Vol 2 | Issue 3 | Sep - Dec 2014 | page:12-16 | Kiran Kalaiah, Vivek N Savsani,  Harish U,  Sunil Kumar P C, Kaladagi P S

Author: Kiran Kalaiah[1], Vivek N Savsani[1],  Harish U[2],  Sunil Kumar P C[1], Kaladagi P S[1]

[1] Mysore Medical College & Research Institute

[2] Registrar,R.N Cooper Hospital,Mumbai.

Institute at which research was conducted: Mysore Medical College And Research Institute,Mysore.
University Affiliation of Thesis: Rajiv Gandhi University Of Health Sciences Karnataka.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Harish U
S/o NO.3 2nd Main 7th Cross Amarjyothinagar, Vijayanagar, Bangalore, Karnataka - 560040
Email: 77harish36@gmail.com

 Abstract

Background: Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone. They are 3-4 times more common in women than in men. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. Internal fixation of trochanteric fractures is a life saving measure in the elderly.There are many options available for internal fixation of trochantric fractures like dynamic hip screw(DHS),dynamic condylar screw(DCS),GAMMA nail,proximal femoral nail,95 degree angle blade plate etc. Our aim in this study is to evaluate surgical and functional outcome of 95° angle blade plate in treatment of , intertrochanteric fractures.
Methods: 20 patients,13 male,7 female. The mean age was 59 years with intertrochanteric fracture of femur were treated by open reduction and internal fixation with 95 degrees angle blade plate.
Results: Evaluation of cases using Kyle Criteria: Results were evaluated by Kyle criteria. 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.
Evaluation of cases according to anatomical outcome: 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.
Conclusion: The 95 degrees angle blade plate is a suitable option for the treatment of intertrochanteric fractures and subtrochanteric fractures.
Keywords: Intertrocantric fracture, 95 degrees angle blade plate.

Introduction

Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone.1 Most of them result from a simple fall from standing height.  They are 3-4 times more common in women than in men. Though the energy is low, comminution of the fracture is usually seen due to osteoporosis. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. A cadaver study has shown that the energy required to break this tough bone is very high in young adults. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. Osteoporotic hip fracture is increasingly recognized as a growing problem in Asia as per the Asian Audit Report, 2009. It is estimated that the incidence of hip fracture will rise from 1.66 million in 1990 to 6.26 million by 2050. Also by 2050, more than 50% of all osteoporotic fractures will occur in Asia. Among elderly patients, hip fractures are associated with an in-hospital mortality of 7-14 %.10,11 In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. But this method is associated with high mortality and morbidity rates, 30% of elderly patients die within 1 year of fracture. After 1 year, patients resume their age-adjusted mortality rate. Current guidelines recommend that surgeons perform hip fracture surgery within 72 hours of injury as observational studies suggest earlier surgery is associated with better functional outcome and lower rates of non-union, shorter hospital stays and duration of pain and lower rates of complication and mortality. Internal fixation of trochanteric fractures is a life saving measure in the elderly. Proper precautions are to be taken during surgery to prevent complications like coxa vara deformity, shortening, limited hip movements and secondary osteoarthritic changes in the hip. Post-fracture rehabilitation is equally necessary. Early post-operative ambulation and physiotherapy is crucial and the best approach for the patient. The overall goal is returning of patient to pre-morbid level of function.

Materials and Methods

The present study includes 20 cases of intertrochanteric fracture of femur in adult patients above 16 years of age irrespective of sex treated by open reduction and internal fixation with 95 degrees angle blade plate, in the Department of Orthopaedics at K.R Hospital, Mysore, attached to the Mysore Medical College & Research Institute, Mysore, from November 2011 to October 2013, selected on the basis of purposive sampling (Judgment sampling) method. The average age incidence was 59 years. 13 males and 7 females. Among them the minimum age was 17 years and maximum age noted was 80 years. 45% of the patients were in the age group of 61 - 70 years with the mean age of 54 years for males and 67 years for females. Predominantly males were affected. Fall from standing height was the most common mechanism of injury. Type II fractures were the most common. The average duration of hospital stay was 20.15 days. 12 patients had fracture on the right side. And 8 patients had a fracture on the left side. In our study 7 fractures were Boyd and Griffin's type II fractures, followed by 6 cases of type III, 4 cases of type I and 3 cases of type IV. . The final results were evaluated by  Kyle criteria, anatomical outcome.

Results

Results were evaluated by Kyle criteria, anatomical outcome.
Evaluation of cases using Kyle Criteria: In our study, 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.

Evaluation of cases according to anatomical outcome:
In our study, 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.

Conclusion

Hip fractures are the leading cause of morbidity and mortality in the elderly. Intertrochanteric fractures are a common injury, more commonly seen in elderly females and arising out of trivial fall. Patients with trochanteric fractures are bed-ridden, which leads to severe health problems and reduced quality of life which increases the burden on the care-givers. Patients with trochanteric fractures undergoing early surgery have an improved ability to return to independent living and prevention of complications of prolonged immobilisation. The 95 degrees angle blade plate can be used for both stable and unstable intertrochanteric fractures, but the final outcome is dependent on various factors such as the type of fracture, the condition of the medial wall, the bony architecture, and the co-morbid conditions of the patient, the operative technique, implant position and post-operative care. The position of the implant should be such that the tip of the blade should be in the lower half of the femoral head and the blade should pass below the superior cortex of the neck. This study shows that the 95 degrees angle blade plate offers a reliable and effective alternative for the treatment of trochanteric fractures.
The 95 degrees angle blade plate is a stable and acceptable implant for the treatment of intertrochanteric fractures.

