacement was 1.2 ± 1.1 millimeters and the average maximum gap displacement was 0.2 ± 0.8 millimeter. On the computerized tomography scans, the average maximum step displacement was 2.2 ± 1.5 millimeters and the average maximum gap displacement was 3.4 ± 3.8 millimeters.
Osteoarthrosis of the Radiocarpal Joint
At the time of the most recent follow-up evaluation, post-traumatic osteoarthrosis of the radiocarpal joint was assessed on the plain radiographs and the computerized tomography scans with use of a modification of the four-grade system of Knirk and Jupiter12 (Table II). According to this system, on the plain radiographs five wrists had no osteoarthrosis (grade 0), ten had grade-I osteoarthrosis, and six had grade-II (Table VII). On the computerized tomography scans five wrists had no osteoarthrosis (grade 0), five had grade-I, and eleven had grade-II (Table VII). The minimum thickness of the remaining joint space within the scaphoid and lunate facets was measured on the computerized tomography scans (Fig. 3) to assess the grade of osteoarthrosis (Table II). Six wrists had no osteoarthrosis (grade 0), five had grade-I, nine had grade-II, and one had grade-III (Table VII).
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FIG3: Fig. 3 Coronal computerized tomography scan of the involved wrist shown in Fig. 2-B. The measured joint space (small arrows) between the scaphoid (S) and the distal aspect of the radius (R) is less than one millimeter. The large arrow shows the deepening of the scaphoid facet seen in Fig. 2-B. There are subchondral radiolucent defects in the distal aspect of the radius. L = lunate and U = ulna.
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The correlations between the maximum step and gap displacements at the time of union and at the time of the most recent follow-up and osteoarthrosis of the radiocarpal joint (as determined on the plain radiographs and computerized tomography scans) as well as the minimum remaining joint space at the most recent follow-up evaluation were examined (Table IV). Strong and significant correlations were seen between the maximum step displacement and evidence of osteoarthrosis of the radiocarpal joint on plain radiographs (r = 0.74; p < 0.001) and computerized tomography scans (r = 0.75; p < 0.001); greater displacements predicted higher grades of osteoarthrosis. Strong correlations were also noted between the maximum gap displacement and osteoarthrosis of the radiocarpal joint on plain radiographs (r = 0.70; p < 0.001) and computerized tomography scans (r = 0.71; p < 0.001)10. Moreover, strong and significant inverse correlations were noted between the minimum remaining joint space in the lunate and scaphoid facets as measured on the computerized tomography scans and the maximum step displacement (r = -0.75; p < 0.001) and the maximum gap displacement (r = -0.66; p = 0.001) at the time of osseous union; larger displacements at the time of osseous union predicted a smaller radiocarpal joint space at the most recent follow-up evaluation.
Osteoarthrosis of the Distal Radio-Ulnar Joint and Non-Union of the Ulnar Styloid Process
The same criteria were used to grade osteoarthrosis of the distal radio-ulnar joint as were used for osteoarthrosis of the radiocarpal joint (Table II). With use of this grading system on the plain radiographs, twelve wrists had no osteoarthrosis of the distal radio-ulnar joint (grade 0), five had grade-I osteoarthrosis, three had grade-II (Fig. 4-A), and one had grade-III (Table VIII). On the computerized tomography scans, eleven wrists had no osteoarthrosis (grade 0), four had grade-I, four had grade-II (Fig. 4-B), and one had grade-III. One patient who had osteoarthrosis of the distal radio-ulnar joint had a Darrach resection of the distal aspect of the ulna eight years and eleven months after the injury and six months before the most recent evaluation. A comparison of the wrists with grade-0 or I osteoarthrosis of the distal radio-ulnar joint with those with grade-II or III osteoarthrosis did not reveal a significant difference between either the total MFA scores (r = -0.24 and p = 0.29 for the plain radiographs; r = -0.28 and p = 0.23 for the computerized tomography scans) or the MFA scores for hand and fine motor skills (r = -0.20 and p = 0.38; r = -0.12 and p = 0.61, respectively). No wrist had evidence of chronic subluxation or dislocation of the distal radio-ulnar joint on the computerized tomography scans. The original fracture pattern in eleven patients included a fracture of the ulnar styloid (Table VIII). Non-union was noted in seven of these wrists at the most recent follow-up. With the numbers available, no significant difference was detected, with regard to the total MFA score (r = -0.40; p = 0.17) or the score for hand and fine motor skills (r = -0.33; p = 0.15), when wrists with evidence of non-union of the ulnar styloid process on plain radiographs were compared with those without evidence of non-union.
