Ligamentotaxis principle in the treatment of intra articular fractures of distal end of radius

1. LIGAMENTOTAXIS PRINCIPLE IN THE LIGAMENTOTAXIS PRINCIPLE IN THE
TREATMENT OF INTRA ARTICULAR TREATMENT OF INTRA ARTICULAR
FRACTURES OF DISTAL END OF FRACTURES OF DISTAL END OF
RADIUSRADIUS
-- -- A PROSPECTIVE STUDY TO ASSESS A PROSPECTIVE STUDY TO ASSESS
CORRELATION BETWEEN RADIOLOGY AND CORRELATION BETWEEN RADIOLOGY AND
FUNCTIONFUNCTION
Dr. Manoj kumar P.N. ( PG Trainee )Dr. Manoj kumar P.N. ( PG Trainee )
Dr. Vinod kumar B.P. ( Asst. Prof )Dr. Vinod kumar B.P. ( Asst. Prof )
Dept of Orthopaedics, MCH TrivandrumDept of Orthopaedics, MCH Trivandrum

2. ABRAHAM COLLE [ 1773- 1843 ]ABRAHAM COLLE [ 1773- 1843 ]

3. # DISTAL END OF RADIUS# DISTAL END OF RADIUS
•1/6
th
of all trauma cases
•3/4
th
of all fractures of forearm
•Occurs in all age groups
•Results from low energy trauma
•No broad consensus regarding the
treatment and the anticipated outcome

4. # DISTAL END OF RADIUS# DISTAL END OF RADIUS
•Numerous classification systems
•Various treatment modalities have been
proposed
•What finally matters is the function
rather than surgical precision

5. # DISTAL END OF RADIUS# DISTAL END OF RADIUS

External skeletal fixation has been
increasingly popular in the treatment of
complex fractures of the distal end of
radius

6. AIMAIM
•To assess the correlation between radiology
and function in the treatment of intra-
articular fractures of distal end of radius
treated by external fixation ( JESS )

7. WHY THIS STUDY ?WHY THIS STUDY ?
•The functional outcome studied in
detail in various other studies
•Few and conflicting reports regarding
correlation between radiology and
function
•Treatment decisions are taken based
on X-rays
•So study assumes significance

8. MATERIALS AND METHODSMATERIALS AND METHODS
•Design of the study – Prospective
study
•Time period – Aug 2006 to Dec 2007
•Site of study – Department of
Orthopaedics, Medical College,
Trivandrum

9. MATERIALS AND METHODSMATERIALS AND METHODS
•Reference population – Southern districts
of Kerala and Tamilnadu
•Sample size -- 45 cases
•Inclusion criteria -- Intra-articular
fractures of the distal end of radius in the
age group of 20- 50 yrs treated by JESS
fixator

10. MATERIALS AND METHODSMATERIALS AND METHODS
•Exclusion criteria -- a) Undisplaced fractures of
distal end of radius with intra-articular extension
treated by plaster cast immobilization.
• b) Displaced intra-articular
fractures treated with JESS fixator which
subsequently got displaced and needed open
reduction and internal fixation
• c) Compound fractures of
the distal end or radius
• d) Displaced intra-
articular fractures of distal end of radius in
patients below 20yrs and above 50 yrs

11. MATERIALS AND METHODSMATERIALS AND METHODS
• Methodology -- Patients satisfying
the inclusion criteria were enrolled into the
study after obtaining due consent and
explaining the alternative treatment
modalities available.
•
•After pre-operative X-rays , JESS fixator was
applied and follow up X-rays were taken
immediate post op and at 3 weeks.

12. MATERIALS AND METHODSMATERIALS AND METHODS
•At 3 weeks JESS fixator was removed
in stable cases and a short arm cast
given. Cast was removed at 6 wks and
follow up X rays are taken at 6 weeks, 6
months and 1 year
•In unstable cases ( Types 3 and 4 ), the
JESS fixator was retained for 6 wks

13. THE FIXATORTHE FIXATOR
Developed by Dr, B B
Joshi from Mumbai
•Two 3.5mm Schanz
pins on the radius
and two 2.5mm pins
on the 2
nd

metacarpal.

14. JESSJESS

15. JESSJESS

16. Mc Murtry and Jupiter types 1 and Mc Murtry and Jupiter types 1 and
22

17. Mc Murtry and Jupiter Types 3 and Mc Murtry and Jupiter Types 3 and
44

18. RADIOGRAPHIC ASSESSMENTRADIOGRAPHIC ASSESSMENT
•The standard radiographic
measurements :
radial inclination
radial length
radial width or shift
palmar slope

19. Acceptable radiographic parameters for Acceptable radiographic parameters for
healed radius fracturehealed radius fracture::
•(Rockwood and Green’s Fractures in adults Vol 1 p
919 Table 26-2)
Radial inclination Less than 5 degree
loss
Radial length - Within 2-3mm of contra
lateral wrist
Palmar slope - No angulation past
neutral
Intraarticular step off - Less than 2mm

20. FUNCTIONAL EVALUATIONFUNCTIONAL EVALUATION
•We used Gartland and Werely’s functional
evaluation scores modified by Stewart
(1984 )
•Functional evaluation was done at 1year
follow-up
•Both subjective and objective evaluation
was done

