pins and plaster treatment of comminuted fractures of the...

304 AUGUSTO SARMIENTO, J. S. COOPER, AND W. F. SINCLAIR

7. HUGHSTON, J. D.: Fracture of Distal Radial Shaft. Mistakes in Management. J. Bone and Joint Surg., 39-A: 249-264, April 1957.8. KNIGHT, R. A., and PURVlS, G. D.: Fractures of Both Bones of the; Forearm in Adults. J. Bone and Joint Surg., 31-A: 755-764, Oct. 1949.9. LATTA, LOREN; ZlLIOLI, ARMAND; SINCLAIR, WILLIAM; and SARMIENTO, AUGUSTO: The Role of Soft Tissues in Fracture Stability. In Proceedings

of the Orthopaedic Research Society. J. Bone and Joint Surg., 56-A: 854, June 1974.10. NAIMAN, P. T.; SCHEIN, A. J.; and SIFFERT, R. S.: Use of ASIF Compression Plates in Selected Shaft Fractures of the Upper Extremity. Clin.

Orthop., 71: 208-216, 1970.11. PATRICK, JAMES: A Study of Supination and Pronation, with Especial Reference to the Treatment of Forearm Fractures. J. Bone and Joint Surg., 28:

737-748, Oct. t946.12. SAGE, F. P.: Medullary Fixation of Fractures of the Forearm. A Study of the Medullary Canal of the Radius and a Report of Fifty Fractures of the

Radius Treated with a Prebent Triangular Nail. J. Bone and Joint Surg., 41-A: 1489-1516, Dec. 1959.13. SAGE, F. P.: Fractures of the Shafts and Distal Ends of the Radius and Ulna. In Instructional Course Lectures, The American Academy of Or-

thopaedic Surgeons. Vol. 20, pp. 91-115. St. Louis, The C. V. Mosby Co., 1971.14. SARMIENTO, AUGUSTO: The Brachioradialis as a Deforming Force in Colles’ Fractures. Clin. Orthop., 38: 86-92, 1965.15. SARMIENTO, AUGUSTO: A Functional Below-the-Knee Cast for Tibial Fractures. J. Bone and Joint Surg., 49-A: 855-875, July 1967.16. SARMIENTO, AUGUSTO: A Functional Below-the-Knee Brace for Tibial Fractures. A Report on Its Use in One Hundred and Thirty-five Cases. J.

Bone and Joint Surg., 52-A: 295-311, March 1970.17. SARMIENTO, AUGUSTO: Functional Bracing of Tibial and Femoral Shaft Fractures. Clin. Orthop., 82: 2-13, 1972.18. SMITH, HUGH, and S,~GE, F. P.: Medullary Fixation of Forearm Fractures. J. Bone and Joint Surg., 39-A: 91-98, Jan. 1957.19. SMITH, J. E. M.: Internal Fixation in the Treatment of Fractures of the Shafts of the Radius and Ulna in Adults. The Value of Delayed Operation in

the Prevention of Non-union. J. Bone and Joint Surg., 41-B: 122-131, Feb. 1959.

Pins and Plaster Treatment of Comminuted Fractures of theDistal End of the Radius

BY DAVID P. GREEN, M.D.*, SAN ANTONIO, TEXAS

From the Hand SurgeD" Service, Division of Orthopaedics, Universi~ of Texas Medical School, San Antonio

ABSTRACT: The technique used in the treatment ofseventy-five patients with severely comminuted, often

intra-articular fractures near the wrist was as follows:Pins were inserted .through the metacarpals and proxi-mal part of the ulna, reduction was done, and the pinswere incorporated in a cast from elbow to knuckles.This allowed movement of the fingers and the elbow.The main complications ~ loss of radial length and pin-tract infection ~ are avoided by attention to technicaldetails. Of the patients with adequate follow-up, 86 percent had good or excellent results.

The optimum treatment of Colles’ fractures remainscontroversial. Some authors la,4o.,’,,,r,~a reported function-ally good results in a h!gh percentage of patients, but themajority noted that the results are not uniformly good I,a,10,14,23,26,28,30,36,43,44 In particular, many fractures of the

distal end of the radius in middle-aged and elderly indi-

viduals are severely comminuted and intra-articular. Itis in these difficult fractures that the results frequently are

poor. There appears to be general agreement that reductionis easy to achieve in these fractures, but is difficult to main-tain.