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Vol 2 | Issue 3 | Sep - Dec 2014 | page:5-8 | Azhar A Lakhani, Neetin Mahajan, Dhiraj V Sonawane

Author: Azhar A Lakhani[1], Neetin Mahajan[1], Dhiraj V Sonawane1[1]

[1] GGMC and Sir JJ group of hospitals, Mumbai.

Institute at which research was conducted: GGMC and Sir JJ group of hospitals, Mumbai.
University Affiliation of Thesis: Maharashtra University of Health Sciences, Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Azhar A Lakhani
S/o Azizuddin Lakhani,
A-2, Flat-2, Salimabad society, sandeep talkiz road,
Yavatmal-445001
Maharashtra
Email: lakhaniazhar@gmail.com

 Abstract

Background: Intracapsular fractures of neck femur have always presented a great challenge to orthopaedics surgeons and remain in many ways the unsolved fracture as far as treatment and results are concerned.
Methods: Cases included in this study are transcervical and subcapital fracture neck femur in patients less than 60 yrs of age managed in Sir JJ Hospital, Mumbai -08.
Results: Fracture type, anatomical reduction and proper implant selection are the most important factor affecting the outcome of management of fracture neck femur whereas age, time interval, method of reduction, and capsulotomy play a less important role.
Conclusion: Dynamic Hip Screw (DHS) is a better implant in management of most of the cases of fracture neck femur. High subcapital fractures are an exception to this rule.
Keywords: Fracture neck femur, transcervical/ subcapital fracture, canulated cancellous screw, dynamic hip screw, avascular necrosis, non union.

Introduction

Fractures of the femoral neck are devastating injuries that most often affects the elderly and have a tremendous impact on the health Care system and society in general. The worldwide incidence of femoral neck fractures has continued to increase. From an estimated 1.3 million hip fractures in 1990. This number is predicted to rise to 2.5 million by 2025 and 4.5 million by 2050, assuming there is no age specific increase. Amongst these the fractures occurring in young patients are particularly troublesome. The fracture is regarded as a vascular injury to the bone's blood supply[3-8]. The degree of vascular compromise is thought to directly correlate with the displacement of the fracture which affects fracture union and leading to complications. Hence intracapsular fracture neck of femur is regarded as an orthopaedic emergency[9] and needs to be reduced with rigid internal fixation which is believed to improve the circulation of femoral head and prevent the non union and avascular necrosis. Internal fixation with cannulated cancellous screws after good anatomical reduction has the advantages of decreased blood loss and operative time, lower transfusion requirements and decreased length of hospital stay[9]. Richards et al has quoted basic advantages of using sliding hip screws in terms of strength greater than multiple cancellous screws, minimization of risk of subsequent subtrochanteric fracture secondary to a stress riser effect, and placement of compression across the fracture at the time of reduction. Disadvantages of the sliding hip screw for femoral neck fracture stabilization include a larger surgical exposure and the potential to create rotational malalignment of the femoral head at the time of screw insertion [10]. However inspite of available modalties and techniques there is high rate of compliations particularly in young patients suffering from fracture neck femur. We have undertaken this comparative study to assess the outcome of both fixation modalities as well as factors influencing the results of these fixations in our population and attempt to fill in the lacunae in our understanding of management of fracture neck femur.

Methods

Cases included in this study are transcervical and subcapital fracture neck femur in patients less than 60 yrs of age. The cases studied for this dissertation were managed in Sir J J Group of Hospitals, Mumbai-08. The ethical clearance for this study has been obtained from this institutions ethical Committee.
The total number of cases studied were 62
The total patients were divided into two subgroups
1. Patients treated with multiple cancellous screws (31 )
2. Patients treated with dynamic hip screw and derotation screw (31).
All the patients were followed up with radiological and functional assesement.

