Injury Vol. 28, No. 4, pp. 283-287, 1997 0 1997 Elsevier Science Ltd. All rights reserved

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Is manipulation of moderately displaced Colles’ fracture worthwhile? A prospective randomized trial

A. J. Kelly’, D. Warwick’, T. I’. K. Crichlow’ and G. C. Bannister’ ‘Department of Orthopaedic Surgery, Southmead Hospital, Bristol, UK and 2Department of Orthopaedic Surgery, Princess Royal HospitalrTelford, UK

Thirty elderly patients zoitk moderately displaced Colles’frczctures were rnndomly assigned to manipulation under Bier’s block or plaster immobilization alone. Moderately displaced was defined as 10” to 30” of dorsal angulation and less than 5 mm of radial shortening compared with tke uninjured side. The groups were well matched for age, sex, fracture type and displacement; immobilization time and rehabilitation were standardized. The outcome measures were: radiological position at union, the functional score of Gartland and Werley, grip strength, cosmesis and nlgodystropky zzssessment. There was no detectable difference between the groups in any of the outcome measures. Two-thirds of the correction of dorsal angulation zzckieved by manipulation was lost by 5 weeks. We conclude that up to 30” of dorsal nngulation und 5 mm of radial shortening may be accepted in selected elderly patients. 0 1997 Elsevier Science Ltd.

Injury, Vol. 28, No. 4, 283-287, 1997

Introduction The commonest treatment of displaced distal radial fractures remains closed manipulation and plaster immobilization. The displacement which can be accepted in the elderly without manipulation has not been established. After reduction, radial shortening and radial deviation revert to virtually the same position as before manipulation1,2. Dorsal angulation deteriorates by an average of 11” from the manipu- lated position and 50 per cent of this slip occurs after removal of the plaster’. Remanipulation does not correct the radial shortening and does not improve the final outcome in the elderly’.

Furthermore, it is not clear whether moderate radiological deformity at union predicts an unsatis- factory functional result. Cassenbaum5 and Tsuka- zakih both report good function independent of anatomy at union. Residual dorsal angulation >ll” reduces the range of palmarflexion, but has no effect on dorsiflexion which is the usual position of wrist

function’,‘. Radial shortening >4 mm reduces the range of radial/ulnar deviation’ and is more common in those patients with persistent pain’. Porter8 found reduced grip strength where dorsal angulation exceeded 20” or radial tilt was less than 10”. In a small retrospective series, a higher incidence of impaired hand function was reported when the fracture united with >12” of dorsal angulation and > 2 mm of radial shift (not radial angulation)“.

If the anatomical improvement produced by manipulation cannot usually be maintained until union, and functional outcome is impaired only when displacement is severe, then the indications for manipulation of moderately displaced fractures must be questioned. Cooney’” has suggested that no manipulation ‘may be acceptable in the elderly even if the radiographic appearance is severe’.

The aim of this study was to determine whether manipulation of fractures with <5 mm radial short- ening and between lo” and 30” of dorsal angulation produces a better outcome than immobilization alone. The outcome measures used were the functional score of Gartland and Werley, final radiological displacement of the fracture and cosmetic result.

Materials and methods Newly presenting elderly patients with moderately displaced distal radial fractures were randomly assigned by a system of prenumbered envelopes to two treatment groups. The first group underwent reduction of the fracture under Bier’s block by a senior house officer in the Accident & Emergency department, followed by immobilization in a dorso- radial plaster of Paris slab. The second group was treated by plaster immobilization only. Antero- posterior (Al’) and lateral radiographs were taken of both wrists to classify the fractures as described by Frykman” and to determine the degree of displace- ment compared with the uninjured side. Moderate

284 Injury: International Journal of the Care of the Injured Vol. 28, No. 4,1997

displacement was defined as between lo” and 30” of dorsal angulation and less than 5 mm of radial short- ening compared with the uninjured side. Radial shortening was defined as the axial difference between the distal radial and ulnar articular surfaces on an AI’ radiograph”. Patients under 65 years old and those with previous ipsilateral forearm fractures were excluded. In three cases of previous contra- lateral fracture, the normal values of radial short- ening, radial tilt and dorsal angulation were taken as 0 mm, 25” and -15” respectively. The dorsoradial plaster of Paris slab was applied in full ulnar devia- tion13 and 20” of palmar flexion in both groups and completed to a forearm cast the next day. Patients were seen in the Fracture Clinic at 1 week, 3 weeks and 5 weeks after injury and the cast was removed at 5 weeks and all patients were referred for physio- therapy. Function of the injured limb was assessed 1 month and 3 months after removal of plaster. Clinical results improved little with longer follow up14. The demerit point scale of Gartland and Werley was used, as modified (Table I) by Sarmiento’,‘5. Grip strength was measured using the Jamar dynamom- eter (TEC, Clifton, New Jersey) and adjusted for dominance using a factor of 1.0716,‘7. The hand was assessed for the clinical features of algodystrophy; pain, stiffness, swelling and vasomotor changes as described by Atkins et a1.18. Pressure sensitivity was

