Concurrent fractures of the hip and wrist: a matched analysis of elderly patients

INTRODUCTION

Osteoporotic fractures involving the hip and wrist are common in the elderly. The incidence of coincident hip and wrist fractures in the same patient is small but may represent a unique subpopulation of elderly with osteoporotic fragility fractures and little information has been published about these patients.

MATERIALS AND METHODS

We performed a retrospective review studying a series of 33 elderly patients who were admitted with concurrent hip and wrist fractures and matched them with patients of similar age, race, gender and co-morbidities with isolated hip fractures analysing their pre-morbid functional status, degree of osteoporosis by the Singh's index, length of stay and re-admission rate.

RESULTS

In our cohort of 33 matched pairs, location of fall in the study group consisted of 21 at home and 26 in the control group. The median duration of stay in hospital was 23 days versus 18 days in the control group. Bone density assessment of our study group revealed 18 patients with severe osteoporosis with Singh's index and 21 severe osteoporosis in the control group. The 1-year re-admission rate for the patients in the study group was 7 and 12 in the control group. Ambulatory status at discharge in the study group was 12 and in the control group 21.

DISCUSSION AND CONCLUSION

Our study population demonstrated a higher proportion of community ambulators with fewer 1-year re-admission rates and a high cervical:trochanteric ratio of 2.7, all of which signify that they belong to a physiologically younger and more active cohort than our control group of isolated hip fractures. Patients with concurrent hip and wrist fractures were not significantly more osteoporotic, and showed a trend toward longer stay in hospital and incurred a higher cost of stay. The confluent upper limb injury was the likely reason for their post-discharge impaired ambulatory status. The most common location of injury in both groups of patients is at home.

[Bulge of the scapholunate ligament: an arthro-CT sign of traumatic scapholunate instability]

Tears of the scapholunate ligament are usually diagnosed during an arthro-CT or arthro-MRI examination. Typically, the contrast agent passes from one joint to the other. In certain cases, fibrous scar tissue devoid of any mechanical effect may block the passage and lead to an erroneous interpretation of the images. We reviewed retrospectively patients who underwent arthroscopic treatment for scapholunate tears and who had normal arthro-CT images. We searched for specific aspects suggestive of ligament injury. Analysis of the arthro-CT images demonstrated that a bulge of the scapholunate ligament could be noted in patients whose diagnosis of scapholunate ligament injury was established arthroscopically. We propose that appropriate lecture of wrist images can identify scapholunate ligament injury in patients wrongly considered to be free of wrist injury, but who actually have an occult injury to the scapholunate ligament.

Case study: musicians' playing-related injuries

Professional and student musicians are at high risk of acquiring a playing-related injury at some point in their careers. Yet, specialized healthcare for musicians is scarce and expensive for most self-employed musicians. Diagnosing these injuries is challenging, and simply taking a break from an activity that has caused physical problems does not address the ergonomic and biomechanic causes of the problem. Under these circumstances, it is not surprising that musicians are reluctant to seek care, and when they do, lack trust in the care that is provided to them. This article is a case presentation of the experiences of a graduate student musician studying performance at a North American university. A narrative style is used to reflect the quality and nature of experiences this musician encountered, followed by a discussion of how to advance a more participatory and holistic approach to enabling return to function.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Present technique and long-term results of toe-to-antebrachial stump transplantation

Complete hand amputation has been considered conventionally as an indication for the use of mechanical prosthetic devices in order to regain some hand like function. A microsurgical option to create a new pinching ability after wrist amputation has been used in a series of 13 patients. The actual operation technique is presented in detail. It was designed by the senior author in 1981 and applied into clinical use in 1983. In order to evaluate the functional results and patient satisfaction in long-term, a questionnaire was sent to 12 patients and 11 patients were interviewed, examined clinically and studied with a hand function scoring test according Sollerman. The operated series consist of 12 adults with posttraumatic distal antebrachial or wrist amputations and 1 adolescent boy with a congenital wrist level amputation. There were 3 females and 10 males in the series. The satisfaction to achieved result was generally good. The ADL section of Tamai score and the one we used correlated well with each other and patient satisfaction. Sollerman hand function test gave worse results in two blind patients and same occurred in two short antebrachial stump patients. However the satisfaction was much better in Tamai score among blind patients, with wrist amputation level amputations. In our opinion this single toe transfer method gives an acceptable pinch reconstruction for hand amputation patients. We measured pinch strength and total active motion. They averaged about half of the normal values. The reconstruction is suitable to the patients, who are not willing to donate multiple toes or who are aware and concerned about the risks of human hand transplantation, which necessarily will need a life-long immunosuppressive medication to prevent from rejection.

Golf injuries and rehabilitation

There are more than 25 million golfers in the united States, and many have an injury related to golf. Low back injuries are the most common golf injuries, followed by elbow injuries. Successful treatment of golf injuries often includes modification of the golf swing. Adaptations allow many individuals, including those who are physically challenged, to enjoy playing golf.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

DATA COLLECTION AND ANALYSIS

The authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done.

MAIN RESULTS

Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. For interventions started during immobilisation, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilisation (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial).

