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COLLES FRACTURE

Posted on: December 15th, 2014 by admin No Comments

A distal radius fracture almost always occurs about 1 inch from the end of the bone. The break can occur in many different ways, however.

One of the most common distal radius fractures is a Colles fracture, in which the broken fragment of the radius tilts upward. This fracture was first described in 1814 by an Irish surgeon and anatomist, Abraham Colles — hence the name “Colles” fracture.

A Colles fracture occurs when the broken end of the radius tilts upward.

Other ways the distal radius can break include:

  • Intra-articular fracture. A fracture that extends into the wrist joint. (“Articular” means “joint.”)
  • Extra-articular fracture. A fracture that does not extend into the joint is called an extra-articular fracture.
  • Open fracture. When a fractured bone breaks the skin, it is called an open fracture. These types of fractures require immediate medical attention because of the risk for infection.
  • Comminuted fracture. When a bone is broken into more than two pieces, it is called a comminuted fracture.

It is important to classify the type of fracture, because some fractures are more difficult to treat than others. Intra-articular fractures, open fractures, comminuted fractures, and displaced fractures (when the broken pieces of bone do not line up straight).are more difficult to treat, for example.

Sometimes, the other bone of the forearm (the ulna) is also broken. This is called a distal ulna fracture.

This illustration shows some of the types of distal radius fractures.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Cause

The most common cause of a distal radius fracture is a fall onto an outstretched arm.

Osteoporosis (a disorder in which bones become very fragile and more likely to break) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position.

A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist.

Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.

Symptoms

A broken wrist usually causes immediate pain, tenderness, bruising, and swelling. In many cases, the wrist hangs in an odd or bent way (deformity).

Doctor Examination

If the injury is not very painful and the wrist is not deformed, it may be possible to wait until the next day to see a doctor. The wrist may be protected with a splint. An ice pack can be applied to the wrist and the wrist can be elevated until a doctor is able to examine it.

If the injury is very painful, if the wrist is deformed or numb, or the fingers are not pink, it is necessary to go to the emergency room.

To confirm the diagnosis, the doctor will order x-rays of the wrist. X-rays are the most common and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there is displacement (a gap between broken bones). They can also show how many pieces of broken bone there are.

(Left) An x-ray of a normal wrist. (Right) The white arrows point to a distal radius fracture.

Treatment

Treatment of broken bones follows one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed.

There are many treatment options for a distal radius fracture. The choice depends on many factors, such as the nature of the fracture, your age and activity level, and the surgeon’s personal preferences.

Nonsurgical Treatment

If the broken bone is in a good position, a plaster cast may be applied until the bone heals.

If the position (alignment) of your bone is out of place and likely to limit the future use of your arm, it may be necessary to re-align the broken bone fragments. “Reduction” is the technical term for this process in which the doctor moves the broken pieces into place. When a bone is straightened without having to open the skin (incision), it is called a closed reduction.

After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed 2 or 3 weeks later as the swelling goes down more, causing the cast to loosen.

Depending on the nature of the fracture, your doctor may closely monitor the healing by taking regular x-rays. . If the fracture was reduced or thought to be unstable, x-rays may be taken at weekly intervals for 3 weeks and then at 6 weeks. X-rays may be taken less often if the fracture was not reduced and thought to be stable.

The cast is removed about 6 weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.

Surgical Treatment

Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.

Procedure. Surgery typically involves making an incision to directly access the broken bones to improve alignment (open reduction).

A plate and screws hold the broken fragments in position while they heal.

Depending on the fracture, there are a number of options for holding the bone in the correct position while it heals:

  • Cast
  • Metal pins (usually stainless steel or titanium)
  • Plate and screws
  • External fixator (a a stabilizing frame outside the body that holds the bones in the proper position so they can heal)
  • Any combination of these techniques

An external fixator.

Open fractures. Surgery is required as soon as possible (within 8 hours after injury) in all open fractures. The exposed soft tissue and bone must be thoroughly cleaned (debrided) and antibiotics may be given to prevent infection. Either external or internal fixation methods will be used to hold the bones in place. If the soft tissues around the fracture are badly damaged, your doctor may apply a temporary external fixator. Internal fixation with plates or screws may be utilized at a second procedure several days later.

Stiff Elbow

Posted on: December 15th, 2014 by admin No Comments

The elbow joint is a type of hinge joint. It bends (flexion) and straightens (extension), as well as rotating to position your palm up or down. The normal range of flexion and extension is from 0 to 145 degrees, although the range of motion that we work within for daily activities is only from 30 to 130 degrees. This means that for most people a bit of loss of motion does not cause problems with function. However, with a reduction of extension greater than 30 degrees and or a flexion less than 130 degrees most people will complain of loss of function. Loss of extension is usually less disabling than loss of same degree of flexion.

Causes

Factors that cause stiffness are divided into those that are within the elbow joint itself (intrinsic) and those in the tissues around the joint, such as the muscles andtendons (extrinsic).

Intrinsic / Intra-articular Causes

  1. Post-traumatic Osteoarthritis
  2. Primary Osteoarthritis
  3. Rheumatoid
  4. Joint Infection
  5. Malunions

Extrinsic / Extra-articular Causes

  1. Burns
  2. Heterotopic Ossification
  3. congenital – arthrogryposis, congenital disloc radial head

Causes of flexion and extension stiffness in arthritis

The commonest cause of stiffness is after trauma and injury. In fact, some stiffness after an elbow injury is very common. Usually this improves, but sometimes it may not. The amount of stiffness isdirectly related to the degree of initial trauma and the degree of involvement of the joint surfaces is most important. The length of immobilisation after injury also leads to more long-term stiffness.

The ‘Simple’ Stiff Elbow is one that recovers well. The criteria are:

Mild to moderate contracture (<80o)

No or minimal prior surgery

No prior ulnar nerve transposition

No or minimal internal fixation in place

No or minimal heterotopic ossification (bone in the muscles)

Normal bony anatomy has been preserved

Treatment

The aim is to give the patient pain-free, functional and stable elbow. This means 30-130 degrees flexion and 100 degrees of rotation.

Physiotherapy involves passive motion exercises and stretching (not too aggressive) and active exercises. Ideally this should be with a physiotherapist who has an interest in upper limb rehabilitation.

Splinting may be used and is well tolerated and is effective when performed in a static progressive fashion.

Surgery is indicated when patients are no longer improving in their original post traumatic rehabilitation program. At least 3 to 6 months should be allowed for the inflammatory phase of soft tissue healing to resolve.

This may be performed via keyhole (arthroscopy) or open surgery. The decision depends on the surgeon’s experience and the type of stiffness.

Arthroscopic release is ideal for stiffness due to arthritis and when there has been no previous surgery. However, if there has been a previous internal fixation and there are extrinsic causes for the stiffness open surgery is required.