Fractures of the Distal radius and Ulna

David S. Ruch The optimal management of distal radius fractures has changed dramatically over the previous two decades from almost universal use of cast immobilization to a variety of highly sophisticated operative interventions. Few prospective studies confirm the benefit of this increasingly aggressive operative approach, however. Surgeons are increasingly faced with the dilemma of when to consider operative management and when cast immobilization is the optimal treatment. Although some patients still seem to confirm Abraham Colles' famous remarks that the casted wrist oewill at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain,_ (1) an increasing preponderance of published studies supports the need for operative intervention in a growing number of patients. In addition to apparent discrepancies regarding surgical interventions, there are other equally disparate studies regarding multiple facets of this fracture. There are conflicting data about the long-term relationship regarding radiographic parameters and patientreported outcomes. Fernandez and Trumble as well as others have reported that as little as 1 mm of articular incongruity is associated with a worse functional outcome (2). Catelano et al have indicated that although there is a correlation between articular incongruity and radiographic arthrosis, there is not a correlation with selfreported function (3). Age is also a confounding variable in determining the need for operative management. Young and Rayan indicated that in elderly patients (mean age 72 years), the radiographic outcome did not correlate with functional outcome despite significant collapse and incongruity (4). By contrast, Madhok indicated that 26% of elderly patients still experience functional impairment after nonoperative management at 1 year following closed treatment (5). Even when operative intervention is clearly indicated, there is still controversy over the use of external fixation versus one of the growing number of internal fixation devices. This chapter examines the presumably known variables including the epidemiology, mechanism of injury, and classification systems as well as the current trends in nonoperative and operative management, and the complications and pitfalls of each.

EPIDEMIOLOGY

Distal radius fractures represent approximately one-sixth of all fractures treated in emergency departments. Data extracted from the National Hospital Ambulatory Medical Care Survey indicate that in 1998, there were approximately 644,985 fractures of the distal radius treated in the United States. The incidence of this injury appears to be both gender and age specific (6). There are three main peaks of fracture distribution: the first peak is in children ages 5 to 14, the second is in males under age 50, and the third peak is in females over the age of 40 years. There seems to be a growing incidence of these fractures in all three groups with the sharpest increase seen in both elderly females and younger adult males (7,8,9). More importantly, these studies suggest that the difference in the two peak incidences indicates that these fractures represent two very different injuries: one, an

Las fracturas de la extremidad distal del radio y cbito

David S. Ruch David S. Ruch The optimal management of distal radius fractures has changed dramatically over the El manejo ptimo de las fracturas del radio distal ha cambiado drsticamente en los previous two decades from almost universal use of cast immobilization to a variety of dos dcadas anteriores por el uso casi universal de la inmovilizacin con yeso a una variedad de highly sophisticated operative interventions. intervenciones quirrgicas altamente sofisticados. Few prospective studies confirm the Pocos estudios prospectivos confirmar la