Several maneuvers have been advocated to avoid lossof reduction or to regain it: wedging the plaster cast 1~;changing the cast seven ,,to ten days. after the initialreduction ze; resecting the distal end of the ulna a4.~4; pin-ning the distal fragment percutaneously ZOal; immobilizing

* 7703 Floyd Curl Drive, San Antonio, Texas 78284.

the forearm and wrist in supination 2.,,.,7; external fixation

with a Roger Anderson device",aI,a2; and fixing thefracture fragments with pins which are incorporated, in a

plaster cast, as advocated in this report 5,8,14,18,24,25,39,41,50.

Brhler advocated pins and plaster treatment as early as.. 1929 4~, and many variations of the method have been de-

scribed (Fig. 1). In each of these techniques, however, the

basic underlying principle was the same: to provide a fixedtraction which prevents shortening of the radius at the frac-ture site. Cole and Obletz 14 concluded that prolonged im-mobilization of eight weeks is required for the comminutedfracture to prevent this shortening. Because of the relativelylong period of immobilization needed, it is imperative thatthe method employed permit free, active motion of the

fingers, particularly full use of the hand, elbow, and shoul-der. Our technique is not original, but the modifications weadvocate are designed for early maximum use of the handand maintenance of a full range of motion of all the joints.

Material

In 1970, a study was begun in which all those patients

with comminuted, intra-articular fractures of the distal endof the radius were selected for treatment with pins and plas-

ter. We estimate that these patients represent approximately15 per cent of all the adults we treated who had fractures ofthe distal end of the radius. Patients with simple, non-

comminuted fractures which did not involve the articularsurface of the radius were treated with the more conven-tional techniques of closed reduction and plaster immobili-

zation.

THE JOURNAL OF BONE AND JOINT SURGERY

COMMINUTED FRACTURES OF THE DISTAL END OF THE RADIUS 305

FIG. 1Since B6hler’s original description of the pins and plaster method in

1929 ~, many variations and modifications of the technique have beenused.

Seventy-eight fractures in seventy-five patients weretreated by the pins and plaster method. The age range wasfrom nineteen to seventy-nine years, with an average age of50.6. The mechanism of injury in thi.rty-two patients was afall on the outstretched hand, the typical cause of a Colles’fracture. Many patients were injured by more violenttrauma, including falls from heights (sixteen patients) andtraffic accidents (eleven patients). Seventeen patients sus-tained multiple injuries. One patient had a concomitantfresh fractu/’e of the scaphoid 13. ,

Sixty-four of the fractures were of the Colles type; thatis, with dorsal displacement (volar angulation) of the distal.fragment. Three of the injuries were Smith’s fractures, with

i!:.!~i~ ~volar displacement (dorsal angulation). There were nineBarton’s or reverse-Barton’s fracture-dislocations; that is,

i~ proximal displacement of the carpus accompanied by afragment of radius including part of the articular surface la.Of the forty-five patients whose end evaluations are re-

}: p°rted here’ f°rty-tw° had c0mminuted intra-articular frac-i~ .ii’~:- tures; s~x of these had severe loss of length, ten had moder-~ii’:ate loss of length, and twenty-six had minimum loss of

length. The other three patients had severely commlnutedfractures with moderate or severe loss of length, but thesefractures were not intra-articular: Two patients with gunshot

s~xteen-m lhmeter sound movie depicting this technique is avail-able in the film library of The American Academy of OrthopaedicSurgeons (Green, D. P., and Williamson, R. W., Jr.: Pins and PlasterTreatment of Comminuted Fractures of the Distal Radius. Film No.

VOL. 57-A, NO. 3, APRIL 1975

wo~ands are included in the series because they presented theessential problem of prevention of loss of length. Insixty-five patients pins and plaster was the initial treatment.In the other ten this method was used two to thirteen daysafter unsuccessful attempts at reduction by closed manipula-tion and application of plaster casts.

