FRAKTUR COLLES – Download as Powerpoint Presentation .ppt), PDF File .pdf ), Text File .txt) or view presentation slides online. fr. colles. The Irish surgeon Abraham Colles described DRFs in the volume of the Edinburgh Medical Surgical Journal. Although his description. lokasi fraktur yang paling umum adalah di tangan dan melibatkan bagian distal dari tulang radius, bernama Fraktur Colles. Fraktur Colles adalah fraktur pada.
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These fractures tend to result in displacement in elderly people because they have osteoporotic bone. Fracture displacement in the elderly, however, does not necessarily result in functional impairment.
This review looks at frzktur current cilles on distal radius fractures in the elderly and the treatment colles for stabilization of these fractures. These include conservative management with cast immobilization or surgical options: They occur more frequently in women than in men.
There are a number of options for stabilization and treatment of these fractures. The elderly patient, however, presents unique management issues in the treatment of these fractures. Distal radius fractures in osteoporotic bone have greatly diminished stability; there is often bone impaction and fracture fragmentation.
This review looks at the current literature related to distal radius fractures in the elderly and the treatment options for stabilization of these fractures.
Fracture instability refers to the tendency of a fracture to displace after manipulation to an anatomic position. Distal radius fractures in elderly people tend to displace because they have osteoporotic bone.
In a study involving women aged over 50 years, who suffered distal radius fractures from low-energy trauma, measures of fracture displacement were compared with bone mineral density. A number of studies have looked at predictors of instability in distal radius fractures treated conservatively.
A study looked at 60 fractures of the distal radius in a low-demand elderly population treated with anatomic reduction and cast immobilization. More than three-quarters of all fractures reverted to a position similar to or worse than the initial deformity.
This is a finding that has been observed in many other studies of elderly patients. There is good evidence that inadequate anatomic reduction of distal radius fractures in a young patient population corresponds to poor functional outcomes. On the contrary, numerous studies have in fact found that radiographic outcomes see Figure 1 do not correlate to clinical outcomes. Radiographic measures of outcome in distal radius fractures. The angle between the line which connects the most distal points of the dorsal and volar cortical rims of the radius a and the line drawn perpendicular to the longitudinal axis of the radius b.
This is a relative measurement, which is taken as the difference between the measurements of the fractured radius c and the normal, uninjured radius d. Vertical distance between a line drawn parallel to the proximal surface of the lunate facet of the distal radius e and a line parallel to the articular surface of the ulnar head f.
Distance between a line drawn at the tip of the radial styloid process, perpendicular to the longitudinal axis of the radius g and a second perpendicular line at the level of the distal articular surface of the ulnar head h.
Angle between a line perpendicular to the longitudinal axis of the radius i and a line joining the distal tip of the radial styloid and the distal sigmoid notch j. Up to 2 mm is acceptable. Two hundred sixteen patients with extra-articular distal radius fractures were prospectively followed for over 1 year.
In another prospective cohort study, acceptable radiographic reduction was not associated with better self-reported functional outcomes SF and DASH or increased satisfaction at 6 months in a cohort of 74 elderly patients with conservatively treated distal radius fractures. This was further supported by a prospective, randomized study of 57 patients above the age of 60 years, which compared cast immobilization with percutaneous pinning. It found no correlation between radiological parameters and functional outcomes in terms of pain, range of movement, grip strength, activities of daily living, and the SF score.
A recent prospective study of 53 patients above the age of 55 years found no relationship between anatomic reduction as evidenced by radiographic outcomes and subjective or objective functional outcomes. Three smaller studies of 30 or less patients found satisfactory functional outcomes in a majority of patients even though they had unacceptable radiographic alignment.
Not all studies, however, have failed to find a correlation between functional outcomes and radiographic outcomes. While treating an elderly patient, the clinician must of course take into account many more factors other than the fracture pattern. One needs to consider medical comorbidities, operative risk, as well as functional demands.
A clinician should have a much higher threshold for intervention in an older patient with an unstable or displaced fracture than in a younger patient. That is not to say that we should accept poor reduction in all patients over a certain age. The increasing fitness and more active lifestyle of some elderly people these days means they are less likely to accept disability or deformity following a fracture.
Closed reduction and cast immobilization is the mainstay of treatment for minimally displaced, stable fractures. A cohort of 60 unstable distal radius fractures in patients with dementia or multiple medical comorbidities was treated by closed reduction and cast immobilization.
This led the authors to conclude there was little benefit to closed reduction in the very old and frail, dependent or demented patient. These patients can be treated with simple cast immobilization.
A systematic review looked at 37 randomized trials comparing different methods of conservative management. In the elderly with unstable osteoporotic fractures, where cast immobilization is not being relied upon to control alignment, the primary role of the cast is for comfort and support.
It should therefore be a functional cast, which should be relatively light and not hinder forearm rotation or finger movements. Early mobilization has been shown to hasten recovery in a randomized prospective trial of patients aged over of 55 years. Displaced fractures were reduced and the patients were randomized to either be treated conventionally or encouraged to mobilize the wrist in a cast that restricted extension. In both categories, patients encouraged to mobilize the injured wrist from the outset recovered wrist movement and strength more quickly than those immobilized in a conventional plaster cast.