AUTHORS' CONCLUSIONS

The available evidence from randomised controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal

Surgical repair of a Palmer type IB triangular fibrocartilage complex (TFCC) tear can be difficult using conventional dorsal portals and it may need special repair kits. The authors describe an arthroscopic technique using an additional volar portal that allows quick access and a secure purchase of peripheral TFCC tears as well as a distinct approach to dorsal wrist structures.

Functional outcome in patients with zone V flexor tendon injuries

INTRODUCTION

Zone V flexor tendon injuries may involve major nerves and arteries as well as the wrist and finger flexors. Although these injuries are not infrequent, few studies have reported functional outcomes. The purpose of this study was to evaluate the functional outcome in patients with flexor tendon repairs in zone V.

MATERIALS AND METHODS

Eighteen patients with repaired zone V flexor tendon injuries were followed up for an average of 20 months. The postoperative rehabilitation program consisted of a combined regime of modified Kleinert and modified Duran techniques. Outcome parameters were hand function according to the Buck-Gramcko assessment system, grip and key pinch strength values, and return to work status.

RESULTS

Functional results were excellent in 92.8% of the digits, good in 1.4%, and poor in 5.8%. Grip strength recovered to an average of 77% and pinch strength to 74% of the uninjured hand. Two tendon ruptures occurred in a patient, and tenolysis was required in 3 patients. Of 15 patients who were employed at the time of injury, 13 returned to their original occupations.

CONCLUSION

Satisfactory functional results can be obtained when proper surgical technique is coupled with careful postoperative management in patients with zone V flexor tendon injuries.

Extra help required by litigants after simple fractures--a questionnaire based study

A questionnaire based interview of 100 patients under fracture clinic review was undertaken to assess the help required with the activities of daily living (ADL) in the first 2 weeks following fractures of the hand, wrist, neck of humerus, foot or ankle. The amount of help patients required was correlated with whether or not the patients were claiming compensation for their injuries. Twenty-five percent were litigating and this was shown to influence the amount of help a patient reported having received with dressing, shopping, cooking, housework, personal hygiene and travelling (p<0.0001) and feeding (p<0.0022), but not with getting in/out of bed (p=0.52). Complications of the fracture were not shown to increase litigation. On average litigants required over 3 h extra help per day compared with non-litigants (6.4 h versus 2.75 h).

Unusual cause of wrist pain in a golfer

Wrist injury is common in golfers and normally occurs at the impact of the club with the ball. The unusual case is reported of a low handicap golfer with wrist pain aggravated by the putting stroke. The condition was resolved with treatment. The likely mechanism for the injury is discussed.

External fixation for unstable intra-articular distal radial fractures in women older than 55 years. Acceptable functional end results in the majority of the patients despite significant secondary displacement

Unstable intra-articular distal radial fractures in women older than 55 years were treated by closed reduction and external fixation to achieve the best functional outcome. Sixteen women had radiographic and functional assessment. Despite initial good alignment secondary displacement occurred in 11 patients, probably due to the comminution of the fracture and possibly influenced by osteoporosis. Malunion of the distal radius was seen in two patients and intra-articular incongruity with an intra-articular step exceeding 1 mm was observed in two other patients. The functional outcome was excellent or good in 10 and fair in two patients. Four patients had a poor functional outcome. Two of these patients had a significant loss of reduction, one resulting in a malunion. The other two had an intra-articular incongruity of more than 1 mm. Three of the four patients with a poor functional outcome had clinical signs of reflex sympathetic dystrophy.

CONCLUSION

Closed reduction and external fixation of "bad case" severely comminuted unstable distal radial fractures in the elderly may result in an acceptable functional outcome in the majority of the cases, although significant secondary displacement occurred in eleven of the sixteen patients.

Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria

OBJECTIVE

This study contrasted the use of responsiveness indices at the group level vs. individual patient level.

STUDY DESIGN AND SETTING

We followed a cohort of 211 patients (50% male; mean age 47.5 years; SD 14) with musculoskeletal upper extremity problems for a total of 3 months. Outcome measures included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Shoulder Pain and Disability Index (SPADI), Patient-Rated Wrist Evaluation (PRWE), and the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12). We calculated confidence intervals on various group-level responsiveness statistics based on effect size and correlation with global change. The proportion of patients exceeding the minimum detectable change (or reliable change proportion) and minimum important difference (MID proportion) were included as indices applicable to the individual patient.

RESULTS

For the DASH, effect size ranged from 1.06 to 1.67 for various patient subgroups, and the reliable change and MID proportions indicated that 50%-70% of individuals exhibited change based on individual change scores. Only the SRM and reliable change proportion indicated differences among the outcome measures used in this study.

CONCLUSION

The reliable change and MID proportions have an intuitive interpretation and facilitate quantitative responsiveness comparisons among outcome measures based on individual patient criteria.

Understanding and meeting the needs of farmers with amputations

BACKGROUND

Despite the hazardous nature of the occupation, farmers who sustain serious permanently disabling injuries return to the physical labor of production agriculture. It is estimated that amputations account for 11% of all major farm-related injuries.

