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Re: неправильно срастающийся перелом дистального луча - тактика?
David Nelson 30 Сентябрь 2008, 18:13
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I have read the abstracts cited above (not the full presentations and certainly not any published paper, as I presume these are not yet printed) and would offer this opinion.
(1) It is difficult to make pronouncements about the outcome of distal radius fractures without closely examining the details of the fractures. Not all aspects are equal; for instance, intraarticular displacement is not the same as loss of radial tilt. So, before making pronouncements that they all do well or they all develop arthritis, we need to see the details of the fractures and the details of the studies.
(2) While the Knirk and Jupiter paper of 1986 is the most widely-cited paper in the literature regarding distal radius fractures and the development of arthritis, Jupiter has stated publicly and privately that, of all the papers he has published, this is the one he most would like to retract. It was a retrospective study, there was no clinical exam, the rating system is defective, and it did not take into account any ligamenous injuries.
(3) Also, no outcomes can be intelligently discussed unless we also state the patient's activity level. For instance, not all 65 year olds are the same: some play competitive tennis or golf, others just want to do ADL's. To discuss outcomes without discussing activity level is impossible.
Therefore, I view the cited abstracts as of limited value.
To get to the case in question, while I think that the current alignment is not ideal (there will be no disagreement there), but I think that the data available to us in the literature do not decisively give any guidance. I would probably not recommend any osteotomy as "necessary". I would discuss with the patient (and document in the chart) that the data is not clear, but there is no certainty or even any strong suggestion that this alignment will result in disability, even in one so young. The patient needs to understand and accept that we do not have a crystal ball and participate (and take responsibility) for their decision. If it were my wrist, I would not have surgery, but I am not the patient.
David Nelson, MD
Hand surgeon, San Francisco
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Re: неправильно срастающийся перелом дистального луча - тактика?
Myles Clough 30 Сентябрь 2008, 18:16
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Interesting and thoughtful post, David.
Is there anything to say that the results of (say) an osteotomy to restore the alignment are much better early (in the first few months) than later after the assessment of long term disability (1-2 years). I found the following paper and am also sending a link to its "Related Articles" Has the conclusion that the results of early osteotomy are better been supported elsewhere?
Handchir Mikrochir Plast Chir. 1992 May;24(3):145-50.Links
[Malposition of healed distal radius fracture. Indications, technique and timing of correction]
[Article in German]
Möllenhoff G, Walz M, Sistermann R.
Chirurgischen Universitätsklinik und Poliklinik, Berufsgenossenschaftlichen Krankenanstalten Bergmannsheil, Bocchum.
Typical complications of distal radius fractures include post-traumatic malalignment in about 20%. This is associated with ulno-carpal pain and impaired wrist function. Various corrective procedures have been recommended. Between 1972 and 1986, 96 patients with posttraumatic disorders after distal radius fractures underwent surgical treatment. Three different procedures were carried out: simple corrective osteotomy of the distal radius, combined correction of the radius and ulna, as well as isolated correction of the ulna (distal resection, step-cut osteotomy, hemiresection arthroplasty). 83 (86.5%) of the patients were followed up for an average of 7 years postoperatively. The functional results were evaluated according to Lidström. Excellent and good results were found in 58 (69.9%), fair in 20 (24.1%) and bad results in 5 (6.0%). The best results were mostly seen in cases with a short interval between trauma and corrective procedure. Distal ulna resection has not been performed in our department since 1986 because of poor results and concommitant wrist-instability. We recommend combined correction procedures in those patients with painful deformities within a period of no more than six to nine months after trauma. The indication should also take individual aspects such as profession, age, activities, complaints, and radiological findings into account. Signs of osteoarthrosis and wrist disorders due to severe soft tissue problems are contra-indications to any of the aforementioned correction procedures.
Myles Clough
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