Technique*

Although no special equipment is needed, all thenecessary instruments must be on hand before the procedureis begun. For applying traction either the wire finger traps orthe Weinberger apparatus is satisfactory. Counter-tractioncan be provided by a padded sling and 2.3 to 4.5 kilogramsof weight from the traction cart.

A pin-fixation tray should provide all the necessary in-struments: a hand drill, a scalpel with No. 11 or No. 15blade, two pairs of needle-nosed pliers, a pin cutter, several2.3.-millimeter smooth (unthreaded) stainless-steel Stein-mann pins, and several towel clips.

Adequate anesthesia must be obtained at the outset.Regional anesthesia by intravenous lidocaine was used inthe majority of our patients, although brachial block or gen-eral anesthesia occasionally was used.

Once anesthesia is established, the finger traps and thecounter-traction sling are applied. At least ten minutes ofuninterrupted traction should be used; that alone will usu-ally achieve the required length of radius, but some gentlemanipulation in addition may be needed.

Roentgenograms are then made in at least two planes,preferably three -- anteroposterior, lateral, and oblique.Distraction of the bones of the carpus should not be of con-cern but it is important that the anatomical length of theradiu.s be restored. While the roentgenograms are being de-veloped, the entire hand and the forearm are scrubbed andthe forearm is draped with sterile towels. It is difficult toisolate the finger traps from the operative field, and thesurgeon should take great care not to contaminate his ~-andsor the instruments.

Careful placement of the distal pin is important. Itshould enter the second metacarpal immediately distal to theflare, of the base, an anatomical landmark easily palpated.The thumb should be adducted and the hand cupped by anassistant during placement of the pin, so that the pin en-gages only the second and third metacarpals. Incorporatingthe :fourth and fifth metacarpals should be avoided,, to pre-vent flattening the normal arch of the palm.

If the pin is left straight in its position of insertion,however, limitation of extension and abduction of thethumb will often result. It was pointed out by one of ourformer residents (Dr. J. W. Tippett) that this problem canbe avoided by bending the pin directly at its exit from thebase of the second metacarpal so as to allow full range ofmotion of the thumb (Fig. 2). We now do this routinely.~This is easily accomplished with the pliers. Although2.3-millimeter pins seem rather large for transfixing themetacarpals, we have found that smaller pins will sag in theplaster cast, resulting in loss of length of the radius. The

306

proximal pin is drilled through the ulna at least six cen-timeters from the tip of the olecranon, passing from medialto lateral to avoid injury to the ulnar nerve. With subsequentactive motion in the elbow, pins placed more proximally inthe ulna are more likely to loosen and drainage to develop.

Sterile cast padding is wrapped directly over the pins.Gauze dressings should not be placed over the exit wounds,because they hinder the purchase of the plaster on the pins.The cast is applied with the wrist in neutral position, neitherflexed nor extended, and the traction must be maintaineduntil the plaster sets. The pins are carefully incorporatedinto the plaster both proximally and distally. No attemptshould be made to contour the cast to its final dimensions.Roentgenograms are made before the cast is trimmed.

F:G. 2

The distal pin is inserted in the second and third metacarpals only;passing" the pin through all four metacarpals flattens out the normal arch ofthe palm and should be avoided. In order to miss the fourth metacarpal, itis necessary to start the pin from palmarwards. If the pin protrudes in thisposition, limitation of abduction and extension of the thumb will result.Therefore, we routinely bend the pin back at the base of the secondmetacarpal with two pairs of needle-nosed pliers.

Generous trimming of the cast is an important part ofthe procedure, because it allows maximum active motion bythe patient. Dorsally the plaster is cut at the level of themetacarpophalangeal joints. Volarly the entire palm, in-cluding the thenar and hypothenar eminences, is uncovered(Fig. 5). At the elbow, the cast is also generously trimmedanteriorly to allow full elbow flexion. Brady a advocated a

similar cast in 1963.The patient should be admitted to the hospital at least

overnight for elevation of the hand and for observation. Theearly post-reduction management is an integral part of thetechnique, and failure to work closely with the patient in thefirst two to three weeks will compromise the result. Thebasic reason for applying the type of cast described is toallow the patient to move the fingers. With this technique,

GREEN

,all patients have some pain in the second and third metacar-pals. The surgeon must succeed in encouraging the patient,during the first days after the pins are inserted, to achiew~ afull active range of motion. If the patient fails to achievethis goal, the services of a physical therapist may be help-ful, but this was not needed in the majority of our patients.

