Research Projects

Symposiums

Written by Amy Hoang-Kim
Tuesday, 08 November 2005

Internal Fixation — The New Gold Standard?

Management of Osteoporotic Wrist Fractures
AAOS Annual Meeting 26 March 2006

Amy L. Ladd MD
Professor of Orthopaedics, Stanford University
Robert A. Chase Hand & Upper Limb Center
alad@stanford.edu

Learning Objectives

1. Identify Major Contributions to Our Past and Current Trends in Wrist Fracture Treatment
2. Identify Pros and Cons of Various Treatment Methodologies
3. Understand Characteristics of Osteoporotic Fractures Which Complicate Treatment

1) Major Contributions in Understanding Wrist Fractures:
Description and Treatment
Historical

• Claude Pouteau 1783 (1)
• Abraham Colles 1814 (see Appendix; 2)
• Jean-Gaspar-Blaise Goyrand 1832 (3)
• John Rhea Barton 1838 (4)
• Robert Smith 1847 (5)
• Frederic Cotton 1900 (6)
• Ricardo Galeazzi 1934 (7)
• Modern Era: Treatment
• Sir John Charnley’s Closed Management book (8)
• John C. Hughston 1957 (9)
• Pins and Plaster (?)
• Roger Anderson (10)
• John Agee: ligamentotaxis 1993 (11)
• Modern Era: Classifications
• Anatomy: Older 1965 (12), Frykman 1967 (13), AO 1987 (14), Mayo 1992 (15), Melone 1984 (16)
• Severity: Lafontaine 1989 (17)
• Mechanism: McMurtry1992 (18), Fernandez/Jupiter 1996 (19)
• Treatment: Rikli 1996 (20), Medoff 1999 (21)
• Modern Era: Improved Technology in Internal Fixation
• Low Profile Dorsal Plates
• Forte - Carter (22), Pi Plate - Hastings/Jupiter (23)
• Fragment Specific Approach – Medoff (20)
• Volar Fixed Angle Plates
• Tine Plates – Putnam (24)
• Fixed Distal Pegs – Orbay (25)
• Fixed with Variability (Everybody)
• Modern Era: Improved Adjunctive Treatment
• PMMA: Charnley (26)
• Calcium Phosphate Cements & Materials - Norian SRS, ß-TCP, etc (27)
• Calcium Sulfate - temporary void filler (?)
• Modern Era: Corrective Osteotomy – Fernandez (28)
• Modern Era: Treatment Outcomes
• Disabilities of Arm, Shoulder, & Hand - DASH (29)
• SF-36, SF-12 (30, 31)
• The Physical Activity Scale for the Elderly PASE (32)

  

Pros and Cons of Internal Fixation vs. More "Traditional" Means (33)

PROS

• Anatomic Reduction Roughly Parallels Restoration of Function
  • "Form Ever Follows Function" (Louis Henri Sullivan, architect)
  • Restoration of Function: Address Defects of Bone
    • Cancellous
    • Cortical
  • Early Fixation Provides Early Stability and Early Functional Return (everybody with a plate in past 10 years)
• Patients Demand Early Rehabilitation
• Aging Population is More Active
• Potentially Cost-Effective (but not borne by health carriers, only to patient thus far)

CONS

• The (Mis) Interpretation of Colles: “They All Do Well”
• Better External Fixators Today
  • Agee Wrist Jack
  • Non-bridging – McQueen (34)
  • No uniformity to suggest internal fixation is superior – Cochrane Database (35, 36)
  • Functional Outcome Acceptable with Ex Fix (37)
• Complications
  • Osteoporosis Confounds Treatment & Complications with Internal Fixation
• Equipment and Operative Costs borne by health carriers and patient

The Downside (Cons) of Specific Internal Fixation Systems:

• Dorsal Plating
  • Wrist Stiffness
  • Tendon Irritation (36)
  • Wound, Hardware Complications
• Fragment Specific
  • Technically Demanding
  • Difficult with Osteoporosis
• Volar Plating
  • System Specific
    • Fiddle Factor
    • Hardware Fixation
    • Self-tapping Screws

3) Understand Characteristics of Osteoporotic Fractures Which Confound Treatment

"The silent crippler, as osteoporosis is often called, sneaks up on its victims and, without any pain, gradually causes bones to become more porous and fragile. Then one day you grab your coat and your wrist snaps; or a friend hugs you and cracks your rib; or you step off a curb and break your hip." (http://www.thehealthpages.com/articles/ar-osteo.html)

Clinical Problems of Osteoporotic Wrist Fractures

• Healing - rare
• Maintaining reduction
• Restoring function

Typical Osteoporotic Fracture = Colles’ Fracture (2)

• "True" Colles
  • Extra-articular
  • Fails in Tension (Bending)
  • Low Energy
• Stable if—
  • Dorsal Periosteum Intact
  • Comminution minimal
• Unstable if—
  • Displaced Intra-articular
  • Comminution high
  • Bone quality is low

Atypical Fracture

• High Energy
• Different Fracture Pattern
• Shear, Shaft, Carpal Involvement
• All the Problems of Young Adult Fractures and More!