21. SUBJECTIVE EVALUATIONSUBJECTIVE EVALUATION
•As per the scoring system, the following
subjective complaints were considered:
1) Pain 2) Limitation of movement
3)Disability 4) Restriction of activity
The results were graded as excellent( 0
points ), good( 2 points ), fair( 4 points ), and
poor( 6 points )

22. OBJECTIVEOBJECTIVE EVALUATIONEVALUATION
•Dorsiflexion <45degrees 5
•Palmar flexion <30degrees 1
•Ulnar deviation <25degrees 3
•Radial deviation <15degrees 1
•Supination <50degrees 2
•Pronation <50degrees 2
•Circumduction Loss 1
•Finger flexion Not to the distal crease 1-2
•Grip Loss of strength 1
•Radial or median Neuritis Mild-Severe 1-3

23. •The total objective evaluation score was
obtained by adding the evaluation scores
for each parameter
•The total functional assessment score is
the sum of the subjective and objective
evaluation scores and is graded into four
categories as follows:

24. FUNCTIONAL SCOREFUNCTIONAL SCORE
•0-2 Excellent
•3-8 Good
•9-14 Fair
•>15 Poor

25. CORRELATIONCORRELATION
•The correlation between radiology and
function was done using standard
statistical variables including the
Pearson’s correlation coefficient

26. OBSERVATIONSOBSERVATIONS
•Age
•The youngest patient
in our series was 22
years old and the
oldest was 50 years
old . The average age
of the patients at
the time of operation
was around
AGE
20
to
30
yrs
30
to
40
yrs
40
to
50
yrs
No.
of
patie
nts
121716

27. OBSERVATIONSOBSERVATIONS
• Gender
•The gender
distribution of
patients was as
follows:

M F %M%F
321372%28%

28. OBSERVATIONSOBSERVATIONS
•Mechanism of
injury
•Fourteen patients
sustained injury in
road traffic
accidents and the
remaining thirty-
one injured
themselves during a
fall
RTA FALL
No. of
patient
s
14 31

29. OBSERVATIONSOBSERVATIONS
•Dominant / Non
dominant side
involved
•Twenty nine fractures
involved the dominant
wrist and sixteen the
non-dominant side.
For all our patients the
right side was the
dominant one
Dom
inant
Non
domi
nant
% R%L
291664%36%

30. OBSERVATIONSOBSERVATIONS
Type - 1 20 (44%)
Type - 2 15 (33%)
Type - 3 06 (13%)
Type - 4 04 (10%)

31. FRACTURE TYPEFRACTURE TYPE
Type -1
Type -2
Type - 3
Type - 4

32. OBSERVATIONSOBSERVATIONS
•Delay in surgery:
•40 patients had their surgery ( JESS
fixator application ) done within 6
hours of presentation in our casualty.
Five patients had preliminary cast
application and so fixator application
was delayed by 24 to 48 hours.

33. OBSERVATIONSOBSERVATIONS
•Associated injuries:
•Fifteen of our 45 patients ( 33% ) had an
associated ulnar styloid fracture. Other
associated injuries included extra-articular
fracture of lower end radius on the other
extremity (1 patient ) , medial malleolus and
pubic rami fracture ( 1 patient ) , and a lower
thoracic spine fracture without neurological
deficits ( 1 patient ).

34. OBSERVATIONSOBSERVATIONS
•Hospital stay:
•Most of our patients were treated as
day case surgeries and were sent home
the same evening or next day morning.
Patients with associated injuries were
however admitted.

35. Type -1 # follow upType -1 # follow up

36. Case follow up-1Case follow up-1

37. Case follow up -1Case follow up -1

38. Case follow up 2Case follow up 2

39. Case follow up - 2Case follow up - 2

40. Case follow up 2Case follow up 2

41. ComplicationsComplications
•Finger stiffness or pain dysfunction
syndrome– 22/45
•Pin tract infection 4/45
•Loss of reduction – 2/45
•No nerve or tendon injuries

42. ResultsResults
•JESS is an rewarding method for the
treatment of intra articular fractures of distal
end of radius as 26 out of 45 cases ( 57.8
% )produced excellent results with this
technique
•Good results were obtained in 13 out of 45
( 28.9 % )
•So overall 85% patients had good to
excellent function in the end.

43. RESULTSRESULTS
•Good or acceptable radiology at 1 yr
produced good to excellent function
regardless of the fracture type.

44. RESULTSRESULTS
Radial length was the most significant
radiological parameter that affected the
functional scores.( Cumulative score of 66.7
at p< 0.05 )
In case No: 5, 6 and 26, in spite of other
radiological parameters being acceptable, a
deficiency of radial length spoiled an
otherwise good result
Similarly, in case no: 1, 14 41 and 45, accurate
restoration of radial length alone produced
good functional scores

45. RESULTSRESULTS
•Bad radiology does not invariably produce a
bad functional outcome ( Ref: Case No.8
where scores of 10/04/07/00 produced a
functional score of 07 indicating good
outcome
•A negative palmar slope consistently gives
bad functional results ( Ref: Case No. 10, 22
and 33 )
•Correction of palmar slope with JESS fixator
is difficult and may require additional
fixations like K wires.

46. To sum upTo sum up
•Good radiology = good function whatever be the
fracture type
•During reduction, correct and maintain the radial
length ( AP view ) and palmar slope ( lat view ).
No further manipulations for radiological finesse.
•Bad radiology may give reasonably good
function in the end
•Palmar slope correction with a JESS fixator is
difficult