|Year : 2022 | Volume
| Issue : 1 | Page : 24-30
Choosing the optimum method of treatment for extra-articular distal radius Colles' type fractures in adult: A retrospective cohort study
Soumendra Kumar Majhi1, Ashis Kumar Gupta2, Sabyasachi Das3, Ramesh Chandra Maharaj2, Debi Prasad Nanda1, Laxman Hansdah2
1 Department of Orthopedics, SCB Medical College, Cuttack, Odisha, India
2 Department of Orthopaedics, PRM Medical College, Baripada, Odisha, India
3 Department of Anesthesiology, PRM Medical College, Baripada, Odisha, India
|Date of Submission||09-Nov-2021|
|Date of Decision||05-Dec-2021|
|Date of Acceptance||06-Dec-2021|
|Date of Web Publication||15-Mar-2022|
Ramesh Chandra Maharaj
PRM Medical College, Baripada - 757 001, Odisha
Source of Support: None, Conflict of Interest: None
Context: Distal radius fractures are often encountered in orthopedic outpatient department, mostly managed with a below-elbow cast though malunion is the commonest known complication. Many researches had already been conducted comparing cast with various surgical methods; however, conclusive results yet to be ascertained. While choosing the treatment, we retrospectively analyzed the results of different methods to reach a conclusion. Subjects and Methods: A total of 92 patients with unilateral extra-articular or partially articular distal radius fracture were analyzed retrospectively over a period of 2 years, 30 of which managed conservatively and 62 with various surgical techniques (plate 27, external fixation 24, and K-wires 11). Functional results were recorded by PRWE score and radiological union was assessed. Statistical Analysis Used: Unpaired t-test was used for numerical value and Chi-square test for categorical values, and analysis of variance was used for multiple comparisons among the groups. Results: PRWE pain score, PRWE functional score, and means of individual radiological parameters measurements did not show any significant association among the study groups, P > 0.05. However, Chi-square test of association showed a significant correlation between radiology and function, P < 0.001. Conclusions: There is no difference between surgical and nonsurgical methods as a whole so as to say which one is better, thus nonsurgical methods still hold a good option today and should be the first choice while dealing with such injuries. Anatomical reduction should always be tried irrespective of methods of treatment as excellent to good function was seen with undisplaced or minimally displaced or well-reduced fractures.
Keywords: Conservative, distal radius fracture, surgery
|How to cite this article:|
Majhi SK, Gupta AK, Das S, Maharaj RC, Nanda DP, Hansdah L. Choosing the optimum method of treatment for extra-articular distal radius Colles' type fractures in adult: A retrospective cohort study. J Orthop Dis Traumatol 2022;5:24-30
|How to cite this URL:|
Majhi SK, Gupta AK, Das S, Maharaj RC, Nanda DP, Hansdah L. Choosing the optimum method of treatment for extra-articular distal radius Colles' type fractures in adult: A retrospective cohort study. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 May 24];5:24-30. Available from: https://www.jodt.org/text.asp?2022/5/1/24/339679
| Introduction|| |
Despite the advances of modern orthopedic science in the last two decades, the distal radius injury is still remained as an unsolved issue. A lot of researches had already been undertaken regarding choosing the optimum modalities of managements for distal radius injury, but still, the entity remained as an unsolved mystery. This anatomical area of our body attracts all orthopedic surgeons because it is the hand and not the brain that makes human to stand apart from the rest. And unfortunately, it is the hand which is often neglected in the emergency department, especially in case of polytrauma patients that leads to poor outcomes which could have been prevented if noticed earlier.
Fracture of distal radius contributes to approximately one-sixth (17%) of all fractures. Age-wise distribution showed three peaks, in children between 5 and 14 years of age, second in male below 50 years of age, and third peak in female over 40 years of age. Associated risk factors are decreased bone mineral density, female gender, ethnicity, heredity, and early menopause which have all been shown to be risk factors for such injuries.
For our research, we have chosen the simplest one, the extra-articular Colles' type fracture or partially articular Chauffeur's type fracture of distal radius injuries or AO type 23 A1–3 and B1. To date, below-elbow cast is the most widely used method and surgery is reserved for more complicated, intra-articular fractures. Result-wise researches have shown to have excellent to good functional outcomes with poor radiological union with conservative treatment as Colles' fracture always heals with a deformity how well it may ever be reduced., Now with the advent of surgery, most of the orthopedic surgeons favor operative management for this type of injury, as better anatomical reduction leads to better function.