  

Complications

"There is no problem so bad that cannot be made worse with surgery"
--Jack Hughston, the "father" of sports medicine

• Predisposing Factors
  • Failure to Recognize Problem
    • Reduce (adequately)
    • Provide stability
    • Hardware sufficient/appropriate
    • Address fragments
    • Loss of Reduction
    • Address cortical and cancellous bone
• Problems
  • Malunion
    • Clinical complaints
    • distal ulna
    • lack of supination

• Hardware problems
• Pins backing out
• Screws loosening
• Self-tapping screws

Other typical problems

• CTS, Stiffness, CRPS (RSD), Wound Healing
  • Treatment Options
    • Address ulna (leveling, Sauve-Kapandji, resection)
    • Osteotomy
      • Closing vs. Opening Wedge
• Graft vs. substitute
• Fusion
• (Wish you had never operated!)

  Treatment Decisions

• Patient factors
• Define Injury
• Fracture Fragments
• Associated Injuries
• Assess Stability

Conclusions: Is Internal Fixation The New Currency of Treatment?

• The Gold Standard is a Quasi-Standard
• Historical monetary international standard, “modified gold bullion standard” until 1978
• Now gold is a commodity, not a basis of currency (fluctuates with the market)
• Internal Fixation: Enhanced Distal Radius Fracture
• Treatment
• Recognition
• A Methodology, not an Absolute
• So Don't Throw Out the . . .
• Plaster
• External Fixator
• Rush Rods
• History Articles & Charnley’s Book

  

