Жақын қол сынағы және оның салдары

Fracture of the radius bone near the wrist
Nerve injury, especially of the median nerve and presenting as carpal tunnel syndrome, is commonly reported following distal radius fractures. Tendon injury can occur in people treated both nonoperatively and operatively, most commonly to the extensor pollicis longus tendon. This can be due to the tendon coming in contact with protruding bone or with hardware placed following surgical procedures. Complex regional pain syndrome is also associated with distal radius fractures, and can present with pain, swelling, changes in color and temperature, and/or joint contracture. The cause for this condition is unknown.

The most common cause of this type of fracture is a fall on an outstretched hand from standing height, although some fractures will be due to high energy injury. People who fall on the outstretched hand are usually fitter and have better reflexes when compared to those with elbow or humerus fractures. The characteristics of distal radius fractures are influenced by the position of the hand at the time of impact, the type of surface at point of contact, the speed of the impact, and the strength of the bone. Distal radius fractures typically occur with the wrist bent back from 60 to 90 degrees. Volar or dorsal tilt A line is drawn joining the most distal ends of the volar and dorsal side of the radius. Another line perpendicular to the longitudinal axis of the radius is drawn. The angle between the two lines is the angle of volar or dorsal tilt of the wrist. Measurement of volar or dorsal tilt should be made in true lateral view of the wrist because pronation of the forearm reduces the volar tilt and supination increases it. When dorsal tilt is more than 11 degrees, it is associated with loss of grip strength and loss of wrist flexion. Indications for each depend on a variety of factors such as the patient's age, initial fracture displacement, and metaphyseal and articular alignment, with the ultimate goal to maximize strength and function in the affected upper extremity. Surgeons use these factors combined with radiologic imaging to predict fracture instability, and functional outcome to help decide which approach would be most appropriate. Treatment is often directed to restore normal anatomy to avoid the possibility of malunion, which may cause decreased strength in the hand and wrist. Distal radius fractures are often associated with distal radial ulnar joint (DRUJ) injuries, and the American Academy of Orthopaedic Surgeons recommends that postreduction lateral wrist X rays should be obtained in all patients with distal radius fractures in order to preclude DRUJ injuries or dislocations. Most children with these types of fractures do not need surgery. The prevalence of nonoperative approach to distal radius fractures is around 70%. Nonoperative management is indicated for fractures that are undisplaced, or for displaced fractures that are stable following reduction. Variations in immobilization techniques involve the type of cast, position of immobilization, and the length of time required in the cast. The position of the wrist in cast is usually slight flexion and ulnar deviation. However, neutral and dorsiflex position may not affect the stability of the fracture. Only 27 32% of fractures are in acceptable alignment 5 weeks after closed reduction. For those less than 60 years in age, there will be a dorsal angulation of 13 degrees, while for those older than 60, the dorsal angulation can reach as high as 18 degrees. In people over 60, functional impairment can last for more than 10 years.

Surgery is generally indicated for displaced or unstable fractures. The techniques of surgical management include open reduction internal fixation (ORIF), external fixation, percutaneous pinning, or some combination of the above. The choice of operative treatment is often determined by the type of fracture, which can be categorized broadly into three groups: partial articular fractures, displaced articular fractures, and metaphyseal unstable extra or minimal articular fractures. Structures at risk include the triangular fibrocartilage complex and the scapholunate ligament. Scapholunate injuries in radial styloid fractures where the fracture line exits distally at the scapholunate interval should be considered. TFCC injuries causing obvious DRUJ instability can be addressed at the time of fixation. Prognosis varies depending on dozens of variables. If the anatomy (bony alignment) is not properly restored, function may remain poor even after healing. Restoration of bony alignment is not a guarantee of success, as soft tissue contributes significantly to the healing process.

These fractures are the most common of the three groups mentioned above that require surgical management. Surgical options have been shown to be successful in patients with unstable extra articular or minimal articular distal radius fractures. These options include percutaneous pinning, external fixation, and ORIF using plating. Patients with low functional demand of their wrists can be treated successfully with nonsurgical management; however, in more active and fit patients with fractures that are reducible by closed means, nonbridging external fixation is preferred, as it has less serious complications when compared to other surgical options. Following the operation, a removable splint is placed for 2 weeks, during which time patients should mobilize the wrist as tolerated. Level of joint restoration, as opposed to surgical technique, has been found to be a better indicator of functional outcomes. For children, both boys and girls have a similar incidence of these types of fractures, however the peak ages differ slightly. Girls peak at 11 years old and boys peak at 14 years old (the age that children experience the most fractures). For adults, incidences in females outnumber incidences in males by a factor of three to two. In adults, the average age of occurrence is between 57 and 66 years. Men who sustain distal radius fractures are usually younger, generally in their 40s (vs. 60s in females). Low energy injury (usually fall from standing height) is the usual cause of distal end radius fracture (66 to 77% of cases). High energy injuries accounts for 10% of wrist fractures. About 57% to 66% of the fractures are extra articular fractures, 9% to 16% are partial articular fractures, and 25% to 35% are complete articular fractures. Unstable metaphyseal fractures are ten times more common than severe articular fractures. Older people with osteoporosis who are still active are at an increased risk of getting distal radius fractures.

Before the 18th century, distal radius fracture was believed to be due to dislocation of the carpal bones or the displacement of the distal radioulnar articulation. In the 18th century, Petit first suggested that these types of injuries might be due to fractures rather than dislocations. Another author, Pouteau, suggested the common mechanism of injury which leads to this type of fractures injury to the wrist when a person falls on an outstretched hand with dorsal displacement of the wrist. However, he also suggested that volar displacement of the wrist was due to the ulnar fracture. His work was met with skepticism from colleagues and little recognition, since the article was published after he died. In 1814, Abraham Colles described the characteristics of distal end radius fracture. In 1841, Guilaume Dupuytren acknowledged the contributions by Petit and Pouteau, agreeing that the distal end radius fracture is indeed a fracture, not a dislocation. In 1847, Malgaigne described the mechanism of injury for distal end radius fractures that can be caused by falling on the outstretched hand or on the back of the hand and also the consequences if the hand fracture is not treated adequately. After that, Robert William Smith, professor of surgery in Dublin, Ireland, first described the characteristics of volar displacement of distal radius fractures. In 1895, with the advent of X rays, the visualisation of the distal radius fracture became more apparent. Lucas Champonnière first described the management of fractures using massage and early mobilization techniques. Anaesthesia, aseptic technique, immobilization and external fixation have all contributed to the management of fixation of distal radius fracture. Ombredanne, a Parisian surgeon in 1929, first reported the use of nonbridging external fixation in the management of distal radius fractures. Bridging external fixation was introduced by Roger Anderson and Gordon O’Neill from Seattle in 1944 due to poor results in conservative management (using orthopaedic cast) of distal end radius fractures. Raoul Hoffman of Geneva designed orthopaedic clamps, which allow adjustments of the external fixator to reduce the fractures by closed reduction. In 1907, percutaneous pinning was first used. This was followed by the use of plating in 1965.