At least eight weeks of immobilization are required forthe treatment of a severely comminuted fracture. We haveseen loss of length of the radius following removal of thepins at six weeks. Ten weeks of fixation may be required forextremely comminuted fractures. During this rather pro-longed period of immobilization, the patient must be en-couraged to use the hand as nearly normally as possible. Alljoints, including those of the fingers, thumb, elbow, andshoulder, must be put through a full range of motion daily.

Results

Of the seventy-five patients we treated by this method,eighteen were lost to follow-up after removal of the pins andplaster. Another twelve patients were treated too recentlyfor follow-up data to be meaningful. These thirty patientswere in essentially the same age distribution as the patientsreported here. The remaining forty-five patients were care-fully reviewed clinically and roentgenographically in a finalfollow-up examination at from six to thirty months after in-

jury, with an average of 13.1 months.The results of treatment in these forty-five patients

were assessed by the following criteria: appearance; rangeof motion of the elbow, forearm, wrist, and fingers; grip

strength; pain; symptoms of median-nerve compression;and status as regards return to work. Each category wa~ as-sessed on a five-point scale.

The end-result roentgenograms were also graded on afive-point scale according to radial tilt, dorsal tilt, andlength of radius. The length of the radius was measured inmillimeters, using the distal end of the ulna (not~the styloidprocess) as a reference. Similar measurements were madeon all roentgenograhas previous to the final one (those madeinitially, those made in finger-trap traction at the time of re-duction, those made immediately after application of thepins and plaster, and check-up roentgenograms made sub-sequently throughout the course of treatment). The com-parison of the serial measurements enabled us to determinewhen any loss of length or position occurred. In the finalexamination roentgenograms of the opposite wrist weremade for comparison, because in some individual.’; theradius actually is shorter than the ulna (the so-called ulna-plus variant).

The examiner’s estimate of the result was good(twenty-nine cases) or excellent (ten cases) in 86 per cent our forty-five patients. Two patients had fair results and onehad a poor result. The results in three patients were consid-ered absolute failures; each of these patients had to have aDarrach procedure -- resection of the distal end of the ulna-- because of excessive shortening of the radius. In two ofthese patients the shortening was due to loss of purchase ofthe pins in the plaster, necessitating premature removal of


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JRGERY


the cast (see Complications). In one patient, loss of lengthwas due to a technical error. The results in all three patientswere rated poor as regards appearance.

The patient’s estimate of the result was good (five) excellent (thirty-five) in 89 per cent. Two patients thoughtthat their results were fair and three thought that they werepoor. There was no significant correlation between the se-verity of the original fracture and the end result. Thepatient’s estimate of the end result was most closely corre-lated with the appearance of the wrist and the range of pro-nation and supination of the forearm.

Besides the three patients who had Darrach proce-dures, deformity was present in thirteen other patients:moderate in one; mild but of some concern to the patient inanother; and minimum and of no concern to the patient inthe remainder. The range of motion of the elbow was nor-mal in all patients. Twenty-four had full range of forearmmotion (pronation-supination); in three it was 50 to 75 percent and in eighteen it was 75 to 95 per cent of the opposite,normal side. Fifteen patients had normal wrist motion; fourhad 50 to 75 per cent and three had 25 to 50 per cent ofnormal motion. All but nine patients had a full range offinger motion at end-result evaluation. One could flex hisfingers so t.hat the finger tips reached to within three cen-timeters of the palmar crease, and in the other eight the in-terval was less than one centimeter. The grip strength wasnormal in thirty patients, 50 to 75 per cent in ten, 25 to 50per cent in four, and less than 25 per cent in one. No patienthad pain severe enough to restrict activity significantly. Nopain was present in twenty-seven. Fifteen patients had achesin cold weather, and three said their pain was mildly restric-tive. One patient had a mild carpal-tunnel syndrome, whichbecame asymptomatic with conservative therapy. All pa-tients returned to their preinjury employment status, onlythree noting some mild limitations.