Table I. Modified Gartland and Werley scoring system to evaluate the end results of healed Colles’ fracture

Remit Points -.-

Residual deformity 1 Residual dorsal tilt 2 Radial deviation of hand 2-3 Maximum 6

Subjective evaluation Excellent: no pain, disability or motion limitation 0 Good: occasional pain, slight limitation, no disability 2 Fair: occasional pain, some limitation, some disability 4 Poor: pain, limitation of movement, marked disability 6 Maximum 6

Objective evaluation Loss of dorsiflexion ~45” 5 Loss of ulnar deviation ~30” 3 Loss of supination <50” 2 Loss of palmar flexion < 30 1 Loss of radial deviation < 15” 1 Loss of circumduction 1 Pain in distal radioulnar joint 1 Maximum 14

Complications Arthritic change

Minimal 1

Moderate 2 Severe 3

Nerve complications l-3 Poor finger function l-2 Grip strength ~50% normal side 1 Maximum 14

Point range on a deduction scale Excellent o-2

Good 3-8 Fair 9-20 Poor 220

measured with a hand-held spring dolorimeter. The load which just started to produce discomfort was measured at five points on all four fingers. The dolorimetry ratio was the sum of these 20 loads on the injured hand divided by the sum for the uninjured side. The normal value is close to unity and a low dolorimetry ratio represents increased pressure sensitivity. Stiffness was defined as a combined loss of movement of greater than 30” at the three joints of the index and middle fingers of the injured hand. The cosmetic result was assessed using a four-point subjective and objective scale: normal, slight deformity noticeable only in comparison with normal wrist, moderate deformity noticeable without comparison, severe deformity8.

All patients gave informed consent for the trial and local ethics committee approval was obtained. Results were stored on and analysed by a Microsoft Excel spreadsheet. Of the variables measured, only dorsal angulation was close to normally distributed. Differences between groups were therefore analysed using the Mann-Whitney U-test data and x2 test for proportions.

Results Fifteen patients were randomized to be treated by manipulation and plaster immobilization (group 1) and fifteen to receive immobilization only (group 2).

The patients were well matched for age, sex, side, dominance, Frykman fracture type (T&e II) and displacement of the fracture compared with the uninjured side (Figure I).

Radiological results Manipulation improved the mean dorsal angulation by 20”, mean radial tilt by 2.5” and shortening by 1 mm in group 1 as measured on the post-manipula- tion radiograph (Figure 1).

Dorsal angulation, radial shortening and tilt all showed a tendency to revert towards their original position after manipulation (Figure 2). None of the fractures displaced beyond the limits for this study before the 3 week follow up; thus none were remani- pulated or subjected to secondary intervention. Two fractures in each group displaced beyond the limits of this study between the 3 week and 5 week follow

Table II. Comparison of group 1 with group 2

Group 1 (N = 15) Group 2 IN = 15)

Age 75.4F7.3 74.327.3 Sex 13 women 14 women Side 8 right, 7 left IO right, 5 left Dominant side 8 9 Frykman 1 and 2 7 8 Frykman 3 and 4 4 5 Frykman 5 and 6 3 1 Frykman 7 and 8 1 1 Radial shortening 2.4k1.28 mm 2.3t2.0 mm Radial tilt 4.0 * 5.4” 9.5 k7.4” Dorsal angulation 22.3 + 5.9” 19.6k8.7

Kelly ei al.: Is manipulation of moderately displaced Colles’ fracture worthwhile? 285

up (three radial shortening of 6 mm and one of 5 mm with dorsal angulation 34”) but were considered to have united.

In group 2 the mean position improved slightly between the initial radiograph and the 1 week follow up, although the range was large. Dorsal angulation was improved in nine out of 15 cases (range, l-9”), was unchanged in three and worse in three.

At 5 weeks there was no significant difference between the manipulated and non-manipulated groups in terms of radial shortening, radial tilt or dorsal angulation (Figure 1). In neither group was the position at union significantly different from the position at the time of fracture.

Radial shortning (mm)

-I T”“’ . . . . . . . . . . . . . . . . . ..___........................................

6

5 i

4 t

3

2

1

0 i

l-

-,J Fracture

Dorsal angulation (degrees) 35 s- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fracture Post MUA 5 weeks

- 10 .- . . . . . . . . . . . . . . . . . . . ..-... _ ..--......,...._........_ - .x._,..__._.__

OGroup 1 q Group 2

IJ Group 1 a Group 2

Radial tilt (degrees)

20

I----

_--. 4 Cl Group 1

1s Y( T

1 Fracture Post MUA 5 weeks i -5 . . . . . . . . . . . . . . ..-.......-........-..... _ . . . ..--._..-.. -.-.-.-..- . . . . . - . . ..__...___..