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FIG4-A: Figs. 4-A and 4-B: Case 8, a twenty-one-year-old man who sustained an AO/ASIF type-C3 fracture20 in a fall.
Fig. 4-A: Posteroanterior radiograph demonstrating narrowing of the distal radio-ulnar joint space and the formation of osteophytes (large arrow). Non-union of the ulnar styloid (small arrow) is also evident.
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FIG4-B: Fig. 4-B Axial computerized tomography scan demonstrating large ulnar osteophytes (large arrow) and multiple subchondral radiolucent defects in the distal aspect of the radius (R) (small arrows). U = ulna.
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Carpal Instability
The average scapholunate angle of the involved wrists was 48 ± 7.0 degrees compared with 53 ± 7.6 degrees for the uninvolved wrists; this difference was significant (p < 0.05). The average capitolunate angle of the involved wrists was 15 ± 9.4 compared with 15 ± 6.4 degrees for the uninvolved wrists (Table VI).
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Discussion
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There is a well established correlation between the development of post-traumatic osteoarthrosis of the radiocarpal joint and residual displacement of articular fragments, as measured on plain radiographs, after intra-articular fractures of the distal aspect of the radius2,5,12,29. However, long-term patient-centered functional outcomes have not been well documented after this injury. By a minimum of 5.5 years (average, 7.1 years) after the injury, sixteen (76 per cent) of the twenty-one wrists in the present series had evidence of osteoarthrosis of the radiocarpal joint on plain radiographs and computerized tomography scans. These results are consistent with those of previous studies in which the prevalence of early osteoarthrosis of the radiocarpal joint on plain radiographs was as high as 92 per cent (twenty-two of twenty-four wrists) after intra-articular fractures of the distal aspect of the radius that healed with more than two millimeters of residual articular incongruity12.
Recent efforts to standardize techniques for measuring displacement of the articular surface of the distal aspect of the radius have revealed poor interobserver agreement among measurements of step and gap displacement on plain radiographs of healed fractures13. Excellent interobserver agreement has been reported, however, for the same measurements made on computerized tomography scans3. In our study, the use of computerized tomography scanning allowed precise evaluation of malunion of articular fracture fragments, quantification of the degree of incongruity of the articular surface, and grading of post-traumatic osteoarthrosis. To our knowledge, computerized tomography scanning has not been used to evaluate the relationship between fracture deformity and long-term functional outcomes. In our series, radiographic evaluation showed highly significant correlations between the extent of the step and gap displacements at the time of osseous union and the development of osteoarthrosis of the radiocarpal joint.
The significant increase between the ulnar variance that was noted on the initial radiographs and that seen on the most recent radiographs was small (average, 0.6 millimeter) and was probably not important from a clinical perspective. This change may have resulted from the fact that the initial radiographs were not made with a standardized technique whereas those made at the most recent follow-up were standardized. Palmer et al. demonstrated a difference in ulnar variance of as much as 0.88 millimeter between radiographs of the same wrist on the basis of the position of the elbow and forearm at the time of imaging22. Alternatively, it is possible that the increase in ulnar variance was due to settling at the site of the fracture. The observation that only one wrist (Case 3) had an increase of more than two millimeters in maximum step displacement (Table III) supports the concept that these fractures were stable after fixation.
Over-all, the functional outcomes in this study were good or excellent, even in the patients who had radiographic evidence of osteoarthrosis of the radiocarpal or distal radio-ulnar joint, or both, or non-union of the ulnar styloid process. Although there were significant differences in strength and range of motion between the involved and uninvolved wrists, only flexion of the wrist was correlated with the magnitude of residual osseous displacement seen radiographically (Table IV). While a significant difference in the scapholunate angle was noted between the involved and uninvolved wrists, the absolute values for both groups were within normal reported ranges (Table VI). Only one patient had to change jobs as a result of the injury, and fourteen patients had the maximum possible functional score in the hand and fine motor skills domain of the MFA. Surprisingly, the results from the MFA showed the greatest self-reported impairments in function among the patients who had the smallest residual displacements.