Discussion

Age, sex and laterality of fracture: We have found no studies suggesting the role of these variables in the outcome of fracture treatment. In our study as well, we have not found these factors to play any role in the outcome of fracture treatment. Modality of treatment: On assessment of patients on follow up with Harris hip score, w e found excellent result in 61.3 % of our patients managed with DHS while only 25.8 % of patients managed with CC screw showed excellent result. On the other hand 9.7 % patients managed with CC screw showed poor results while none of the patients managed with DHS showed poor result. This difference is statistically significant with p value of 0.024 as calculated by Chi-square test. Also overall Harris hip score of patients managed with DHS was higher as compared to the score in patients managed with CC screw. We have found DHS not only to be to be more stable but also allows better compression across the fracture, allowing early mobilization and early union. There was no complication of non-union in patients managed with DHS while 3 patients managed with CC screw progressed to non-union. Average time for union in our study was 14 weeks for patients managed with DHS while it was 18 weeks for patients managed with CC screw. We recommend use of DHS with derotation screw for managing all the patients of fracture neck femur i/v/o early mobilization, early union and reduced risk of non-union. Fracture type: Pauwel's type-3 femoral neck fractures are problematic to treat, with non-union rates higher than those reported for historical controls. In one of the studies on Pauwel's type III fractures [11] non-union rate of 16% was reported with cannulated screws and 8 % with fixed angle device and supports the theory that these type-3 fractures experience shear and may demonstrate a higher rate of varus, shortening, and non-union. In our study, 8 patients had Pauwel's type III fracture of which 5 patients were managed with DHS while 3 patients were managed with CC screw. Complications like delayed union and varus were seen in patients managed with CC screw. However no patients with type III fracture ended up in non-union. Biomechanically, it has been shown that a sliding hip screw device is stronger than three parallel cancellous screws for the treatment of Pauwel's type III intracapsular neck femur fractures. Stability and the quality of reduction appeared to influence the rates of adverse outcomes in our series. We recommend use of DHS with derotation screw in Pauwel's type III fractures as adequate compression is achieved intraoperatively by placing 5 mm shorter lag screw in inferior quadrant of the neck and placing the derotation screw wider apart in superior quadrant. We have found limitation of this construct in high subcapital fracture where DHS threads won't have enough purchase in femoral head[12 ]. Time interval between injury and surgery: Advocates of early surgery suggest that the main advantages of prompt reduction of a displaced femoral neck fracture are unkinking of the vessels and performance of an intracapsular decompression to remove the hematoma that increases intracapsular pressure [13,14,15]. This improves and restores blood flow to the femoral head, minimizing the risk of femoral head osteonecrosis. In our study majority of our patients were treated within twenty-four hours after the injury. However, the exact time to treatment is difficult to ascertain. In our study however higher risk of non-union was seen in patients managed with CC screw who underwent surgery more than 72 hrs after trauma. The probable reason is that when surgery is delayed for more than 72 hrs there is resorption at fracture ends and compression across the fracture site is poor, more so with CC screw as compared to DHS.[16 ]. Method of reduction (open vs. closed): In our study only 13 % (8 patients) required open reduction of which 1 patient developed Avascular Necrosis. Hence we do not consider open reduction as a risk factor for AVN. Role of Capsulotomy: The role of capsulotomy in the treatment of femoral neck fractures remains controversial, and the practice varies by trauma program, region, and country. Clinical studies [17-21] have shown that decompressing the intracapsular hematoma by means of a capsulotomy or aspiration reduces the intracapsular pressure. This decrease in the intracapsular pressure results in improved blood flow to the femoral head and may reduce femoral head Ischemia [17-23]. In our study the difference in the rate of osteonecrosis between those who had and those who had not received a capsulotomy was small; however, our sample size was too small for us to make definitive conclusions about the value of capsulotomy. Capsulotomy was not done in patients managed with DHS as reaming for lag screw placement was considered to decompress the femoral head. Post-operative radiological reduction: Portzmann RR et al [24] and Lee ch et al [25] and several others have found increased complications like non-union and AVN in patients with non- anatomical post operative reduction. Complications like non-union, AVN, shortening and post operative poor functional outcome were seen more commonly in patients who were fixed in malalignment. Hence it is recommended by us to reduce the fractures anatomically or in valgus impacted position. Positioning of Lag screw and type of barrel: Screw position26 can be assessed with implant-cortical bone purchase by evaluating the distance from the implant to the cortex. Baumgaertner et al.[27] proposed what has become the well-known concept of the tip-apex distance (TAD). In our study the exact distance was not measured due to variable magnification of available x-rays and lack of proper scaling of the x rays and hence the stability of reduction and the relation of TAD with the outcome could not be commented. Similarly, we have found that placement of DHS lag screw in the inferior quadrant along the calcar and use of long barrel plate increases the stability of fixation and hence is recommended by us. We have also found Dynamic Hip Screw with derotation screw to have greater ability to compress across the fracture site as compared to Canulated Cancellous screw. However, further biomechanical studies are recommended for confirmation. Duration of surgery and blood loss: Average duration of surgery in patients managed with CC screw was 50 mins while that in DHS group was 90 mins. Incision for CC screw group was smaller as compared to DHS group. Average blood loss for CC group was 50 cc while that of DHS group was 150 cc. Complications: In this study, the risk factors for fracture non-union after internal fixation of intracapsular femoral neck fractures, we found that a displaced fracture, borderline and unacceptable reduction, and more centralized screw position were risk factors for non-union and implant failure. The factors that have been most consistently found to be predictive of non-union after fixation of intracapsular femoral neck fractures are poor reduction and fracture displacement. Age and sex are not risk factors for non-union in most studies, including our study. Fracture site, fracture level, and bone density were not found to be related. Of the 3 patients managed with CC screw that went into non-union, 2 patients were fixed in borderline retroversion and 1 was fixed in varus. [28] In our study we have achieved union rate of 100 percent with DHS while it is 90 % in patients managed with CC screw. High rate of union in DHS group was due to significant compression and impaction achieved across the fracture site. Avascular Necrosis : AVN was seen in 6 cases (9.7 %) in our series. Of this 4 cases were managed with DHS while 2 patients were managed with CC screw. Of the patients who developed AVN, none of the patients required further surgical management in the form of hip replacement till follow-up. Further collapse was prevented in these patients with the use of bisphosphonates. Union was confirmed radiologically by corticalization across the fracture site in AP and lateral views and filling of earlier bone defects with remodelling of bone. Minor complications like superficial infection and bursitis were encountered but these complications were managed with oral/ IV medications. None of these minor complications were found to affect the overall functional outcome.

Clinical Message

The aim of this study was to study various factors related to the anatomical and functional outcome in the management of fracture neck femur. With the increasing incidence of fracture neck femur in young adults this study aims in providing precise management protocols and thereby reducing the incidence of complications in young patients. Anatomical reduction is of prime importance for any fracture neck femur to unite. All cases of fracture neck femur in patients less than 60 years of age should be managed with DHS with Derotation screw with the exception of high subcapital fracture which should be managed with Canulated cancellous screws.

