Lars Soelberg Vadstrup
Baggrund Oftest lav energi fraktur (> 90 %) Kvinder repræsenteret op til 7 gange hyppigere end mænd Incidensen hos kvinder stiger indtil 60-64 års alderen og falder først i 75-79 års alderen Incidensen hos mænd stiger indtil 50-54 års alderen og falder herefter Incidens rate hos kvinder 330/100.000 (Malmø 1953-57) Incidens rate hos mænd 50/100.000 (Malmø 1953-57) Incidence of Colles' Fracture in a North American Community, R. A. OWEN et al, AMPH June 1982, Vol. 72, No. 6
Baggrund
Incidence of Colles' Fracture in a North American Community, R. A. OWEN et al, AMPH June 1982, Vol. 72, No. 6
Befolkningsgrundlag ♂
1980
1990
2000
♀
2006
1980
1990
2000
2006
0-9 år
25575
19280
26034
26121
0-9 år
24784
18353
24566
24817
10-19 år
28481
25927
21063
25664
10-19 år
27539
25237
19963
23934
20-29 år
21477
23957
17756
13433
20-29 år
21651
22320
17335
13016
30-39 år
31686
24727
28079
25512
30-39 år
31727
25069
28754
27532
40-49 år
21321
31035
26432
29560
40-49 år
19932
31271
26758
29458
50-59 år
16259
19732
29319
26519
50-59 år
15345
19038
30081
27865
60-69 år
11312
13876
17564
23212
60-69 år
12155
14507
18041
24276
70-79 år
5980
8052
10154
11353
70-79 år
8013
10371
12326
13274
80-89 år
1874
2439
3372
4217
80-89 år
3403
4847
6290
7081
90-99 år
191
243
338
474
90-99 år
433
776
1062
1331
100-109 år
1
3
2
2
100-109 år
2
7
17
35
Data fra Danmarks Statistik, tidl. Frederiksborg Amt
Befolkningsgrundlag ♂
1980
1990
2000
♀
2006
1980
1990
2000
2006
0-9 år
25575
19280
26034
26121
0-9 år
24784
18353
24566
24817
10-19 år
28481
25927
21063
25664
10-19 år
27539
25237
19963
23934
20-29 år
21477
23957
17756
13433
20-29 år
21651
22320
17335
13016
30-39 år
31686
24727
28079
25512
30-39 år
31727
25069
28754
27532
40-49 år
21321
31035
26432
29560
40-49 år
19932
31271
26758
29458
50-59 år
16259
19732
29319
26519
50-59 år
15345
19038
30081
27865
60-69 år
11312
13876
17564
23212
60-69 år
12155
14507
18041
24276
70-79 år
5980
8052
10154
11353
70-79 år
8013
10371
12326
13274
80-89 år
1874
2439
3372
4217
80-89 år
3403
4847
6290
7081
90-99 år
191
243
338
474
90-99 år
433
776
1062
1331
100-109 år
1
3
2
2
100-109 år
2
7
17
35
Data fra Danmarks Statistik, tidl. Frederiksborg Amt
2006-2008 Data* Skadestuerne i Nordsjælland diagnosticerede i år 2008 1152 håndledsbrud (DS 52.5) 2Voksne 293 Operationer (voksne) 255 Hillerød 165 Skinner 86 K-tråde 4 Ekstern fiksation 38 Frederikssund 7 Skinner 9 K-tråde 22 Ekstern fiksation Tak til Anne Grete Kjersgaard
Behandlingsregime Frakturer vurderes efter AO klassifikationen. 23 A, B og C
Behandlingsregime - Hillerød A – Ek str a ar tik ulær e håndledsbr ud Oper ation: K-tr åde a.m. K apandji Volar vinkelstabil sk inne B og C – Par tiel intr aar tik ulær og komplette intr aar tik ulær e br ud Oper ation: Volar vinkelstabil sk inne Post oper ativ behandling • I mmobiliser ende sk inne i 2 uger • Amb kontr ol ink l. r tg. efter 2 uger, sk ift til aftagelig sk inne (w r ist laser ) • Amb kontr ol ink l. r tg. efter 5 uger, afbandager ing, evt. er go henvisning
Lars Soelberg Vadstrup og Nikolaj Winther
References
Hypothesis
The use of Palmar Locking-plate in treatment of unstable, displaced distal radial fractures (AO classification 23-A, 23-B og 23-C) is combined with a low complication rate and a minimal loss of reduction at 1 year follow up.
Lars Vadstrup and Nikolaj Winther
Treatment in 2006 • Extra articular fracture (AO 23-A): K-wire osteosynthesis a.m. Kapandji or palmar locking-plate osteosynthesis.
Partially and complete intra articular
fracture (AO 23-B og 23-C): Palmar locking-plate osteosynthesis.