References

1. Pouteau C. Memoire, contenant quelques reflexions sur quelques fractures de l'avant-bras sur les luxations incomplette du poignet sur les diastasis. In: Oeuvres Posthumes de M Pouteau. Paris: Ph.-D. Pierres, 1783
2. Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med Surg J. 1814;10:181-6.
3. Goyrand G: Memoire sur les fractures de l'extrémité inférieure du radius qui simulent les luxations du poignet. Gaz Med 3:664-667, 1832
4. Barton, John Rhea: Views and treatment of an important injury of the wrist. Medical Examiner 1:365-368, 1838
5. Smith, Robert W: A treatise on Fractures in the Vicinity of Joints, and on Certain Forms of Accidental and Congenital Dislocations. Dublin: Hodges and Smith, 1847, p. 162
6. Cotton, Frederic J: The Pathology of Fracture of the Lower Extremity of the Radius. Annals of Surgery, 32:194-218, 1900
7. Galeazzi, Ricardo: Concerning a particular syndrome of injury of the forearm bones. Arch orthop Unfallchir, 35:557-562, 1934 (translated by D. Pevsner)
8. Charnley, John: The Closed Treatment of Common Fractures. 3rd ed. Edinburgh: Churchill Livingstone, 1950, 1961
9. Hughston JC: Fracture of the distal radius shaft. Mistakes in management. J Bone Joint Surg 1957; 39A: 249-264.
10. Grana WA, Kopta JA. The Roger Anderson device in the treatment of fractures of the distal end of the radius.. J Bone Joint Surg Am. 1979 Dec;61(8):1234-8
11. Agee, John M. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 9:577-85, 1993
12. Older, TM, EV Stabler, WH Cassebaum: Colles' fracture: Evaluation and selection of therapy. J Trauma 5:469-476, 1965
13. Frykman, Gösta: Fracture of the distal radius including sequelaeÑshoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of function. Acta Orthop Scand (suppl) 1-155, 1967
14. Fernandez, Diego L: Avant-bras segment distal. In: Classification AO des Fracture des Os Longs, ME Müller, ed. Berlin: Springer-Verlag,, 106-115, 1987
15. Missakian M, WP Cooney, PC Amadio, HL Glidewell: Open reduction and internal fixation for distal radius fractures. J Hand Surgery 17A:745-755, 1992
16. Melone Charles P Jr: Articular fractures of the distal radius. Orthopedic Clinics of North America 15:217-236,1984
17. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989 Jul;20(4):208-10.
18. McMurtry R, J Jupiter: Fractures of the distal radius. In B Browner, J Jupiter, A Levine, P Trafton: Skeletal Trauma. Philadelphia: WB Saunders, 1993
19. Fernandez, Diego L, and Jesse B Jupiter: Fractures of the Distal Radius. A Practical Approach to Management. New York: Springer, 1996
20. Rikli DA, Regazzoni P.: Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br. 1996 Jul;78(4):588-92
21. Medoff RJ, Kopylov, P. Open reduction and immediate motion of intra-articular distal radius fractures with a fragment specific fixation system. Arch Am Acad Orthop Surg 2: 53-61, 1999
22. Carter PR, HA Frederick, GF Laseter: Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surgery, 23A:300-307, 1998
23. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H II: Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 22A:777-84, 1997
24. Gesensway D, Putnam MD, Mente PL, Lewis JL.Design and biomechanics of a plate for the distal radius.J Hand Surg [Am]. 1995 Nov;20(6):1021-7.
25. Orbay JL.The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000 Dec;5(2):103-12.
26. Charnley J: The healing of human fractures in contact with self-curing acrylic cement. Clin Orthop 1966; 47:157-63
27. Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, Husband J, Ladd A, Seitz WR, Constanz B. Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am. 2003 Nov;85-A(11):2127-37.
28. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius.. J Bone Joint Surg Am. 1988 Dec;70(10):1538-51.
29. Hudak PL, PC Amadio, C Bombardier: Recent developments and future issues in the use of health status assessment measures in clinical settings. Med Care 30:MS23-MS41, 1992
30. Ware JE Jr, CD Sherbourne: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473-483, 1992
31. Ware JE Jr, M Kosinski, SD Keller: A 12 item short-form health survey, construction of scales and preliminary tests of reliability and validity. Med Care 34::220-233, 1996
32. Washburn RA, et al: The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol. 1993 Feb;46(2):153-62
33. Ladd AL, ed: Fractures of the Distal Radius: A Visual Approach. CD-ROM, American Society for Surgery of the Hand, 2001.
34. McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus non-bridging external fixation. J Bone Joint Surg Br. 1998 Jul;80(4):665-9.
35. Handoll HH, Madhok R: Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2001;(3):CD003209.
36. Handoll HH, Madhok R, Howe TE.Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev. 2002;(2):CD003324.
37. Hegeman JH, Oskam J, Vierhout PA, Ten Duis HJ. External fixation for unstable intra-articular distal radial fractures in women older than 55 years. Acceptable functional end results in the majority of the patients despite significant secondary displacement. Injury. 2005 Feb;36(2):339-44.
38. Kambouroglou GK, TS Axelrod: Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: a brief report. J Hand Surgery 23:737-741, 1998

From JBJS online Commentary (reprinted with permission):
http://www.jbjs.org/Comments/2003/cp_nov03_ladd.shtml

Commentary & Perspective on "Norian SRS Cement Compared with Conventional Fixation in Distal Radial Fractures: A Randomized Study" by Charles Cassidy, MD, et al.

Amy L. Ladd, MD*, Stanford Hand and Upper Limb Center, Stanford University School of Medicine, Palo Alto, California

In Praise of Abraham Colles

Until recently, teaching ascribed to Abraham Colles has supported substantial advances in operative treatment of other periarticular fractures. This conservative philosophy, however, was not truly espoused by Colles. Indeed, his classic article of 1814 (see article at end of this commentary) devotes attention to enumerating the importance of an appropriate reduction and early intervention, which, if not performed, will create a "doomed" and miserable patient. He offers the consolation that, if not reduced, "the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain; the deformity, however, will remain undiminished throughout life." This phrase, perhaps one of the most oft-quoted lines in all of orthopaedic literature1, supports the tradition of nonintervention when taken out of context from his preceding admonitions. Colles described a fracture that was most likely extra-articular, sustained primarily by women who probably had too many children and not enough sunlight. Vehicular trauma (horse and carriage) was less common than simple falls in pre-industrial Europe, and although Roentgen did not discover x-rays for another eighty-one years, it is safe to assume the fracture described by Colles was a low-energy injury. But with our current modes of high-speed transportation and with the higher activity level of our older patients, we now see a more heterogeneous injury pattern. Yet, the eponym "Colles fracture" persists: a simple internet PubMed search ("www.Pubmed.org") using keywords "Colles" and "fracture" occurring in the title or abstract produced more than forty articles within the past ten years alone. Only a handful of these articles focus on low-energy injuries, underscoring how traditional nomenclature is inadequate for current definitions.