Bibliography

1. David g lavelle, fractures and dislocations of the hip in : campbells operative orthopaedics. Terry canalle s, beaty JH : editors. Pennsylvania. 2008; mosby Elsevier. 11th edition, volume -3 : p3237-308
2. Ross k Leighton, fractures of neck of femur in rockwood and greens fractures in adults. Bucholz R W heckman J D, courtbrown C M. Editors Philadelphia. 2006, lippincot Williams and Wilkins, 6th edition, vol 2, p 1753-92
3. Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976;58:689-95.
4. Thuan V. Ly and Marc F.Swiontkowski. Treatment of Femoral Neck Fractures in Young Adults. J Bone Joint Surg Am. 2008;90:2254-2266.
5. Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986 ;26:932-7.
6. Zetterberg CH, Irstam L, Andersson GB. Femoral neck fractures in young adults. Acta Orthop Scand. 1982;53:427-35.
7. Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837-46.
8. . Luice RS, Fuller, Stephen, Burdick DC and Johnston RM,: ―Early prediction of avascular necrosis of the femoral head following femoral neck fractures‖. Clinical Orthopaedics. 1981; 161: p207-14. 9. Ross K Leighton. Fractures of the Neck of Femur. In: Rockwood and Green's Fractures in Adults. Bucholz RW, Heckman JD, Court-brown CM: editors. Philadelphia. 2006; Lippincott Williams & Wilkins. 6th ed,vol-2; p1753-92.
10. Behr JT, Dobozi WR, Badrinath K. The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop 1985;198:173â€―178.
11. Liporace F, Gaines R, Collinge C, Haidukewych GJ.: Results of internal fixation of Pauwels type-3 vertical femoral neck fractures.: J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS
12. MP Singh, Aditya N Aggarwal, Anil Arora, Ish K Dhammi, and Jagjit Singh:Unstable recent intracapsular femoral neck fractures in young adults: Osteosynthesis and primary valgus osteotomy using broad dynamic compression plate: Indian J Orthop. 2008 JanMar; 42(1):43-48.
13. Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837-46.
14. Claffey TJ. Avascular necrosis of the femoral head. An anatomical study. J Bone Joint Surg Br. 1960;42:802-9.
15. Swiontkowski MF, Tepic S, Rahn BA, Cordey J, Perren SM. The effect of fracture on femoral head blood flow. Osteonecrosis and revascularization studied in miniature swine. Acta Orthop Scand. 1993;64:196-202.
16. George J. Haidukewych, Walter S. Rothwell, David J. Jacofsky, Michael E. Torchia and Daniel J. Berry: Operative Treatment of Femoral Neck Fractures in Patients Between the Ages of Fifteen and Fifty Years: J Bone Joint Surg Am. 2004;86:1711-1716.
17. Bonnaire F, Schaefer DJ, Kuner EH. Hemarthrosis and hip joint pressure in femoral neck fractures. Clin Orthop Relat Res. 1998;353:148-55.
18. Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br. 1991;73:73-5.
19. Holmberg S, Dalen N. Intracapsular pressure and caput circulation in nondisplaced femoral neck fractures. Clin Orthop Relat Res. 1987; 219:124-6.
20. Crawfurd EJ, Emery RJ, Hansell DM, Phelan M, Andrews BG. Capsular distension and intracapsular pressure in subcapital fractures of the femur. J Bone Joint Surg Br. 1988;70:195-8.
21. Str¨omqvist B, Nilsson LT, Egund N, Thorngren KG, Wingstrand H. Intracapsular pressures in undisplaced fractures of the femoral neck. J Bone Joint Surg Br. 1988;70:192-4.
22. Swiontkowski MF, Tepic S, Perren SM, Moor R, Ganz R, Rahn BA. Laser Doppler flowmetry for bone blood flow measurement: correlation with microsphere estimates and evaluation of the effect of intracapsular pressure on femoral head blood flow. J Orthop Res. 1986;4:362-71.
23. Woodhouse CF. Dynamic influences of vascular occlusion affecting the development of avascular necrosis of the femoral head. Clin Orthop Relat Res. 1964;32:119-29.
24. Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976;58:689-95.
25. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. 2003;123:527-33.
26. Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques.J Orthop Trauma. 2007;21:544-8
27. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64.
28. Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck. Injury. 2002;33 Suppl 3:C24-32. .

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Vol 2 | Issue 3 | Sep - Dec 2014 | page:9-11 | Saraogi Akash Ashok, Sonawane Dhiraj V, Chandanwale Ajay, Jagtap Sanjay A,  Shah Nadir Z, Bhoyar Rahul P

Author: Saraogi Akash Ashok[1], Sonawane Dhiraj V[1], Chandanwale Ajay[1], Jagtap Sanjay A[1],  Shah Nadir Z[1], Bhoyar Rahul P[1]

[1] J.J. Hospital, Byculla, Mumbai-08

Institute at which research was conducted: Grant Government Medical College & Sir J.J. Group Of Hospitals, Byculla, Mumbai-08.
University Affiliation of Thesis:Maharashtra University Of Health Sciences, Nashik.
Year of Acceptance: 2014

Address of Correspondence
Dr. Saraogi Akash Ashok
Assistant Professor, M.S. (Ortho.), J.J. Hospital, Byculla, Mumbai-08.
Email: saraogiakash@gmail.com

