Session III - Upper Extremity
Fri., 10/8/04 Upper Extremity, Paper #21, 3:44 pm
Long-Term Functional Results of Distal Radius Fractures in Young Adults
Purpose: The purpose of this retrospective study was to determine the long-term functional and radiographic outcome of a series of young adults treated operatively for a displaced intraarticular fracture of the distal radius. A secondary outcome measure was to determine how their function, perception of their recovery, and radiographic appearance changed over the last 6 years.
Method: Originally, 26 fractures in 26 patients treated between 1986 and 1990 met the inclusion criteria for the study. Twenty-one of these patients underwent physical examination (range of motion, grip, and pinch strength), imaging (plain radiographs and CT scans), and completion of an MFA questionnaire at an average of 7.1 years after injury. Fifteen of these original 21 patients (75%) have returned for a similar assessment (including CT scans) with the addition of an Epic Hand Function Sort at a minimum 13-year follow-up. An evaluator not involved in the initial care of the patients performed the physical examinations. The plain radiographs and CT scans were assessed in a blinded fashion by an independent observer who measured the radiographic parameters with standardized methods, and the MFA and EHFS were interpreted by a physiatrist proficient with these evaluations. Fractures were classified according to Frykman, Melone, and AO/OTA to determine whether fracture classification correlated with long-term functional or radiographic outcome.
In this assessment there were 9 male and 7 female patients with an average age at the time of injury of 30 years (range, 17 to 42). The mechanism of injury was a fall for 11 patients, a direct blow in 3 patients, and a motor vehicle collision in 2 patients. There were 4 Frykman type VII and 12 Frykman type VIII fractures. There were eight Melone type 2, one Melone type 3, and seven Melone type 4 fractures. According to the AO/ASIF classification, 2 fractures were type B, and 14 fractures were type C. Open reduction internal fixation was performed at an average of 5.2 days (range, 0 to 16) after injury. Fixation was obtained as deemed necessary by the attending physician with plate and screws, Kirschner wires, and external fixators or a combination of these. All patients began protected mobilization of the wrist no later than 9 weeks after surgery.
Results: Average follow-up was 14 years (range, 13 to 17). Originally, osteoarthrosis of the radiocarpal joint was evident on the plain radiographs and CT scans of 16 (76%) of 21 wrists, and 13 (86%) of the current 16 patients. During each assessment, 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 original assessment and at the time of the most recent follow-up, as determined by physical examination and MFA questionnaire, did not correlate with magnitude of the residual step and gap displacement. For each evaluation, each patient had a good or excellent functional outcome, based upon the MFA, irrespective of radiographic evidence of osteoarthrosis of the radiocarpal or the distal radioulnar joint or nonunion of the ulnar styloid process. There was little or no deterioration of function despite advancement of osteoarthritis over the last 6 years.
Conclusion and Significance: High levels of function after prolonged periods of time can be expected despite the development of posttraumatic osteoarthritis after intraarticular fractures of the wrist. Although the development of posttraumatic osteoarthritis correlated with residual articular incongruity, function was not adversely affected. However, it is our recommendation, as well as those of others, that articular reductions be sought during the treatment of displaced intraarticular fracture to minimize the risk of posttraumatic arthritis. The findings of this long-term follow-up study underscore the importance of treating the patients and not making treatment decisions based solely on radiographic evaluation.