Aftercare: Wrist immobilized in below elbow splint for 5 weeks X-ray after surgery and at 2 and 5 weeks Occupational therapy if needed
Lars Vadstrup and Nikolaj Winther
Main Outcome Measures Complications Hardware failure Tendon rupture Tenosynovitis Soft tissue irritation CRPS (Complex regional pain syndrome) Infection Carpal Tunnel Syndrome
Lars Vadstrup and Nikolaj Winther
Main Outcome Measures Radiographic
assesment
Ulnar variance Radial inclination Volar tilt Fracture union
Lars Vadstrup and Nikolaj Winther
Main Outcome Measures Objective functional results Grip strength Supination/Pronation strength Active range of motion
Flexion/extension Supination/Pronation
Subjective functional results Wrightington score (function of the operated hand) DASH score (function of both upper limbs)
Lars Vadstrup and Nikolaj Winther
Patients Age 18 or above Consecutive patiens treated for an
unstable, displaced distal radius fracture at Nordsjællands Hospital Hillerød in H1 2006 with a palmar locking-plate.
Lars Vadstrup and Nikolaj Winther
Database
D emogr aphy
I njur y data
Sur ger y
2 w eek s
Lars Vadstrup and Nikolaj Winther
5 w eek s
F ollow up
Database D emogr aphy
I njur y data
Sur ger y
2 w eek s
Gender Age D ominant hand
Lars Vadstrup and Nikolaj Winther
5 w eek s
F ollow up
Database D emogr aphy
I njur y data
Sur ger y
2 w eek s
D ate of injur y T r auma type F r actur ed hand
Radiogr aphi c assesment AO classificatio n
N er ve injur y Lars Vadstrup and Nikolaj Winther
5 w eek s
F ollow up
Database D emogr aphy
I njur y data
Sur ger y
2 w eek s
OP dat e Bone gr aft Radiogr aphi c assesment D ecompr es. N . M edianus
Lars Vadstrup and Nikolaj Winther
5 w eek s
F ollow up
Database D emogr aphy
I njur y data
Sur ger y
2 w eek s
5 w eek s
Radiogr aphi c assesment
Radiogr aphi c assesment
Complications
Complications
Lars Vadstrup and Nikolaj Winther
F ollow up
Database D emogr aphy
I njur y data
Sur ger y
2 w eek s
5 w eek s
F ollow up
Radiogr aphic assesment Complications
D ASH (D isabilities of the Ar m, Shoulder and H and) Wr ightington scor e
F unctional r esult s
Gr ip str ength Supination / Pr onation str ength
Str ength
F lexion/extension Supination / Pr onation
Act ive r ange of motion
Lars Vadstrup and Nikolaj Winther
Patient flow
* Follow up time 12 – 32 months
Lars Vadstrup and Nikolaj Winther
Demography
Lars Vadstrup and Nikolaj Winther
Results Loss of reduction
Loss of reduction increases up to 5 weeks
after surgery. No further loss of reduction at final review. Lars Vadstrup and Nikolaj Winther
Results Mean grip strength at follow up was 85
% (± 22%) of the uninjured side.
Lars Vadstrup and Nikolaj Winther
Results Mean pronation strength at follow up
81 % (± 15%) of the uninjured side. Mean supination strength at follow up
87 % (± 19%) of the uninjured side.
Lars Vadstrup and Nikolaj Winther
Results
Lars Vadstrup and Nikolaj Winther
Results Active Range of Motion
Lars Vadstrup and Nikolaj Winther
Results Subjective functional results: DASH score (physical function of the arm)
14 (0-34) Wrightington score (physical function of the
hand) Mean 10 (8-20)
Lars Vadstrup and Nikolaj Winther
Results Complication rate:
27% (n=12)
Non-union Infection, deep
0 0 0 7% (n=3) 16%
CRPS Tendon rupture (EPL) Hardware related
(n=7) Loosening of locking screw (n=5) f All non-symtomatic
Soft tissue irritation (n=2) f Plate removal
Carpal tunnel syndrome, secondary
(n=2) f Plate removal and decompression Lars Vadstrup and Nikolaj Winther of the median nerve.
5%
Complication, soft tissue irritation plate removed
Lars Vadstrup and Nikolaj Winther
Complication, EPL rupture
Lars Vadstrup and Nikolaj Winther
Screw loosening 5 weeks 1 year
Lars Vadstrup and Nikolaj Winther
AO 23-C3 fracture post op
Lars Vadstrup and Nikolaj Winther
AO 23-C3 fracture 5 weeks after surgery
Lars Vadstrup and Nikolaj Winther
Conclusions Minimal loss of reduction at follow up
after treatment with palmar locking plate. Good recovery of grip, pronation and supination strength at final review. High subjective functional outcome despite high complication rate.
Lars Vadstrup and Nikolaj Winther
Thank you for your attention
Lars Vadstrup and Nikolaj Winther
Plate positioning
Ref. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin. 2005; 21:347–354
Lars Vadstrup and Nikolaj Winther
Wrightington score Activity
Can use the back pocket of the trousers Personal care Can use a screwdriver Can place the hand flat to the face Can take up coins offered as change Can lift object with hand gripping Can use the hand to rise from a chair Can do usual work
Activities are graded for function 1= normal; 2 = with difficulty, 3 = aid needed, 4 = unable to complete Best score possible = 8 Worst score possible = 32 (Cannot complete any of the activities)
Lars Vadstrup and Nikolaj Winther