 Abstract

Background: Management of distal radius fractures has changed significantly since Colle's proclamation in 1814. Our study is intended to find out both conceptual and practical guidance for precision treatment with an expectant favorable result.
Method: 120 patients of distal end radius fractures were treated with Cast immobilization, Augmented External fixation, Volar locking plate fixation, Percutaneous Pinning and plaster immobilization. A.O. classification was used. Functional outcomes were assessed using “Demerit point rating system” of Gartland & Werley (modified).
Results: The most common fracture type was A2. 63.3% excellent results were obtained in the plating group as compared to 46.7% in the cast group and the k-wiring group. 63 patients had excellent result outcome, 31 patients had good, 23 patients had fair and 3 patients had poor result outcome.
Conclusion: Functional outcome depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures. They are related more to the quality of anatomical reduction than to the method of immobilization. Volar locking plating is a safe and effective treatment for unstable fractures. Specially locking implants provide advantages in fractures with metaphyseal comminuted zones (A3 and C2 fractures).
Keywords: Distal Radius Fracture, Functional Outcome, Colle's Fracture, Volar Plating.

Thesis Question: Which is best modality of treatment of Distal End Radius Fracture?
Thesis Answer: Depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures, however, volar locking plating is a safe and effective treatment for unstable fractures.

Introduction

The management of distal radius fractures has changed significantly since Colle's proclamation in 1814. Distal radius fractures have an approximate incidence of 1:10,000 people and represent 16% of skeletal and 74% of forearm fractures. They are more prevalent among females. The most common trauma mechanism is falling over the outstretched hand. The desire for anatomical restoration of the distal radial joint is the rationale for operative treatment. The extent of displacement, the degree of articular disruption, the stability and the reducibility of each fracture, as well as any concurrent injury to adjacent nerves, tendons or carpal structures must be assessed carefully in the planning of logical treatment. More than 1000 peer-reviewed studies have been published on the subject, yet there is no consensus on which treatment is superior or firm guidelines for treatment decisions. Distal End Radius fracture is frequently comminuted & this is responsible for slipping of the reduction, which is a rather common late feature. It is observed, therefore, that this fracture possesses little or no stability following closed reduction & it goes on for gradual collapse.

Aims & Objectives

1. To study fracture patterns of distal radius fractures & compare the results of different methods of treatment of fracture distal end radius.
2. To find out relationship between articular incongruity or perfect anatomical restoration of distal radius fractures and functional results & find out basis for selecting the method of treatment.

Materials and Methods

Study Design:
In this study 120 patients were treated for fractures of distal end radius in a tertiary care centre in a metropolitan city.
Inclusion criteria:
· Age - 15 to 65 years.
· The patient presented within two weeks of the injury.
Exclusion criteria:-
· Immature skeleton
· Congenital Deformity
· Compound cases
Study Period:
May 2011 to Oct 2013

Method Of Study:
After the approval from Institutional Ethics Committee, 120 patients of distal end radius fractures were enrolled in the study after obtaining informed written consent. A.O. classification was used for classification of fractures.
Techniques used:
1. Conservative — Cast immobilization
2. Operative —
a) External fixation
b) Internal Fixation - Volar locking plate fixation.
c) Percutaneous Pinning and plaster immobilization.
Intervention was done within a week after presentation.
Scoring System
Functional outcomes were assessed at final follow up visit using “Demerit point rating system” of Gartland & Werley {modified by Sarmiento et al (1975) & further modified by Lucas & Sachtjen(1981)} [2]

Results

The most common fracture type treated by Casting was A2 type, by Augmented external fixation was C2 type & by K-wiring was A2 type. The most common fracture type in this study was A2 followed by C2 & A3. The mean age of the study participants was 37 years. Age range was 18-65 years. Males were more commonly affected with M:F ratio of 3.3 : 1. Non-dominant side was more commonly involved than the dominant side. The mean volar tilt in the augmented external fixation group was -0.30 degrees whereas the median of the same group is 4 degrees. The mean for plating group is 3.43 degrees. The mean radial angle is highest in the plating group i.e. 19.13 degrees whereas it is lowest in K-wiring group i.e. 16.33 degrees. Mean value of Modified Gartland & Werley Total Demerit Score was 4.23 for the plating group whereas it was 6.37 for the K-wiring group. One patient developed pin tract infection in the k-wire group whereas 2 patients developed pin tract infection in the exernal fixator group. 2 patients in the Volar LCP group developed superficial infection, which resolved with antibiotics and dressings. 63.3% excellent results were obtained in the plating group as compared to 46.7% in the cast group and the k-wiring group. Overall, 63 patients had excellent result outcome, 31 patients had good, 23 patients had fair and 3 patients had poor result outcome.