PURPOSE

This report describes the process of reentry to farm work of farmers across the United States who experienced above-the-wrist traumatic amputations.

SAMPLE

Interviews with 16 farmers revealed the unique features of the work and world view of these workers who labor in the fields.

FINDINGS

The occupational recovery process included questioning, analyzing, and "getting along." Prostheses and formal rehabilitation programs were viewed as minimally helpful. Suggestions and resources that may be helpful for the orthopaedic nurse to assist this high-risk work group are included.

Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex lesions

Triangular fibrocartilage complex (TFCC) lesions are commonly repaired arthroscopically. Most of the interest in repairing TFCC lesions is focused on the development of an internal technique to avoid an extra incision of the skin. The most common techniques in use today are the inside-out or the outside-in, both of which have the disadvantage of requiring an additional opening to tie the suture. We suggest a personal method that allows an all-inside repair for type 1B lesions with a technique similar to the one used for rotator cuff repair in the shoulder.

Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy

A hand therapy clinic used a systematic process to select an outcome tool for routine use. After a literature review of available instruments, the choice had been narrowed to two instruments: the Disability of the Arm, Shoulder, and Hand (DASH) and the Patient-Rated Wrist Evaluation (PWRE). The PRWE was modified to attribute to the hand/wrist. A cohort of 60 patients (36 hand problems, 24 wrist problems) completed a DASH and PRWHE at their initial clinic visit and three months later. Standardized response means (SRMs) and effect sizes indicated a large treatment effect. The PRWHE had slightly higher responsiveness than the DASH (SRM=1.51 vs. 1.37). Because this level of responsiveness was obtained with fewer items, it was considered more efficient. A supplementary esthetics question was less responsive than either scale, but was thought to be an important option for selected patients. On completion of the trial period, the therapists unanimously selected the PRWHE with a supplemental esthetics question to be routinely used in measurement of outcomes.

Functional evaluation of comminuted intra-articular fractures of the distal humerus (AO type C). Long term results in twenty-six patients

The authors present the results achieved in 26 patients who presented with intra-articular fractures of the distal humerus (8 AO type C1, 8 C2 and 10 C3) and who were operatively treated between 1999 and 2001; they were retrospectively evaluated after a mean follow-up period of 70.2 months. There were 12 males and 14 females with a mean age of 46.1 years. After a standard posterior approach with olecranon osteotomy, internal fixation was achieved with unilateral or bilateral plates and screws, or isolated screws and/or Kirschner wires. Anterior intramuscular transposition of the ulnar nerve was performed in 14 of the patients. The results were evaluated using the criteria of Morrey. The results were graded as excellent in 6 patients (23.1%), very good in 15 (57.6%) and fair in 5 (19.3%). Complications included postoperative ulnar nerve palsy (1), wire migration (4), heterotopic ossification (3), infection (2) and material failure (2). The overall re-operation rate was 38.4%. The authors conclude that careful preoperative planning, transolecranon approach for good visualisation, routine ulnar nerve exploration and stable internal fixation facilitating early active rehabilitation, remain the gold standard for the treatment of intra-articular fractures of the distal humerus.

Nonunion of distal radius fractures

Nonunion of a distal radius fracture is extremely uncommon. Healing problems in the distal radius seem to be related to unstable situations, such as concomitant fracture of the distal radius and ulna, and to an inadequate period of immobilization. Nonunion should be suspected if there is continuing pain after remobilization of the wrist in combination with a progressing deformity. The diagnosis may be confirmed by showing movement at the fracture site on lateral radiographs of the wrist in flexion and extension. Because of the rarity of distal radius fracture nonunion, it is not surprising that there is no consensus on the optimum mode of operative treatment. Based on our experience with reconstruction surgery in 23 patients, we think that most nonunions of the distal radius are amenable to attempts to re-align and heal the fracture even when the distal fragment is small. Therefore, surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

[Three cases of chronic volar dislocation of the distal radioulnar joint that were treated with the Sauvé-Kapandji procedure]

Three cases of chronic volar dislocation of the distal radioulnar joint were treated with the Sauvé-Kapandji procedure. All patients were in their twenties. They visited our clinic complaining limitation of forearm wrist rotation and pain around the wrist for more than 6 weeks after an injury. Radiograph and CT scan revealed chronic volar dislocation of the distal radioulnar joint. Closed reduction failed. The Sauvé-Kapandji procedure was required to prevent the distal radioulnar joint from becoming unstable after open reduction. Range of motion of the injured wrist improved greatly, pain disappeared and they were able to return to sports after the operation and rehabilitation. Therefore, the Sauvé-Kapandji procedure is effective in curing chronic volar dislocation of the distal radioulnar joint.

[Aftercare following distal forearm fractures and carpal trauma]

Rehabilitation following operative or conservative treatment of fractures of the distal forearm and carpal trauma takes effect through adequate immobilization and ought to be maximized by a differentiated application of every means of physiotherapy, ergotherapy, and physical medicine available. Rehabilitation of the fractured distal forearm and carpal trauma are presented based on the therapeutic guidelines as applied by the Department of Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftliches Unfallkrankenhaus Hamburg.