Normal volar tilt of the distal part of the radius was not

restored in any patient; in the majority (twenty-eight), theradial art.icular surface ended up in a neutral plane on thelateral roentgenogram. Many. of the patients with this roent-genographic finding had excellent results, with virtuallynormal motion of the wrist and forearm. Eight patients hadmore than 10 degrees of dorsiflexion tilt, and eight had zeroto 10 degrees. One had volar tilt of 5 degrees.

Using a computer analysis, each of the fifteen clinicaland roentgenographic parameters was correlated with all theothers. Failure to restore normal radial length or normal ra-dial tilt correlated closely with a less than satisfactory re-sult. This loss in length was frequently accompanied bypoor appearance and limitation of wrist flexion-extensionand forearm rotation, the last presumably related to disrup-tion of the distal radio-ulnar joint. No change in length wasrecorded in twenty-one patients; eighteen lost zero to twomillimeters, three lost three to five millimeters, and one lostmore than five millimeters. Two had arthritic changes in thewrist in addition to loss of length. Irregularity of the distalarticular surface of the radius was most frequently the resultof failure to reduce a dorsomedial intra-articular fracture

F~G. 3

The so-called die-punch fracture was seen as a part of many intra-¯ :ticular fractures. Usually it is on the dorsal aspect, but in this patient itwas on the volar side. Frequently the die-punch fracture can be reduced intraction, but in several of our patients, including this one, it was not com-pletely reduced, leaving some slight incongruity of the articular surface.

fragment, the so-called die-punch fracture as. In some pa-t:ients with this fragment, the initial traction and manipula-tion reduced the fracture; in several others it was not re-duced anatomically (Fig. 3).

The end results of radial tilt were normal in fifteen pa-t!ients, while twenty-one had between 15 and 20 degrees andnine had between I0 and 15 degrees.

Advanced age is not a contraindication to tl~-~ use ofthis technique. Excellent anatomical and functional resultswere obtained in many elderly patients, including aseventy-nine-year-old female piano teacher who resumedher usual occupation following treatment. In contrast, thepatients who did most poorly as a group in this series werethe young men with severely comminuted fractures sec-ondary to violent trauma. Originally we thought that thesepatients would be ideal candidates for pins and plastertreatment, but this proved not be the case? Two of thethree absolute failures in this series, the patients requiringDarrach procedures, were men, aged twenty-one and thirty.Pins and plaster were much more poorly tolerated by theseyoung men than by the elderly women in our series. Theexplanation for this is not readily apparent to us. Perhapsthese fractures in young men were not true Colles’ fractures,but in fact were much more serious injuries with considera-bly more extensive damage to adjacent soft tissues as wellas more severe comminution of the bone itself.

A comparison of the results achieved in the differentreported series of patients with fractures of the distal end of

VOL. ~7-A, NO. 3, APRIL 1975

308

the radius is difficult, because there is a wide spectrum offracture patterns classified in the broad category of Colles’fracture. However, the study of Gartland and Werley’s endresults 23 with Colles’ fractures showed that 31.7 per cent oftheir patients with injuries similar to those in the presentstudy which were treated by conventional closed reductionand cast immobilization had unsatisfactory results. The pinsand plaster method in our group of patients with commi-nuted fractures showed a significant increase in satisfactory(good or excellent) results (86 per cent). Similar resultswere obtained by other authors using the pins and plastermethod: 95 per cent good or excellent results by Brady 8, 94per cent by Cole and Obletz 14, 81 per cent by Hammond 30,and 75 per cent by Scheck ~o. Other methods of treatingthese difficult comminuted fractures yielded similarlygood results: DePalma 20 reported 82.1 per cent good or ex-cellent results using ulnar pinning, and Cozen 17 had goodor excellent results in twenty-one of twenty-three patientstreated by wedging the plaster to prevent loss of reduction.