Discussion

The demerit point system was chosen over other functional scoring systems as it takes into consideration not only objective evaluation but also the subjective parameters and complications associated with treatment like poor finqer function, nerve complication and pain due to arthritis. The cast immobilization was done in non-articular undisplaced, non-articular displaced reducible and stable and articular displaced reducible and stable fractures (A.O. type- A2, B1 & C1 in this study). It has given Excellent to Good results in 80% cases treated conservatively. The results were better than in a series presented by Gartland and Werley (1951) (Excellent to Good results in 68.3%) due to proper selection of treatment in present series whereas in other series cast were given in all cases.
Indications for operative management were:
Displaced intra-articular fractures with (either of them):
1.Post reduction articular step of > 2 mm,
2.Post reduction radial shortening of > 3 mm,
3.Post reduction > 15 degrees of saggital plane angulation (as measured from the anatomical volar tilted position).
The type of operative treatment was selected was according to the fracture anatomy.
Augmented External fixator with ligamentotaxis was used in non-articular irreducible displaced fractures; articular, displaced fractures which were reducible but unstable; irreducible and complex fractures (A.O.Type- A3, C2, C3 in this study). Excellent to Good results were obtained in 76.6% cases, Fair in 20% eases. The results were comparable to other series (Good 85%, Fair 12% - Cooney WP et al 1979).
Trans-fixation with k-wire and immobilization in cast was done for non-articular displaced reducible but unstable fracture and articular displaced reducible and stable fractures (A.O.Type – A2, A3, B1, C1, C2, C3 in this study). In the present series, results were Excellent to good in 70%, fair in 23.3% and poor in 6.7% cases. In a series presented by Suman R.K. (1983) Excellent to Good results were in 81.1% and Fair to Poor results in 18.9% cases.
Internal fixation with volar LCP system was used in 30 patients (A.O.Type- A2, A3, B2, B3, C1, C2, C3]. In the present series, results were excellent in 63.3%, good in 23.3%, fair in 13.3% as compared to study by Murakami K. et al who treated 24 patients (Chiba, Japan) showed 83.3% excellent results & 16.7% good results with volar LCP. An advantage of volar plating technique is the comfort that it provides to patient in initiating early finger & wrist motion. Despite, our use of an early motion rehabilitation protocol, the distal end radius fracture reduction was maintained at the follow- up periods. Early rehabilitation had the additional advantage of enabling the patient to regain independence in daily activities rather quickly. In a present series, 6.7% patients developed arthritis, in whom, 80% had articular incongruity of 1-2 mm. In a retrospective study by Knirk J.L.et al (1986), it was concluded found that accurate articular restoration was the most critical factor in achieving a successful result. While interpreting the results it may be said that articular incongruity, loss of radial length and angular deviation were the most significant influences in that order, on the development of post-traumatic arthritis and overall end result

Conclusion

The treatment goal for fractures of the distal end of the radius is fully functional recovery of the wrist and prerequisites are restoration of the anatomy and early mobilization. Extra-articular fractures give better results than intra-articular fractures. Functional outcome depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures. It has also been shown that functional results are related more to the quality of anatomical reduction than to the method of immobilization. Volar locking compression plating is a safe and effective treatment for unstable fractures of the distal radius. It can also stabilize dorsally unstable distal radius fractures with least complications. Specially locking implants provide advantages in the treatment of distal radius fractures with metaphyseal comminuted zones (A3 and C2 fractures).

Bibliography

1. Belloti JC, Tamaoki MJ, Franciozi CE, Santos JB, Balbachevsky D, Chap Chap E, Albertoni WM, Faloppa F. Are distal radius fracture classifications reproducible? Intra and interobserver agreement. Sao Paulo Med J. 2008 May 1;126(3):180-5 PubMed PMID: 18711658.
2. Vaughan PA, Lui SM, Harrington IJ, Maistrelli GL. Treatment of unstable fractures of the distal radius by external fixation. J Bone Joint Surg Br. 1985 May;67(3):385-9. PubMed PMID: 3997946.
3. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951 Oct;33-A(4):895-907. PubMed PMID: 14880544.
4. Phadnis J, Trompeter A, Gallagher K, Bradshaw L, Elliott DS, Newman KJ. Mid-term functional outcome after the internal fixation of distal radius fractures. J Orthop Surg Res. 2012 Jan 26;7:4. doi: 10.1186/1749-799X-7-4. PubMed PMID: 22280557; PubMed Central PMCID: PMC3398340.
5. Cooney WP 3rd, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. J Bone Joint Surg Am. 1979 Sep;61(6A):840-5. PubMed PMID:479230.
6. Suman RK. Unstable fractures of the distal end of the radius (transfixion pins and a cast). Injury. 1983 Nov;15(3):206-11. PubMed PMID: 6642635.
7. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci. 2007 Mar;12(2):134-40. Epub 2007 Mar 30. PubMed PMID: 17393268.
8. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986 Jun;68(5):647-59. PubMed PMID: 3722221.

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Vol 2 | Issue 3 | Sep - Dec 2014 | page-17-20 | Reshma P Chavan, Shivraj M Ingole, V. W. Patil , Shubhangi M Dalvi , Dhiraj V Sonawane

Author: Reshma P Chavan[1], Shivraj M Ingole[1], V. W. Patil[1], Shubhangi M Dalvi[1], Dhiraj V Sonawane[1]

[1]GGMC and Sir JJ group of hospitals, Mumbai-08

Institute at which research was conducted: GGMC and Sir JJ group of hospitals, Mumbai-08.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2014

Address of Correspondence
Dr Reshma Prakash Chavan.
Flat No-14, Building no-4 “Swastik” Sir J. J. Hospital Campus, Byculla. Mumbai-08
Email: entproblem@gmail.com

 Abstract

Background: Tobacco chewing and smoking are leading preventable causes of death. Researchers have rated nicotine as even more addictive than heroin, cocaine, marijuana or alcohol (Worldwide trends in tobacco consumption and mortality, WHO). The disrupted oxidative-reductive milieu proceeds a lipid per oxidation, altered antioxidative enzyme activities and depletion of non-enzymatic endogenous antioxidants, several of which can be detected in the pre-symptomatic phase of many diseases. So the association between oxidative stress and tobacco consumption in disease condition is studied.
Conclusion: Tobacco consumption causes increased oxidative stress. In tobacco chewing and smoking oral cavity lesions were more common. Allergic factor and hearing loss was not seen in tobacco chewing and smoking. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions.
Keywords: Tobacco, Oxidative stress, Otorhinological diseases.

