Bhattacharyya Rahul, Morgan Bethan Sian, Mukherjee Pavel, Royston Simon
Department of Trauma and Orthopaedics Northern General Hospital, Herries road, Sheffield S5 7AU UK.
Emergency Medicine trainee East Midlands North Deanery, UK. Derby Royal Infirmiry, Uttoxeter Road, Derby, DE22 3NE UK.
Iowa Orthop J. 2014;34:118-22.
Distal radial fractures are one of the most common orthopaedic injuries. An effective treatment strategy is needed to ensure good outcome and better resource usage.
To identify the significance of the number of instability markers in distal radial fractures in predicting outcome and proposing a standardized management strategy.
Data was collected retrospectively over three months at the Northern General Hospital, Sheffield. All patients who had a distal radius fracture in the defined time period and matched our criteria were included. Relevant instability markers identified through a literature review were: age >60 years, dorsal angulation >20°, intra-articular fracture, ulna fracture, dorsal comminution, radial shortening and osteoporosis. The number of instability markers, management and outcome were recorded for each patient. The strategy of management was subdivided into: plaster cast immobilisation with subsequent rehabilitation, manipulation with subsequent cast immobilization and surgery (locked volar plating). Outcomes were graded as "good" or "poor" based on the complications and the function achieved at discharge from follow-up.
Two hundred and seven patients were included in our study. One hundred and nineteen patients had <3 instability markers (Group A) and 88 had >4 (Group B). One hundred and sixty-two were female and 45 were male. The average age was 60 years and the age range was 19 to 96 years. In Group A, 91% achieved "good" outcome regardless of management strategy, versus 66% in Group B (p<0.001). In Group B, amongst patients who had surgery (29), 79% achieved "good" outcome, however those with manipulation alone (38), only 58% achieved "good" outcome (p > 0.03 (one tailed), p > 0.06 (double tailed)).
We have found that four or more instability markers are globally associated with a poorer outcome. Patients with four or more markers who underwent surgery did uniformly better than those with manipulation alone. However, in patients with three or fewer markers, non-operative management yielded equally good outcomes. We plan to use this as a pilot study for future primary research.
桡骨远端骨折是最常见的骨科损伤之一。需要一种有效的治疗策略来确保良好的治疗效果并更好地利用资源。
确定桡骨远端骨折中不稳定指标的数量在预测治疗效果及提出标准化管理策略方面的意义。
在谢菲尔德北部总医院进行了为期三个月的回顾性数据收集。纳入在规定时间段内发生桡骨远端骨折且符合我们标准的所有患者。通过文献综述确定的相关不稳定指标为：年龄>60岁、背侧成角>20°、关节内骨折、尺骨骨折、背侧粉碎、桡骨短缩和骨质疏松。记录每位患者的不稳定指标数量、治疗方法及治疗效果。治疗策略分为：石膏固定并随后进行康复治疗、手法复位并随后石膏固定以及手术治疗（锁定掌侧钢板固定）。根据随访出院时的并发症和功能情况，将治疗效果分为“良好”或“不佳”。
我们的研究纳入了207例患者。119例患者有<3个不稳定指标（A组），88例患者有>4个不稳定指标（B组）。其中女性162例，男性45例。平均年龄为60岁，年龄范围为19至96岁。在A组中，无论采用何种治疗策略，91%的患者治疗效果为“良好”，而B组为66%（p<0.001）。在B组中，接受手术治疗的患者（29例）中有79%治疗效果为“良好”，然而仅接受手法复位的患者（38例）中，只有58%治疗效果为“良好”（单尾p>0.03，双尾p>0.06）。
我们发现四个或更多的不稳定指标总体上与较差的治疗效果相关。有四个或更多指标且接受手术治疗的患者总体上比仅接受手法复位的患者情况更好。然而，对于有三个或更少指标的患者，非手术治疗也能取得同样良好的效果。我们计划将此作为未来初步研究的一项试点研究。
