RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / Name of the candidate and address
(in block letters) / DR. VARGHESE JOE C
POST GRADUATE STUDENT,
DEPARTMENT OF ORTHOPAEDICS,
SDM COLLEGE OF MEDICAL SCIENCES & HOSPITAL,
MANJUSHREE NAGAR, SATTUR,
DHARWAD (KARNATAKA) – 580009
2. / Name of the Institution / SDM College of Medical Sciences and Hospital,
Dharwad (Karnataka) – 580009
3. / Course of study and subject / M.S.(Orthopaedics)
4. / Date of admission to the course / 23-05-2011
5. / Title of the Topic / Outcome of Distal Radius Fractures treated with closed reduction and percutaneous pinning
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study:
Distal radial fractures are among the more common fractures encountered in orthopaedics and account for nearly 1/6 of all fractures treated in the emergency room. The optimal management for many of the varieties of distal radial fractures remains controversial. In general, fractures of the distal radius are treated non-operatively if the bone fragments can be held in anatomical alignment by a plaster cast. However, if this is not possible, then operative fixation is required. There are several operative techniques described for fixation of these fractures, One of which is the method of “indirect reduction and percutaneous fixation by k-wires”. This method has the advantage of decreased surgical morbidity, as it is performed closed, thus decreasing the stay in hospital. Also it can be performed under a brachial block or short general anaesthesia. This technique of percutaneous fixation is also very cost effective, and in a developing country like ours, where insurance cover is rare, cost plays a major factor. Thus there is a need to further evaluate the outcome of this procedure.
6.2 Review of the literature:
In 2008 J. Vasenius from the Dextra Hand Clinic, Helsinki, Finland in his article on operative treatment of distal radial fractures compares various operative treatments for distal end radius fractures. He concludes that
there is not a single method that performs well in the treatment of all kinds of distal radius fractures. also, no osteosynthesis method gives clearly better results than another in the treatment of the most common type of
fractures.6
In 2009 Loren Geller et al. in their article “Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures” published in the Canadian Journal of Surgery stated that Treatment with ORIF (open reduction and internal fixation) for comminuted, intra-articular distal radius fractures produces good radiographic results with maintenance of surgical radio - graphic parameters, whereas NSEF (non spanning external fixator) and CRPP (closed reduction and percutaneous pinning) of less complex fractures also provide good results. This suggests that fracture-specific fixation with CRPP or NSEF are
sufficient for certain distal radius fractures.4
In 2007 Santiago A. Et al. In their study “Retrospective comparison of percutaneous fixation and volar internal fixation of distal radial fractures” published under the auspices of The American Association for Hand Surgery concluded that results of volar plate fixation are comparable to those of percutaneous treatment methods relatively simple distal radius fractures.2
In 2005 Tristan Barton et al. in their study article “Do Kirschner wires maintain reduction of displaced colles fractures” published in the International Journal of Care of the Injured concluded that Closed reduction and k-wire stabilisation is an attractive technique because it is relatively noninvasive compared with plating or external fixation. This technique successfully maintains reduction of dorsal angulation but not radial shortening at fracture union. At fracture reduction, radial shortening must be reduced to zero to allow for this loss of radial height.3
In 2008 H.V Kurup et al in their study “Late collapse of distal radius fractures after k-wire removal: is it significant” published in the Journal of Orthopaedis and Traumatology concluded that Kirschner wire fixation for unstable fractures of distal radius is a good technique to prevent redisplacement. Removal of wires can be done at any convenient point after the fourth week as practiced widely but preferably before 6 weeks. Loss of reduction after removal of wires is insignificant and is not influenced by age, fracture comminution and period of fixation.5
6.3 Aims and Objectives of the study:
To analyze the results of treatment of distal radial fractures with closed reduction and percutaneous pinning at SDM Medical college and Hospital, Dharwad.
7. / Materials and Methods:
7.1 Source of data:
All the patients coming to SDM Hospital with distal radial fractures and are treated with closed reduction and percutaneous pinning.
Type of Study: A Retrospective and Prospective study design.
Inclusion criteria
1. Sustained a fracture of the distal radius (comminuted extra-articular and intra-articular).
2. They are over the age of 18.
3. The patients present within 2wks of injury.
Exclusion criteria:
1. The fracture is open with a Gustillo Anderson grading greater than 1.
2. Fractures which require open reduction/ligamentotaxis (external fixator).
3. There is evidence that the patient will be unable to adhere to trial procedures or complete questionnaires, such as in cognitive impairment.
Study area:
The study will be conducted in the SDM College of Medical Sciences and Hospital, Dharwad.
Study Period
The study will be carried out over a period of one year from November 2011 to October 2012.
7.2 Methods of collection of data:
Sample size
Number of cases selected for the study is 50.
The sampling method to be applied for collection of cases will be convenient sampling.
1. All patient’s attended to by the department of orthopaedics at the SDM Hospital who fulfill the criteria mentioned previously.
2. Evaluation of the pre-op clinical and X-ray status by an orthopaedic surgeon.
3. Evaluation of the post-op clinical and X-ray results by 2 orthopaedic surgeons at immediate, 6 weeks, 8 weeks, 12 weeks, 6 months and 1 year.
Parameters used:
Name,
Age,
Sex,
Mode of injury ,
Clinical examination – Routine protocol for examination of the wrist joint will be followed.
X-ray Findings- Fractures will be classified as per Fernandez and AO classification.
CT Scan where appropriate.
Statistical Analysis:
Functional results were analyzed by
1. Modified Demerit point system of Gartland and Werley7
2. Sarmiento’s modification of Lindstrom criteria7
Appropriate statistical tests will be used to analyze the data.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
YES, The study requires x-rays and surgical intervention of closed reduction with placement of k-wires and post operative physiotherapy.