Introduction

Oxidative stress is tied to mitochondrial oxidation of foodstuff and the generation of the energy necessary to sustain life occupies a place of central importance. Oxidative stress is a state of altered physiological equilibrium within a cell, tissue, or organ. It is a condition arising when there is a serious imbalance between the levels of free radicals in a cell and its antioxidant defences. It is estimated that 1-3 billion reactive oxygen species (ROS) are generated/cell/day. Therefore the body's antioxidant defence system for the maintenance of health is important.  Tobacco also causes increase in oxidative stress. Tobacco products have no safe level of consumption. It is not only tobacco related products alone, but also local Indian products like bidis, gutkas and pan masalas, which are the culprits. The role of tobacco in alteration of enzymatic activity (SOD, GTR, GTP, and MAD) and their association with development of benign and malignant condition was studied.

Aims and Objectives
1) To study the activity of enzymes melanodealdehyde (MDA) superoxide dismutase (SOD), glutathione peroxidise, catalyse activity of patients with and without tobacco consumption.
2) To study whether there is significant correlation between biochemical parameters and ENT parameters.
3) To study clinical conditions like allergic rhinitis, nasal polyposis, sensorineural hearing loss, leukoplakia, melanoplakia, erythroplakia, submucous oral fibrosis, oral cavity malignant tumour, nose and throat malignancy seen in tobacco consumers.

Methods

A Group of people was selected and both tobacco consumers and non consumers were compared for biochemical parameters. Exclusion criteria were patients with diabetis mellitus, hypertension, pancreatic diseases, liver diseases, kidney diseases and heart diseases, H.I.V. positive patients, and genetic disorders. Patients were selected between 18-60 yrs age group.

Sampling:-
Venous Blood samples were collected after overnight fasting.

1.Hemolysate prepared from heparinised blood specimens were used for estimation of activities of catalase (CAT), Superoxide dismutase (SoD), glutathione peroxidise (GHS-PX), glutathione reductase (GR) and Melondialdehyde (MDA).

2.Citrated blood collected was utilized for estimation of blood glutathione (GSH).

All samples were stored in refrigerator and the estimations were done within 24 hours of specimen collection.

A)Serum malondialdehyde:-

Method: Buege and Aust
Malondialdehyde (MDA) is a highly reactive three carbon dialdehyde, produce from lipid hydroperoxide. It can, however, also be derived by the hydrolysis of pentose's, deoxyribose, hexoses, from some amino acids and from DNA. MDA has most frequently been measured by thiobarbituric acid reaction.MDA is measured as an index of lipid Peroxidation.

Principle:- Serum sample is first treated with TCA for protein precipitation and then treated with thiobarbituric acid. The mixture is heated for 10 minutes in boiling water bath. One molecule of MDA reacts with two molecules of thiobarbituric acid. The resulting chromogen is centrifuged and intensity of colour developed in supernatant is measured spectrophotometrically at 530nm.MDA levels are expressed in nmol /mL.
Reagents:-
a) 40% Trichloroacetic acid (TCA).-40 gms of TCA in 100 mL of distilled water.
b) 0.67 % Thiobarbituric acid (TBA) 0.67 gm of TBA in 100 ml of distilled water in boiling water bath.
c) Standard Malondialdehyde (MDA).
Stock MDA is Prepared from the 1,1,3,3 tetraethoxy propane by acid hydrolysis. A solution containing 0.1105 ml 1,1,3,3 tetraethoxy propane in 50 mL distilled water and 0.5mL 0.1 M HCl is warmed at 500C for 1 hour and volume adjusted to 100 mL with distilled water. The concentration of free MDA was determined spectrophotometrically at 267nm, using a molar absorption coefficient of 31,800.

Sample processing:-

The above reaction mixture was heated in boiling water bath for 10 minute. It was then cooled at R.T. and centrifuge. The absorbance of supernatant ar 530 nm was noted. The result was calculated from standard graph.

B) Superoxide-Dismutase Activity (SOD)
Method:- Arthur JR, Boyne R
Principle:-The role of superoxide dismutase (SOD) is to accelerate the dismutation of the toxic superoxide radical (02), produced during oxidative energy processes, to hydrogen peroxide and molecular oxygen.This method employs xanthine and xanthine oxidase (XOD) to generate superoxide radicals which react with,
2‑(4‑iodophenyl)‑3‑(4‑nitrophenol)‑5‑phenyltetrazolium chloride (I.N.T.) to form a red formazan dye. The superoxide dismutase activity is then measured by the degree of inhibition of this reaction. One unit of SOD is that which causes a 50% inhibition of the rate of reduction of INT under the conditions of the assay.
XanthineXODUric acid + O2.I. N. TO2.Formazan DayO2. + O2. + 2 H+ O2 + H2O2SODOR

C) Glutathione Peroxidase(GSH-PX)

Method: - Paglia Donald E & Valentine William N.

Principle:-This enzyme has been shown to catalylase with high specificity the invitro detoxification of hydrogen peroxide by the oxidation of reduced glutathione according to following reaction:

Reaction Principle
GPX
2GSH + ROOH ROH + GSSG + H2O

GR
GSSG + NADPH + H NADP+ + 2GSH
It measures the rate of GSH Oxidation by H2O2 as catalyzed by the GSH; however, this substrate is maintained at 2 constant concentrations by the addition of exogenous GSSG-R and NADPH, which immediately convert any GSSG convert any GSSG produced to the reduced form.
The rate of GSSG formation was then measured by following decrease in absorbance of the reaction mixture of 340nm as NADPH is converted to NADP.