Complications

A significan( number of the patients in this series(twenty of forty-five) had minor or major complications some point during the period of treatment. Most of thesecomplications were preventable. Many occurred in patientstreated early in the series and we were able to eliminate orminimize them as we gained more experience.

Failure to maintain the restoration of radial length andinclination achieved by the initial reduction was the mostcommon complication in this series. It was attributableeither to use of pins of inadequate diameter or to immobili-zation for less than eight weeks. In the first patients in thisseries, Kirschner wires 1.6 millimeters in diameter wereused, but it soon became apparent that they would bend,with resulting loss of up to five millimeters of radial length.Finally it was demonstrated that 2.3-millimeter Steinmannpins were the smallest that would not bend. Although thesepins seem rather large for insertion in the second and thirdmetacarpals, our experience showed that pins of smallerdiameter will almost invariably bend.

Eight weeks of immobilization are usually required toensure adequate consolidation of bone in these severelycomminuted fractures. Patients in whom the pins and plas-ter immobilization was discontinued at the end of six weeksor earlier frequently lost two to three millimeters of radiallength over the next several weeks, even if plaster im-mobilization without pins was instituted when the pins wereremoved. In no patient was radial length lost after removalof the pins and plaster if they had been maintained for eightweeks.

Drainage from pin tracts was relatively frequent (one-third of the patients), but rarely serious. In 9nly one patientdid the drainage not resolve promptly after removal of thepins. This patient required curettage of the pin tract (os-teomyelitis of the ulna), and the lesion then healed promptly.Pin-tract drainage was more common early in our series. Itseems to be directly related to motion of the pins, which in

D. P. GREEN

tu~ is dependent to a large extent on the purchase of thepins in the bone and in the plaster cast. It is important to becertain that the proximal pin has solid bicortical purchase inthe ulna; in two patients, the pin came loose because it hadbeen inserted in the dorsal crest of the ulna. Another com-mo:a cause for loss of purchase by the plaster on the pinswa.,; cutting the pins off too short. At least 2.5 centimetersof pin should protrude from the bone to ensure adequate in-corporation in the plaster cast.

With our method, which allows unrestricted activeelbow motion, there is considerable stress and motion ofsoft tissues around the proximal (ulnar) pin if it is placed tooclose to the elbow. The ulnar pin should be inserted at leastsix centimeters distal to the olecranon and should be leftprotruding sufficiently to ensure solid incorporation in theplaster cast. Then drainagefrom the proximal pins isminimized. In several of our patients, removal of the prox-imal pin was necessary prior to eight weeks after injury(range, twelve days to seven weeks). Additional loss length was minimized (but not totally prevented) by then in-co~porating the distal pin into a long cast. This was done byhanging the hand up in finger traps with a counter-weightacross the upper arm (as for the initial reduction), removingthe original cast and proximal pin, and then applying a newca:st above the elbow, incorporating the distal pin but againleaving the fingers and palm completely free for full rangeof motion of the fingers. This procedure was necessary inni~ae patients, and all of these had at least one to two mil-limeters loss of radial length.

Drainage around the distal pin was less frequent, butdid occur. It was caused most commonly by loss of pur-.chase because of inadequate length of the pin (less than 2.5cefitimeters) protruding from the skin for incorporation intoplaster.

Many patients in the series maintained nearly a fullrange of motion of the fingers throughout the entir__e eightweeks of immobilization, but other, less well-motivated pa-

tients did not. However, permanent stiffness of the fingerjoints of significant degree was encountered in only one pa-tient. She lost flexion, so that the finger tips lacked threecentimeters from reaching the p~lmar crease in full flexion.C~ne patient with multiple injuries, including a severe closedhead injury, remained unconscious for nearly the entireeight weeks that her wrist was being treated with pins andplaster. Daily passive range of motion was performed by thenurses, physical therapists, and physicians, and when thecast was removed all the small joints of the hand were corn-pletely supple.

One patient, a female inmate of the county jail, sus-tained a fracture of the second metacarpal at the site of thedistal pin when she struck a fellow prisoner.