7.4 Has ethical clearance been obtained from ethical committee of your institution in case of 7.3?
Clearance is obtained from the Ethical committee of SDM College of Medical Sciences and Hospital, Dharwad. (Annexure V).
8. / List of References:
1. David S. Ruch, Margaret M. Mcqueen. Distal Radius and Ulna Fractures. In, Robert W. Bucholz, Charles M. Court-Brown, James D. Heckman. Rockwood & Green’s Fractures in Adults, 7th edition. Philadelphia, Lippincott Williams and Wilkins, 2010;829-80.
2. Santiago A, Lozano-Calderon, Job N Doornberg. Retrospective comparison of percutaneous fixation and volar internal fixation of distal radial fractures. American Association for Hand Surgery 2008;3:102-10.
3. Tristan Barton, Charles Chambers, Emma Lane. Do Kirschner wires mantain reduction of displaced colles fractures. International Journal of the Care of the Injured 2005;36:1431-34.
4. Lorren Geller, Mitchell Bernstien, Alberto Carli. Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures. Canadian Journal of Surgery. 2009;52(3):E161-66.
5. H. V. Kurup, V. M. Mandalia, K.A. Shaju. Late collapse of distal radial radius fracture after k-wire removal: Is it significant. Journal of Orthopaedics and Traumatology 2008;9:69-72.
6. Vasenius J. Operative Treatment of Distal Radial Fractures, Scandanavian Jounal OF Surgery 2008;97:290-307.
7. Abhishek K Das, Nandkumar Sundaram, Thiruvengita G Prasad. Percutaneous pinning for non-comminuted extra-articular fractures of distal radius. Indian Journal of Orthopaedics 2011;45(5):422-26.
9. / Signature of the candidate /
DR VARGHESE JOE C
10. / Remarks of the guide / RECOMMENED
11. / Name and Designation
11.1 Guide / DR. CHANDRAKANTH D. NALLULWAR,
Professor & HOD,
Department Of Orthopaedics,
SDM College of Medical Sciences & Hospital,
Sattur, Dharwad.
11.2 Signature
11.3 Co- Guide
11.4 Signature
11.5 Head of the Department / DR. CHANDRAKANT D. NALLULWAR ,
Professor &. HOD,
Department Of Orthopaedics,
SDM College of Medical Sciences & Hospital,
Sattur, Dharwad.
11.6 Signature
12. / 12.1 Remarks of the Principal and Chairman
12.2 Signature
ANNEXURE-I
VOLUNTEER’S CONSENT FORM
Principal investigator Co-investigatorsDR.VARGHESE JOE C DR. C. D. NALLULWAR
Post Graduate Student Professor and Head
Dept of Orthopaedics Dept of Orthopaedics
SDMCMS&H, Dharwad-09 SDMCMS&H, Dharwad-09
STUDY- Outcome of distal radial fractures treated with closed reduction and percutaneous pinning.
1. This study has been explained to me and I understand what the study involves.
2. The complications associated with the procedure have been explained to me.
3. I understand that I can refuse to permit carrying on with the any of the procedure said above.
4. I understand that the above said procedure is for my treatment and for the purpose of research.
I therefore agree to take part in this study.
Signature of the Patient………………………………………………
Full name…………………………………………………………..
Date……………………..
Full address………………………………………………………….
………………………………………………………………………….
I HAVE BEEN PRESENT WHILE THE PROCEDURE HAS BEEN EXPLAINED TO THE PATIENT AND I HAVE WITNESSED HIS/HER CONSENT FOR THE PROCEDURE
Signature of the witness…………………………………………….
(The witness should not be a person connected with the study)
Full name……………………………………………………………
Date…………………..
Full address……………………………………………………………………………..
ANNEXURE – II
DEMERIT POINT SYSTEM OF GARTLAND & WERLEY WITH SARMIENTO et al MODIFICATION (FUNCTIONAL EVALUATION)
Residual deformity
Prominent ulnar styloid 1
Residual dorsal tilt 2
Radial deviation of hand 2-3
Point range 0-3
Subjective evaluation
Excellent
No pain, disability or limitation of movement 0
Good
Occasional pain, slight limitation of motion, no disability 2
Fair
Occasional pain, some limitation of motion, feeling of weakness
in the wrist, no particular disability if careful, activities slightly 4
restricted
Poor
Pain, limitation of motion, disability, activities more or less markedly 6
restricted
Objective evaluation
Loss of dorsiflexion 5
Loss of ulnar deviation 3
Loss of supination 2
Loss of palmarflexion 1
Loss of radial deviation 1
Loss of circumduction 1
Loss of pronation 2
Pain in DRUJ 1
Grip strength – 60% or less of opposite side 1
Point range 0-5
End result point ranges
Excellent 0-2
Good 3-8
Fair 9-20
Poor 21 and above
ANNEXURE – III
SARMIENTO’S MODIFICATION OF LINDSTROM CRITERIA
Residual Loss of Radial Loss of radial
deformity palmar tilt shortening deviation
(degrees) (millimeters) (degrees)
Excellent No/ 0 <3 5
Insignificant
Good Slight 1 – 10 3 – 6 5 – 9
Fair Moderate 11 – 14 7 – 11 10 – 14
Poor Severe At least 15 At least 12 >14
ANNEXURE – IV
PROFORMA
1) Name
2) Age
3) Sex
4) Occupation
5) Address
6) Month and year of trauma
7) Hospital no.
8) Mode of injury
9) Associated injury
10) On examination
11) Radiographic assessment
12) Classification
13) Mode of treatment
14) Post reduction x-rays
15) Early complication
16) Period of immobilization
17) Functional outcome
18) Complications
1