We chose this study to compare functional and radiological outcomes by various surgical and nonsurgical means for such types of fractures and statistically correlate them to find out the best option among them. We took a special interest in such type of injury as only a couple of meta-analysis shown to have comparing multiple methods of treatment for extra-articular Colles' type fractures.,
| Subjects and Methods|| |
This study included 92 patients of extra-articular distal radius fractures whose treatment outcomes were studied retrospectively from December 2018 to December 2020 in a tertiary care institute of the east zone of India with ethical committee clearance. As it was a retrospective study, selection bias was excluded associated with observational study in selecting patients seeking different types of treatment for the single aliments. Patients over 18 years of age with unilateral isolated distal radius fracture of extra-articular or partial articular types (AO– 23A1, 23A2, 23A3 and 23B1) with previous history of intervention for fracture were included in the study. Bilateral or segmental fracture or associated open injury or neurovascular injury were excluded from the study. For all patients, who were already being intervened surgically or conservatively, their data were collected from admission notes, operation notes, and follow-up records, and all of them were enrolled for functional and radiological evaluation by means of personal appearances or over phone or E-mails. Out of 92 patients, 30 managed conservatively with below-elbow cast with wrist in slight flexion and ulnar deviation and 62 by various means of surgical management, 27 with plate osteosynthesis, 24 with ligamentotaxis by external fixation, and 11 managed with close manipulation and K-wire fixation with cast. During an evaluation, fracture considered united if there was no pain on palpation or attempted motion, no increase in warmth at the fracture site, no discomfort on carrying weight, and serial X-rays demonstrating bone trabeculae crossing the fracture sites. The functional and pain results were recorded according to PRWE scoring system. These pain and functional scores of this study were compared with latest researches from the literature to reach a conclusion. Radiological grade was based on measuring radial height, radial inclination in coronal plane, and volar or dorsal angulation in sagittal plane using MicroDicom software (www.microdicom.com). These radiological outcomes were correlated with PRWE functional scores taking Stewart et al. distal radial measurements as a basis for comparison.
Data collected were entered in Microsoft excel 2019. Data analysis was performed using Statistical Packages for Social Sciences (IBM SPSS Statistics for Windows, IBM corp, New York, USA) version 20. Categorical data were presented as proportions; continuous data were presented as mean and standard deviation. The strength of association between two or more categorical variables was calculated using Chi-square test and for numerical data, unpaired t-test was applied. Analysis of variance (ANOVA) test was applied to estimate the association between more than three groups of continuous variables. P < 0.05 was considered as significant with a 95% confidence interval of the estimate.
| Results|| |
There were a total of 92 patients, with an average duration of follow-up being 4.53 ± 1.19 months. Thirty patients were treated conservatively and 62 with different types of surgical methods. The average age of the patient was 46.88 ± 10.44 years, with highest in 51–60 years of age group (33.7%). Males (69.2%) were more prone than females (31.1%). Right hand (91.2%) was affected more than left (8.5%) with a 100% right-hand dominant sample of population under study. Fracture classification: AO type 23A1–3 comprised 70% and 23B1 subtype 30%. Normal anatomical variations of the distal end of radius calculated from the contralateral wrists were mentioned below [Table 1].
The average mean pain score of PRWE system was found to be 19.25 ± 8.55, out of which conservative group, external fixation, K-wire, and plate osteosynthesis group had mean scores of 21.20 ± 8.16, 15.67 ± 9.54, 19.83 ± 7.11, and 21.45 ± 8.17, respectively. Multiple comparisons between mean scores of different groups using ANOVA showed no significant association, P > 0.05 for the PRWE pain scores [Table 2].
|Table 2: Multiple comparisons of patient-rated wrist evaluation pain score in all groups|
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Overall mean functional score according to PRWE system was found to be 19.20 ± 8.22, out of which conservative group, external fixation, K-wire, and plate osteosynthesis group had mean scores of 21.47 ± 7.77, 16.19 ± 9.25, 18.92 ± 6.77, and 21.00 ± 8.25, respectively. On comparison, the means using multiple comparisons with ANOVA showed no significant difference, P > 0.05 for the PRWE functional scores among the study groups [Table 3].