There are a number of plausible explanations for these results. The limited number of patients in this study may have obscured real trends and may have reduced our ability to discern significant differences between groups. Longer follow-up may demonstrate deterioration in function with the development of osteoarthrosis in the wrists with greater magnitudes of residual articular incongruity. The radiographic measurement of step and gap displacements may be imprecise because of non-standardized radiographic techniques (such as varied position of the forearm or the wrist), overlying radiopaque implants, soft-tissue shadows, or the complex structure of the distal aspects of the radius and ulna. Also, fourteen patients had a perfect score in the hand and fine motor skills domain, and this may have created a so-called ceiling effect1, making the results from the MFA unrepresentative of the health status across the entire patient population. Although the most recent evaluation, for the collection of subjective, objective, and radiographic data, was prospective, the patient-based information for this study was obtained retrospectively. In addition, the patients had a variety of fracture patterns, which were treated with a number of different methods of fixation. However, all of the fractures were caused by a high-energy injury with a minimum of one millimeter of displacement, and stable fixation was attained in all patients. With one exception (Case 3), there were no substantial changes in the position of the fracture fragments, and there was osseous union of all fractures after the initial operation (Table III). Union was achieved within a narrow range of time (seven to nine weeks), and rehabilitation was initiated at that point for all patients. Moreover, as the focus of this study was a correlation of articular abnormalities of the healed radius with functional outcome, the precise method of operative fixation was not examined. Finally, while three patients had associated fractures of the ipsilateral extremity, none had symptoms referable to those injuries at the most recent evaluation, and there was no correlation between the associated injuries and the outcome in any of the patients.
We believe that the minimum duration of follow-up in this study is the longest reported for a series of wrists treated with open reduction for a displaced intra-articular fracture of the distal aspect of the radius. Assessment of the plain radiographs at the time of osseous union revealed residual articular incongruity (step or gap displacement, or both) of at least one millimeter in sixteen of the twenty-one wrists. The results demonstrate a strong correlation between residual articular incongruity and the development of post-traumatic osteoarthrosis at a minimum of 5.5 years (average, 7.1 years). However, no patient had a poor functional outcome according to the MFA at the most recent follow-up evaluation. It is unclear whether longer follow-up will reveal a correlation between residual articular incongruity at the time of fracture-healing and functional outcome or whether the natural history of fractures treated with open reduction is not as poor as earlier radiographic outcome studies had suggested4,11,20,28.
On the basis of these results, we recommend, as have others3,11,21,24,26, that computerized tomography scans be made before reduction to assess displacement of intra-articular fractures of the distal aspect of the radius when the fracture pattern, the extent of comminution, or the magnitude and direction of the displacement of the fracture fragments cannot be determined with certainty on plain radiographs. Also, we advocate that the goal of treatment be anatomical restoration of the articular surface of the distal aspect of the radius in order to minimize the risk of osteoarthrosis of the radiocarpal joint. However, the longer-term functional outcome data from this study revealed surprisingly high levels of function at an average of 7.1 years, even in the presence of early radiographic evidence of deterioration of the joint. Thus, we believe that it is appropriate to base the decision regarding the performance of salvage operative procedures on the presence of important symptoms or on disabling loss of function rather than on radiographic evidence of osteoarthrosis of the radiocarpal joint.
NOTE: The authors thank Robert Bane, M.D., and Lawrence Catalano for their assistance in the collection of data for this study.
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Footnotes
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*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Department of Orthopaedic Surgery (L. W. C., III; R. H. G.; and J. B., Jr.), Division of General Medical Sciences, Department of Medicine (B. A. E.), and the Mallinckrodt Institute of Radiology (L. A. G.), Washington University School of Medicine, One Barnes Hospital Plaza, Suite 11300, St. Louis, Missouri 63110.
The Orthopaedic Clinic, 1068 Cresthaven Road, Suite 400, Memphis, Tennessee 38119.
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Abstract
Introduction