The theoretical advantages of internal fixation of distal radius fractures lie not only in achieving anatomical reduction, but also in establishing stable fixation to allow early range of motion and rehabilitation. Internal fixation devices, however, have a much weaker hold in osteoporotic bone and are therefore more likely to loosen and lose fracture alignment. They act as a fixed internal buttress transferring the articular loads across the fractured metaphyseal bone to the intact diaphysis see Figure 2.
With the evolution of the fixed-angle locking plate, there has been a change in the treatment of distal radius fractures in the elderly. This has been highlighted by a study which looked at Medicare data in the United States for distal radius fractures in the elderly. This trend toward increased operative intervention is supported by studies examining functional outcomes in the elderly following surgery.
A retrospective analysis of 24 distal radius fractures in patients aged over 75 years treated with a volar fixed-angle plate showed good results with no significant loss of reduction. Functional outcomes were comparable to those of younger patients treated with internal fixation. In another cohort of 20 patients aged over 60 years treated with internal fixation following failed conservative management, 17 had a return to preoperative functional levels.
There were six plates removed due to dorsal wrist pain — a relatively high number of complications. Eighteen patients aged over 60 years in another retrospective series were treated with open reduction and internal fixation.
A comparative study of nonoperative treatment with volar locking plating in 70 patients aged over 70 years showed significantly better radiological outcomes in the operative treatment arm. External fixation of fractures of the distal radius has been in use since the s.
External fixation in elderly patients again presents difficulties due to weak hold of the pins in osteoporotic bone.
There are two main techniques of external fixation: A randomized control trial compared these two different methods of external fixation in a group of 38 elderly patients. A randomized controlled trial compared external fixation with conservative management for redisplaced fractures in 43 patients aged over 55 years.
A more recent retrospective trial of 46 consecutive patients aged over 65 years compared functional outcomes in patients treated with external fixation with those treated with conservative management.
There was no statistically significant difference in the DASH scores in wrist flexion, radial deviation, pronation, supination, grip strength, or pinch strength.
A smaller series looked at 16 women aged over 55 years with intra-articular distal radius fractures treated with external fixation. Only four patients had a poor functional outcome. One technique to prevent fracture displacement is to use percutaneous pinning as an augmentation to external fixation.
Biomechanical studies have shown increased stability. They were compared to a cohort of patients younger than 60 years treated with the same method, and there was no statistical difference in radiographic or functional outcomes.
The main complication of external fixation is pin-tract infection. The use of percutaneous pins Kirschner wires is an accepted practice for treatment of distal radius fractures either alone or as a supplement to external fixation. In severely comminuted or osteoporotic fractures, the trabecular bone of the metaphysis provides little inherent stability.
Wrist – Fractures
These fractures were considered a contraindication to percutaneous pin fixation. This view is supported by a prospective, randomized trial comparing percutaneous pinning with conservative treatment in 57 patients aged over 60 years with unstable, extra-articular frwktur of the distal radius.
This did not correlate with an improved functional outcome. In contrast, a retrospective study of 46 patients aged over 55 years comparing percutaneous pinning with conservative management had opposing results. The results showed superior anatomical and functional results in the group treated with Kapandji wiring. In elderly patients with osteoporosis, it is often difficult to fill the void left by impacted metaphyseal bone.
Bone substitutes may be injected into this void to support the compromised bone. Initially, polymethylmethacrylate cement was utilized.
More recently, the development of bone mineral substitutes promises better integration into the osseous matrix as well as providing similar mechanical properties to the bone. A Cochrane Review of 10 randomized control trials with bone substitutes found improved anatomical outcomes compared to plaster cast alone in 7 of the trials.
Reported complication of bone scaffolding was transient discomfort resulting from extraosseous deposits. These trials were not specific to an elderly population. A prospective, randomized study compared the outcome of conservative treatment with that using an osteoconductive synthetic material on patients aged over 50 years with fractures of the distal radius.
Functional results at 1 year were significantly different: The rates of malunion were Complications in the bone substitute group included extraosseous cement deposits causing discomfort in 30 patients and one case of intra-articular cement requiring surgical removal.
Stabilization and treatment of Colles’ fractures in elderly patients
Other draktur have shown that these bone substitutes may be better used as an adjunct to other forms of fixation rather than in isolation. Distal radius fractures in the elderly are often a result of osteoporosis.
Physical activity has been shown to reduce fracture risk by increasing bone density 54 and improving mobility, which decreases the risk of falls. There is a strong evidence that fraktuf reduce the risk of fracture in patients with osteoporosis. As can be seen from the studies in this review, there remains no absolute consensus on the best method for treatment of distal radius fractures in the elderly. Many of the trials in this review are observational studies with relatively few enrolled patients.
High-powered randomized controlled trials are required to better evaluate the different methods of stabilization in elderly populations. One thing that the clinician can appreciate from this review is the vast difference in patient characteristics in an elderly population.
In an active, healthy patient with an unstable fracture, an attempt at anatomic reduction and fixation through surgical means is more likely to render good functional results.