In the last decade, the conservative management philosophy for this fracture has eroded in the face of outcome studies, epidemiologic shifts, and new treatment options. The material presented in the article by Cassidy and coauthors is a multicenter trial monitored by the United States Food and Drug Administration (FDA) that incorporated outcomes analyses and large-scale randomization. This type of study is expensive and made possible only with substantial funding. This study, which had corporate sponsorship, should serve as a model for future evaluations of osteobiologic materials that required FDA monitoring and regulation. A new device requires pre-market approval (PMA), as in the case of Norian SRS, or if a competitive product is introduced, it must undergo an approval known as the 510(k) process, in which a product must show substantial equivalence to an existing marketed device, known as the predicate device. In the future, new biologic materials will undergo an evaluation process that is more like the one in place for pharmaceuticals than the one for devices, which will make the process even more rigorous.

The industry of osteobiologic materials is burgeoning, and the competition is intense. In the last decade, we saw new surgical techniques that improve surgical options for many complex fractures. Calcium phosphate cement in this study provided early stability in patients with classic low-energy fractures, who demonstrated earlier rehabilitation and therefore more independence in the post-injury period. New materials currently in development may provide even earlier healing.

The World Health Organization has deemed this the Bone and Joint Decade. One of its goals is to emphasize the education and involvement of the patient in decision-making. Sir Abraham Colles had neither radiographs nor anesthesia at his disposal, nor the many other tools available to us, but he was indeed a pioneer of early intervention. He would have applauded fracture management which minimizes the "mistakes" causing "considerable lameness and stiffness" endured by the patient for "many months." Our patients increasingly desire early rehabilitation and functional restoration, and they will likely be the biggest force driving these exciting options for treatment in the future.

*The author did not receive grants or outside funding in support of their research or preparation of this work. The author received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Norian Corporation). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

1. Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med Surg J. 1814;10:181-6.

Copyright © 2003 by the The Journal of Bone and Joint Surgery, Inc. Reprinted with permission

On the Fracture of the Carpal Extremity of the Radius. Edinburgh Med Surg J. 1814;10:181-6.

By Abraham Colles (1773-1843)

The injury to which I wish to direct the attention of surgeons, has not, as far as I know, been described by any author. Indeed, the form of the carpal extremity of the radius would rather incline us to question its being liable to fracture. The absence of crepitus, and of the other common symptoms of fracture, together with the swelling which instantly arises in this, as in other injuries of the wrist, render the difficulty of ascertaining the real nature of the case very considerable.

This fracture takes place at about an inch and a half above the carpal extremity of the radius, and exhibits the following appearances.

The posterior surface of the limb presents a considerable deformity; for a depression is seen in the fore-arm, about an inch and a half above the end of this bone, while a considerable swelling occupies the wrist and metacarpus. Indeed, the carpus and base of metacarpus appear to be thrown backward so much, as on first view to excite a suspicion that the carpus has been dislocated forward.

On viewing the anterior surface of the limb, we observe a considerable fulness, as if caused by the flexor tendons being thrown forwards. This fulness extends upwards to about one-third of the length of the fore-arm, and terminates below at the upper edge of the annular ligament of the wrist. The extremity of the ulna is seen projecting towards the palm and inner edge of the limb; the degree, however, in which this projection takes place, is different in different instances.

If the surgeon proceeds to investigate the nature of this injury, he will find that the end of the ulna admits of being readily moved backwards and forwards.

On the posterior surface, he will discover, by the touch, that the swelling on the wrist and metacarpus is not caused entirely by an effusion among the softer parts; he will perceive that the ends of the metacarpal, and second row of carpal bones, form no small part of it. This, strengthening the suspicion which the first view of the case had excited, leads him to examine, in a more particular manner, the anterior part of the joint; but the want of that solid resistance, which a dislocation of the carpus forward must occasion, forces him to abandon this notion, and leaves him in a state of perplexing uncertainty as to the real nature of the injury. He will therefore endeavor to gain some information, by examining the bones of the fore-arm. The facility with which (as was before noticed) the ulna can be moved backward and forward, does not furnish him with any useful hint. When he moves his fingers along the anterior surface of the radius, he finds it more full and prominent than is natural; a similar examination of the posterior surface of this bone, induces him to think that a depression is felt about an inch and a half above its carpal extremity. He now expects to find satisfactory proofs of a fracture of the radius at this spot. For this purpose, he attempts to move the broken pieces of the bone in opposite directions; but, although the patient is by this examination subjected to considerable pain, yet, neither crepitus nor a yielding of the bone at the seat of the fracture, nor any other positive evidence of the existence of such an injury is thereby obtained. The patient complains of severe pain as often as an attempt is made to give to the limb the motions of pronation and supination.