Functional results Gartland and Werley demerit scores declined (i.e. function improved) between 4 and 13 weeks after removal of plaster. Group 1 scores improved from a mean of 9.6 (range, 2-12) to 5.81 (range, 1-12) and group 2 from 9.6 (range, 7-14) to 6.61 (range, 3-14). On the basis of this score, 12 in group 1 and 11 in group 2 had a good or excellent functional result. There was no significant difference between groups in the Gartland and Werley scores (Mann-Whitney U-test) or between the proportions achieving a satis- factory (excellent or good) result (x” test with Yates correction).

Grip strength Three patients with previous contralateral fractures were excluded from this part of the study. Mean grip strength was 49 per cent of the value predicted in group 1 and 56 per cent in group 2. There was no significant difference between the groups (Table 111).

Algodystrophy One patient in each group scored over 3 for the algodystrophy questionnaire; the same two patients had dolorimetry ratios of less than 0.85. Two further patients in each group had finger stiffness as defined above without other features of algodystrophy. The mean and standard deviations of the stiffness and dolorimetry ratios are given in Table III.

Cosmesis Eleven of 15 patients in group 1 and nine of 15 in group 2 considered that their wrist was of normal appearance or had only a slight deformity visible only by comparison with the uninjured side. The assessment of the examiner was 11 in group 1 and 10 in group 2.

Discussion The displacement which can be accepted without manipulation in the elderly who sustain a distal radius fracture has not been established. The mean age in this study was 75 and the results are not applicable to younger patients with high functional demands. The radiological inclusion criteria were established on the basis of previous studies’,5-7. The post-manipulation film in group 1 confirmed a good reduction, achieving a radial length within 1.5 mm and dorsal angulation within 2.5” of the anatomical position. Both these positions are close to the limit of accuracy of radiological measurement. Interestingly, in nine out of 15 group 2 fractures the position improved between the fracture film and 1 week follow up. This may represent differences in rotation or inaccuracies of manual radiological measurements, or a real improvement in position may have occurred during moulding of the dorsoradial backslab even though no manipulation was attempted. In group 1 patients, an average of 13.4” of dorsal angulation recurred between manipulation and 5 weeks. This is

Figure 1. Radiological outcome slightly greater than the 11” in Gartland’s series and

286 Injury: International Journal of the Care of the Injured Vol. 28, No. 4,1997

Figure 2. Case 7. Gradual loss of position after manipulation. All measurements compared with the uninjured side. a, Fracture position. Radial shortening 3 mm. Dorsal angulation 30”. Radial deviation 5”. b, Post manipulation position. Radial shortening 2 mm. Dorsal angulation -5”. Radial deviation 0”. c, 1 week position. Radial shortening 2 mm. Dorsal angulation -5”. Radial deviation 0”. d, 5 week position. Radial shortening 3 mm. Dorsal angulation 5”. Radial deviation 0”.

may be related to the advanced mean age of our patients.

The functional outcome in this study is compar- able with other series which have used the same functional score, despite the age of our patients. We used this score to allow comparison’,7,‘3,‘4, although other tests may be more sensitive for the detection of functional disability.

In terms of the radiological outcome, we found that manipulation led to an improvement in final dorsal angulation of 1.3” (95 per cent confidence interval -7.6” to 10.2”). Even if the true difference lies at the upper end of this range, such a small radiological difference is not clinically significant. This study is therefore large enough to have ex-

Table III. Functional outcome

Gartland and Werley score

Stiffness Dolorimetry ratio Grip strength % predicted

Group 1

5.8 (range, I-12)

16k14 0.96+0.1 48.8+ 17%

Group 2

6.6 (range, 3-14)

22*29 0.93+0.1 55.8+19%

eluded large differences; a much larger study would be required to exclude a type 2 statistical error if only a small true difference between groups does exist. However, any small true benefit of manipulation in these patients must be judged against the cost and risks of a Bier’s block regional anaesthetic.

Conclusions When a moderately displaced Colles’ fracture in the elderly is treated by closed manipulation and plaster immobilization, the majority of the reduction is lost by the time of union. In this study there was no detectable difference in radiological or functional outcome between the groups. We conclude that in selected elderly patients, up to 30” of dorsal angula- tion and 5 mm of radial shortening compared with the uninjured side may be accepted without manipulation.

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Paper accepted 4 December 1996.

Requests for reprints should be addressed to: Mr A. J. Kelly, Department of Orthopaedic Surgery, Winford Unit, Avon Orthopaedic Centre, Southmead Hospital, Westbury- on-Trym, Bristol, Avon BSlO 5NB, UK.