|Table 3: Multiple comparisons of patient-rated wrist evaluation functional score in all groups|
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On comparison, means of different radiological parameters of different treatment groups using ANOVA showed no difference P > 0.05, but a significant correlation was found between radiology between function using Chi-square test, P < 0. 001. Thus, though there is no difference between study groups for radiological outcome, anatomical reduction is desirable for better function [Table 4] and [Table 5].
|Table 4: Comparison of means of radiological parameters among study groups using ANOVA|
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|Table 5: Chi-square test of association of radiological parameters with functional scores|
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To conclude the analysis, we compared the means of pain, function, and radiology scores of nonsurgical with surgical groups using unpaired t-test and found no association between them [Table 6].
|Table 6: Comparison of mean scores nonsurgical with surgical groups for extra-articular or partially articular distal radius fractures|
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Mean pain scores for the conservative treatment and other surgical techniques are 21.20 and 18.31, respectively. Similarly, the functional scores in the groups are 21.47 and 18.10, respectively. Radial inclination for right and left side for both the groups was 20.68, 20.85, 23.75, and 23.63, respectively. The radial length for the right and left side was 8.777, 9.23, 11.80, and 12.12, respectively. Palmar tilt for the right and left side for both the groups was found to be 8.10, 8.37, 8.78, and 8.64, respectively. No statistical difference was observed between the conservative treatment group and the surgical management group.
| Discussion|| |
Out of 92 patients, 64 (69.5%) were male and 28 (31.5%) were female with a mean age of 46.88 ± 10.44, with the most common age group affected being between 51 and 60 years (33.7%). This was similar to Kapoor et al. with male predominance, but most of the literature like Chung et al. showed females being more commonly affected with 86.7% with a mean age of 70.9 ± 8.9 years, indicating it as an elderly disease.,
From the morphometric analysis the normal anatomical variations of distal radius were found out. It showed that the mean radial inclination of distal radius as 23.6° ± 1.74°, mean radial bone length as 12.02 ± 1.06 mm and mean palmar tilt as 8.6° ± 0.97°. This is comparable with the findings of Mishra et al. and Dario et al.,
This study included mostly extra-articular distal radius fractures (AO23A 1–3), 70%, whereas partial articular type AO23B1 type was 30%, thus ruling out the articular involvement which is an important factor affecting the long-term functional outcome may be the drawback of the study.
The average PRWE pain score was 21.20 ± 8.16 and 18.37 ± 8.7 and mean PRWE functional scores were 21.47 ± 7.77 and 18.096 ± 8.20 for nonsurgical and surgical groups, respectively. Group statistics between surgical and nonsurgical using unpaired t-tests and multiple comparisons using ANOVA between individual treatment groups for means of PRWE pain score, PRWE functional score, and means of individual radiological parameters measurements did not show any significant association among the study groups, P > 0.05. However, Chi-square test of association showed a significant correlation between radiology and function, P < 0.001. Thus, this study suggested that there was no difference in terms of pain, function, and radiology among the different treatment groups following extra-articular or partially articular distal radius fracture which was also supported by the meta-analysis by Ochen et al., Song et al., and He et al.[Table 7].,,
This study showed a significant association of radiological parameters of dorsal angulations of <10°, loss of radial inclination of <9°, and loss of radial bone length of <6 mm with PRWE functional score below 50, P < 0.001, though there was no association among means of different parameters on multiple comparison with ANOVA. This was quite similar to the results of Smilovic and Bilic who pointed out a definite relationship exists between anatomical reduction and functional outcome following distal radius fractures, thus anatomical reduction is always desirable.
The limitation of this study, apart from the small sample size (n = 92) and small duration of follow-up of 4.53 ± 1.17 months, was the type of fractures. Articular involvement is a major deciding factor for long-term outcomes in distal radius fractures which was not considered in this study.
The strength of this study is no such study of this kind except for couple of meta-analysis was conducted for comparing the results of different modalities for extra-articular and partially articular fracture of distal radius and correlating them with extensive statistical analysis. As there was no difference between the different study groups in terms of functions, pain, and radiology scores following distal radius fractures, nonsurgical methods still hold a good option today and should be the first modality of choice. But as there is a significant association of radiology with function, anatomical reduction is always desirable while selecting the treatment methods and surgery should be reserved for those cases where good anatomical reduction is not achieved with nonoperative methods, as excellent or good functional results were seen only in stable, minimally comminuted and minimally displaced fracture patterns.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]