D) Glutathione Reductase

Method: - Goldberg DM. & Spooner RJ
Principle:- Glutathione reductase (E.C.1.6.4.2) catalyses the reduction of glutathione (GSSG) in the presence of NADPH, which is oxidized to NADP+. The decrease in absorbance at 340 nm is measured.

GR
NADPH + H+ + GSSG NADP+ + 2GSH

Centrifuge 0.5 ml of whole blood for 5 min at 2000 rpm. Remove the plasma and buffy coat, Wash the erythrocytes three times by in 0.9% NaCl, centrifuging for 5 min at 2000 rpm after each wash. Lyse the cells by resuspending in cold redistilled H20, back up to 0.5 ml. Leave for 10 min at +2 - +8"C. Centrifuge lysate for 5 min at 2000 rpm to remove stroma. Dilute 100 µl of lysate with 1.9 ml of 0.9% NaCl solute on for assay.

E) Catalase (CAT)
Method:- Aebi
Principle:- In the UV range H2O2 shows a continual increase in absorption with decreasing wavelength. The decomposition of H2O2 can be followed directly by the decrease in extinction at 240nm.

Reagents:-
1. Phosphate buffer (50 mM, pH 7.0)
a) Dissolved 6.81 gms of potassium dihydrogen phosphate (KH2PO4) IN glass distilled water and volume made to 1 liter.
b) Dissolved 8.90 gms of disodium hydrogen phosphate (Na2HPO4) in glass distilled water and volume made to 1 liter. Mix solution A and B in the proportion of 1:1:55
2. Hydrogen Peroxide (30mM)
Diluted 0.34 ml of 30% H2O2 solution with phosphate buffer to 100ml which was prepared just before use.
Assay system
Calculation:
1 Unit = 2.3 Log A1 1000 1
_______ X ______ X ______ X ______ X 10
0.693 Log A2 6.93 Co
C0 = Concentration of the original enzyme sample in assay system. A1A240 at t=0 and A2 --A240 at t=15 sec.
Result was expressed by converting in Units/gm of Hb.
Observations-
Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in control and different categories of ENT lesions were studied.. Glutathione ReductaseU/gHb was significantly lower in diseased states.In control group Glutathione ReductaseU/gHb was 11.49973±1.972828.In benign conditions the Glutathione ReductaseU/gHb values were 5.8068 ±0.876812 while in cancer patients Glutathione ReductaseU/gHb was 3.8948±0.735391. Correlations between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions were studied. In benign Otorhinolaryngologicalogical conditions R values for MDA/Glutathione Reductase, MDA/ Glutathione Peroxidase, MDA/ SODU and MDA/ Catalase for were between -0.925 and -0.981. In cancer group R –value was between -0.784 and- 0.965. P values for correlation between MDA/Glutathione Reductase, MDA/ Glutathione Peroxidase, MDA/ SODU and MDA/ Catalase in benign and cancer group was 0.00. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions.

Discussion

Tobacco contain carcinogens like polycyclic aromatic hydrocarbons, aldehydes, benzo[alpha]pyrene, ethylene oxide, 4-aminobiphenyl and nitrosamines which are metabolically activated by hydrolysis, reduction, or oxidation by xenobiotic metabolism through phases I and II enzymes.[8] Therefore in tobacco consumer there are elevated levels of enzymes indicative of increased oxidative stress. Oxidative stress (OS) can also result from conditions like excessive physical stress, exposure to environmental pollution and xeno-biotics. Oxidative stress, as a pathophysiological mechanism, has been linked to numerous pathologies, poisonings, and the ageing process. Accordingly, from the point of view of routine clinical-diagnostic practice, it would be valuable to routinely analyze OS status parameters to earlier recognize potential disease states and provide the basis for preventative advance treatment with appropriate medicines. The role of tobacco in alteration of enzymatic activity (SOD, GTR, GTP, and MAD) is associated with development of carcinoma in the oral sub mucus fibrosis. Tobacco also causes increase in oxidative stress which is duration dependent. Reactive oxygen species and reactive nitrogen species, endogenously or exogenously produced, can readily attack all classes of macromolecules (protein,DNA, unsaturated fatty acid).The disrupted oxidative-reductive milieu proceeds via lipid per oxidation, altered antioxidative enzyme activities and depletion of non-enzymatic endogenous antioxidants, several of which can be detected in the pre-symptomatic phase of many diseases. These biochemical parameters can be used as biomarkers for certain diseases states. Different ear, nose, throat diseases were studied in detail according to staging and biochemical parameters. During the study it is observed that the ENT diseases seen in tobacco consumers were dose and duration dependant. Also there are certain factors like addition of lime, betal nuts along with use of tobacco were more prone for the disease process Also alcohol intake along with tobacco increases disease severity and staging. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions. Chronic exposure to tobacco smoke aggravated eosinophilic inflammation and promoted airway remodeling and nasal polyp formation in a murine model of ERSwNPs. [11] But there was no significant allergic complaints and hearing loss seen in tobacco consumers. The malignant transformation rate of OSF has been reported to be around 7.6% over a 17-year period.

Conclusion

Oxidative stress parameters were increased in tobacco chewers and both benign and malignant conditions of ear, nose and throat.
There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions. There were no significant allergic complaints and hearing loss seen in tobacco consumers.
Further study is required to see the malignant transformation of these benign lesion with continued and discontinuation of tobacco consumption.

Keywords

Distal femoral fractures,retrograde intramedullary nail,supracondylar,intracondylar.

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