benefit of this increasingly aggressive operative approach, however. ventaja de este sistema operativo cada vez ms agresivos, sin embargo. Surgeons are Los cirujanos son increasingly faced with the di lemma of when to consider operative management and cada vez ms ante el dilema de cundo considerar la gestin operativa y when cast immobilization is the optimal treatment. cuando la inmovilizacin no es el tratamiento ptimo. Although some patients stil l seem Aunque algunos pacientes parecen to confirm Abraham Colles' famous remarks that the casted wrist oewill at some para confirmar las observaciones famoso Abraham Colles que la mueca enyesada oewill en algn remote period again enjoy perfect freedom in all of its motions and be completely perodo remoto de nuevo disfrutar de la perfecta libertad en todos sus movimientos y estar completamente exempt from pain, _ (1) an increasing preponderance of published studies supports exento de dolor, _ (1) una creciente preponderancia de los estudios publicados apoya the need for operative intervention in a growing number of patients. la necesidad de una intervencin quirrgica en un nmero creciente de pacientes. In addition to Adems de apparent discrepancies regarding surgical interventions, there are other equally discrepancias aparentes en relacin con las intervenciones quirrgicas, hay otros igualmente disparate studies regarding multiple facets of this fracture. estudios dispares en relaci n con las mltiples facetas de esta fractura. There are conflicting data Hay datos contradictorios about the long-term relationship regarding radiographic parameters and patientreported acerca de la relacin a largo plazo en relacin con los parmetros radiolgicos y patientreported outcomes. resultados. Fernandez and Trumble as well as others have reported that as Fernndez y Trumble, as como otros han dicho que a medida que little as 1 mm of articular incongruity is associated with a worse functiona l outcome slo 1 mm de incongruencia articular se asocia con un peor resultado funcional (2). (2). Catelano et al have indicated that although there is a correlation between CATELANO et al han indicado que si bien existe una correlacin entre articular i ncongruity and radiographic arthrosis, there is not a correlation with selfreported incongruencia articular y artrosis radiogrfica, no hay una correlacin con selfreported function (3). funcin (3). Age is also a confounding variable in determining the n eed for La edad tambin es una variable de confusin en la determinacin de la necesidad de operative management. gestin operativa. Young and Rayan indicated that in elderly patients (mean age Jvenes y Rayan indic que en pacientes de edad avanzada (edad media 72 years), the radiographic outcome did not correlate with functional outcome despite 72 aos), los resultados radiogrficos no se correlacion con el resultado funcional a pesar de significant collapse and incongruity (4). cada significativa e incongruencia (4). By contrast, Madhok indicated that 26% of Por el contrario, Madhok indic que el 26% de elderly patients still experience functional impairment after nonoperative management pacientes de edad avanzada todava experimenta deterioro funci onal despus de tratamiento conservador at 1 year following closed treatment (5). despus del tratamiento en un ao cerrado (5). Even when operative intervention is clearly Aun cuando la intervencin quirrgica es claramente indicated, there is still con troversy over the use of external fixation versus one of the se indica, todava existe controversia sobre el uso de fijacin externa versus uno de los growing number of internal fixation devices. creciente nmero de dispositivos de fijacin interna. This chapter examines the presumably Este captulo examina los supuestamente

known variables including the epidemiology, mechanism of injury, and classification variables conocidas como la epidemiologa, mecanismo de lesin, y la clasificacin systems as well as the current trends in nonoperative and operative management, and sistemas, as como las tendencias actuales en el tratamiento no quirrgico y quirrgico, y the complications and pitfalls of each. las complicaciones y dificultades de cada uno.

EPIDEMIOLOGY EPIDEMIOLOGA
Distal radius fractures represent approximately one -sixth of all fractures treated in Fracturas del radio distal representan aproximadamente una sexta parte de todas las fracturas tratadas en emergency departments. los servicios de urgencias. Data extracted from the National Hospital Ambulatory Los datos extrados del Hospital Ambulatorio Nacional Medical Care Survey indicate that in 1998, there were approximately 644,985 Encuesta sobre la atencin mdica indican que en 1998, haba aproximadamente 644.985 fractures of the distal radius treated in the United States. las fracturas del radio distal tratadas en los Estados Unidos. The incidence of this injury La incidencia de esta lesin appears to be both gender and age specific (6). parece ser el gnero y edad especficos (6). There are three main peaks of Hay tres principales picos de fracture distribution: the first peak is in children ages 5 to 14, the second is in males distribucin de la fractura: el primer pico se encuentra en nios de 5 a 14, el segundo es en los hombres under age 50, and the third peak is in females over the age of 40 years. menores de 50 aos, y el tercer pico es en las mujeres mayores de 40 aos. There seems No parece to be a growing incidence of these fractures in all three groups with the sharpest a una creciente incidencia de estas fracturas en los tres grupos con la ms aguda increase seen in both elderly females and younger adult males (7,8,9). aumento observado tanto en mujeres de edad avanzada y los ms jvenes los varones adultos (7,8,9). More Ms importantly, these studies suggest that the difference in the two peak incidences importante, estos estudios sugieren que la diferencia en las dos incidencias pico indicates that these fract ures represent two very different injuries: one, an indica que estas fracturas son dos lesiones muy diferentes: uno, un