If the surgeon locks his hand in that of the patient's, and makes extension, even with a moderate force, he restores the limb to its natural form; but the distortion of the limb instantly returns on the extension being removed. Should the facility with which a moderate extension restores the limb to its form induce the practitioner to treat this as a case of sprain, he will find, after a lapse of time sufficient for the removal of similar swellings, the deformity undiminished. Or, should he mistake the case for a dislocation of the wrist, and attempt to retain the parts in situ by tight bandages and splints, the pain caused by the pressure on the back of the wrist will force him to unbind them in a few hours; and if they be applied more loosely, he will find, at the expiration of a few weeks, that the deformity still exists in its fullest extent, and that it is now no longer to be removed by making extension of the limb. By such mistakes the patient is doomed to endure for many months considerable lameness and stiffness of the limb, accompanied by severe pains on attempting to bend the hand and fingers. One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain: the deformity, however, will remain undiminished throughout life.

The unfavourable result of some of the first cases of this description which came under my care, forced me to investigate with peculiar anxiety the nature of the injury. But while the absence of crepitus and of the other usual symptoms of fracture rendered the diagnosis extremely difficult, a recollection of the superior strength and thickness of this part of the radius, joined to the mobility of its articulation with the carpus and ulna, rather inclined me to question the possibility of a fracture taking place at this part of the bone. At last, after many unsuccessful trials, I hit upon the following simple method of examination, by which I was enabled to ascertain, that the symptoms above enumerated actually rose from a fracture, seated about an inch and a half above the carpal extremity of the radius.

Let the surgeon apply the fingers of one hand to the seat of the suspected fracture, and, locking the other hand in that of the patient, make a moderate extension, until he observes the limb restored to its natural form. As soon as this is effected, let him move the patient's hand backward and forward; and he will, at every such attempt, be sensible of yielding of the fractured ends of the bone, and this to such a degree as must remove all doubt from his mind.

The nature of this injury once ascertained, it will be a very easy matter to explain the different phenomena attendant on it, and to point out a method of treatment which will prove completely successful. The hard swelling which appears on the back of the hand, is caused by the carpal surface of the radius being directed slightly backwards, instead of looking directly downwards. The carpus and metacarpus retaining their connexions with this bone, must follow it in its derangements, and cause the convexity above alluded to. This change of direction in the articulating surface of the radius is caused by the tendons of the extensor muscles of the thumb, which pass along the posterior surface of the radius in sheaths firmly connected with the inferior extremity of this bone.

The broken extremity of the radius being thus drawn backwards, causes the ulna to appear prominent toward the palmar surface, while it is probably thrown more towards the inner or ulnar side of the limb, by the upper end of the fragment of the radius pressing against it in that direction. The separation of these two bones from each other is facilitated by a previous rupture of their capsular ligament; an event which may readily be occasioned by the violence of the injury. An effusion into the sheaths of the flexor tendons will account for that swelling which occupies the limb anteriorly.

It is obvious that, in the treatment of this fracture, our attention should be principally directed to guard against the carpal end of the radius being drawn backwards. For this purpose, while assistants hold the limb, in a middle state between pronation and supination, let a thick and firm compress be applied transversely on the anterior surface of the limb, at the seat of the fracture, taking care that it shall not press on the ulna; let this be bound on firmly with a roller, and then let a tin splint, formed to the shape of the arm, be applied to both its anterior and posterior surfaces. In cases where the end of the ulna has appeared much displaced, I have laid a very narrow wooden splint along the naked side of this bone. This latter splint, I now think, should be used in every instance, as, by pressing the extremity of the ulna against the side of the radius, it will tend to oppose the displacement of the fractured end of this bone. It is scarcely necessary to observe, that the two principal splints should be much more narrow at the wrist than those in general use, and should also extend to the roots of the fingers, spreading out so as to give a firm support to the hand. The cases treated on this plan have all recovered without the smallest defect or deformity of the limb, in the ordinary time for the cure of fractures.

I cannot conclude these observations without remarking, that were my opinion to be drawn from those cases only which have occurred to me, I should consider this as by far the most common injury to which the wrist or carpal extremities of the radius and ulna are exposed. During the last three years, I have not met a single instance of Dessault's dislocation of the inferior end of the radius, while I have had opportunities of seeing a vast number of the fracture of the lower end of this bone.

Last Updated ( Tuesday, 08 November 2005 )