One patient had 45 degrees of active extensor lag in thelong and ring fingers for the duration of his period of im-mobilization. It was feared that the extensor tendons hadbeen lacerated by the distal pin, but within a few days afterpin removal full active extension was regained. Presumablythere had been some interference with normal tendon glid-



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RGERY

FIG. 4-AFigs. 4-A, 4-B, and 4-C: Disruption of the distal radio-ulnar joint is a

frequent concomitant injury seen with fractures of the distal end of theradius. In many cases the irregularity of the joint surfaces is reduced withrestoration of the normal length of the radius; in this patient it was not.

Fig. 4-A: A fifty-six-year-old woman sustained this severely commi-nuted intra-articular fracture of the distal end of the radius, with obviousdisruption of the distal radio-ulnar joint.

FIG. 4-B(R~asonably good restoration of the radius was achieved, but the irregu-

larity of the radio-ulnar joint was not reduced.

FIG. 4-CThe end result one year later. Although there was a fairly good joint sur-

face and length of radius, the distal radio-ulnar joint ~vas clinically androentgenographically dislocated, resulting in significant loss of rotation ofthe forearm and, therefore, a poor result.

ing without actual disruption of the tendon, and this compli-cation corrected itself without specific treatment. In anotherpatient there was a similar extensor lag in the ring and small

Fro. 5The entire palmar aspect of the cast is trimmed away to allow com-

pletely unrestricted range of motion of all the small joints of the fingersane thumb. The cast should also be generously trimmed over the ante-cubital fossa to allow full flexion of the elbow.

fingers, which also returned to normal after removal of thepir, s.

In one patient there was a transient ulnar-nerve palsycaused by injury to the nerve at the time of insertion of theproximal pin. This complication is preventable by carefullypui!ling the soft tissues away from the subcutaneous borderof the ulna as the pin is introduced into its medial side.

One of the most important reasons for attempting to re-store radial length is to allow realignment of the distalradio-ulnar joint 4r,~, and therefore to allow full rotation ofthe-forearm. Occasionally, the distal radio-ulnar joint wasnot restored by simple manipulation and traction (Figs. 4-A,4-R, and 4-C).

No patient in this series had symptoms of median-nerve compression during the period of treatment. One pa-tient was found to have mild symptoms of carpal-tunnelsyndrome on the follow-up examination, but she respondedreadily to conservative treatment. The pins and plasterme:thod was employed in one patient after carpal-tunnelsyndrome developed following closed reduction and castimmobilization with the wrist in flexion. Following surgicaldecompression (at which time a hematoma was found in thesubstance of the mediannerve), maintenance of the reduc-tion was achieved with pins and plaster. A forced position

¯ of wrist flexion was therefore avoided. This patient is notincluded in the present series because her fracture did notfulfill the criteria laid out in the prospective study. It indiocates an uncommon but useful application of the pins andplaster technique.

Discussion

The results of this study support the concept that goodfunctional and anatomical results can be achieved in manypatients with these difficult fractures. The method is notindicated in patients with simple, non-comminuted fracturesof the distal end of the radius which do not involve the ar-

310 D. P. GREEN

ticular surface, because equally satisfactory results can beachieved with simpler methods.

The technique is not difficult and requires little in theway of special equipment. However, it does demand of thesurgeon a willingness to work very closely with the patientin the early days following reduction so that the discomfortcaused by the distal pin, which all of our patients had to agreater or lesser degree, will not prevent active motion. If

the patient is encouraged to move the fingers and use thehand fully during the period of fracture healing, one neednot fear that the prolonged period of immobilization re-quired in this method of treatment will result in stiffness ofthe small joints of the hand.

This method carries with it many potential pitfalls andcomplications, but with careful attention to detail most ofthese can be avoided.

References

1. AMENDOLA, F. H.: The After-Treatment of Colles Fracture. J. Am. Med. Assn., 112: 1803-1806. 1939.2. ANDERSON, ROGER, and O’NEIL, GORDON: Comminuted Fractures of the Distal End of the Radius. Surg., Gynec. and Obstet., 78: 434-440, 1944.3. BACORN, R. W., and KURTZKE, J. F.: Coltes’ Fracture. A Study of Two Thousand Cases from the New York State Workmen’s Compensation

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pins and plaster treatment of comminuted fractures of the...

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