The use of external fixator in the treatment of comminuted fractures of the distal radius

Abstracts

Foi realizado um estudo combinado retrospectivo e de reavaliação de uma população original de 60 pacientes, somando 64 fraturas da extremidade distal do rádio submetidas ao tratamento pelo método da fixação externa, num período de dez anos (janeiro 86 a janeiro 96). Foram estudados retrospectivamente 46 pacientes com 50 punhos. Compareceram para reavaliação 32 pacientes, totalizando 35 punhos. No estudo retrospectivo, foi realizada a medida dos parâmetros ângulo radial, ângulo volar, comprimento relativo do rádio, ângulo escafo-semilunar, ângulo luno-capitato e sinal do anel no escafóide, nas radiografias finais do seguimento dos pacientes. Na reavaliação, além dos parâmetros clínicos e funcionais, a medida da diastase escafo-semilunar em incidência radiográfica especial foi adicionada aos parâmetros radiográficos previamente estudados. Os resultados mostraram que o método da fixação externa restabelece a anatomia da extremidade distal do rádio, propiciando bons resultados clínicos e funcionais na maior parte dos pacientes, com baixo índice de complicações.

Fratura cominutiva; Extremidade distal do rádio; Fixação externa

ARTIGO ORIGINAL

The use of external fixator in the treatment of comminuted fractures of the distal radius

Cláudio Henrique Barbieri^I; Nilton Mazzer^II; Ricardo José Cabello^III; Emerson Luiz Cardia de Campos^III; Meirelles Carril Elui^IV

Hand and Upper Limb Surgery and Microsurgery Service - Hospital das Clínicas de Ribeirão Preto, Disciplina Ortopedia e Traumatologia da Faculdade de Medicina de Ribeirão Preto – USP. - 14048-900 Ribeirão Preto SP

^ITitular Professor

^IIAssociate Professor

^IIIResident R4

^IVOcupational Therapist

SUMMARY

A combined retrospective and survey study of an original population of 60 patients, summing up 64 comminuted fractures of the distal radius treated by external fixation in a ten-year period (January 86 to January 96) was carried out. Forty-six patients summing up 50 wrists were retrospectively studied and 32 patients with 35 wrists were reviewed. In the retrospective study the parameters radial angle, volar angle, relative length of the radius, scapholunate angle, lunocapitate angle and scaphoid ring sign were measured in the final X-ray controls of all patients. In the survey study, apart from the clinical and functional evaluation, the measurement of the scapholunate diastasis, as observed in a special X-ray view, was added to the radiological evaluation. The results showed that the method of external fixation restores the anatomy of the distal end of the radius, so as to produce good clinical and functional results in the majority of the cases, with a low complication rate.

Key Words: Comminuted fracture; distal end of radius; external fixation

INTRODUCTION

Radial distal end fractures are very common. Most of them are suitable for conservative treatment, under plaster or other immobilization means with generally good results. ^{(1,11,13,24,27,29,30)}.

Some of these fractures, however, particularly those presenting comminution, articular involvement and significant deviation are a real challenge for conservative treatment due to difficulty in obtaining and keeping an adequate reduction in terms of anatomy and clinically satisfactory results.^{(1,3,5,14,16,24,27,28,30,31)}

Many authors have presented alternative methods, generally more aggressive than plain reduction by external manipulation aiming to keep the reduction achieved. So, already in the twenties Boehler⁽⁸⁾ introduced the bipolar traction/fixation using two percutaneous Kirschner wires or Steinmann nails, one placed in the radius, close to the fracture, and the other one in the metacarpals. After traction and reduction of the fragments, a plaster cast was placed involving the wires.

Boehler's technique was also modified by some other authors. ^{(16, 18, 25, 28, 30, 31)}, being the common aspect of all modifications the maintenance of tension in the radio-carpal ligaments allowing a more stable and adequate reduction of eventual intra-articular fragments avoiding open surgery. ⁽⁵⁾. Even though good results reported by many authors, all methods using wire and cast bring some inconveniences such as infection at the pin placement, which remains covered by the cast, making impossible to clean the skin wound. In case of loosening of reduction it is also difficult to re-manipulate, requesting the cast model to be removed. ^{(5, 10, 16)}.

The existence of these inconveniences lead to the development of external fixators, in which a light metallic frame plays the role of the cast model, keeping the wires under tension. After Anderson and O'Neil's work ⁽²⁾, other authors studied the external fixation method, some proposing other models of external fixator ^{(3, 7, 12, 20, 23, 26),} reporting good results and low related to the fixator complication rates. In fact, its use avoided the disadvantages of wire and cast combination, since the exposed wires can be easily cleaned and re-manipulation is relatively easy to perform with any model of fixator, what contributed to bring an universal acceptance to the method.

However it is not always that ligament traction obtained by means of the external fixator is enough to produce and keep reduction of the several fragments of very much comminuted fractures, which use to involve both radio-carpic and radio-ulnar joints. In these cases, it should be added of a percutaneous Kirschner wire fixation, or, after an open reduction of articular fragments with or without bone grafting. ^{(3, 20, 21, 23, 26)}.

By the middle of the eighties, the external fixation method combined or not to Kirschner wires fixation was standardized by the authors (CHB e NM) for the treatment of comminuted fractures of distal radius Frykman grade 7 and 8 ⁽¹⁵⁾. Immediate results of the method always looked good to the authors, and this conclusion was based only on ambulatory follow-up of patients submitted to the method. However, late results were not yet known, even because all patients were discharged from follow-up no longer than 6 months after the fracture.

For this reason, the objective of this work was to evaluate the late results of the method in 50 wrists of 46 patients treated over a period of 10 years with emphasis on functional recovery in comparison to the anatomical result as evaluated by roentgen examination.

MATERIAL E METHODS

The work was developed in two phases. In the first one, it was performed a retrospective analysis of all cases of distal radius fractures treated by means of ligamental traction with an external fixator recorded from January 1986 to January 1996. In the second, selected patients were recalled for reevaluation of late treatment results.

Retrospective Analysis

In the retrospective analysis 60 patients were found, performing 64 wrists (four were bilateral) and 14 were dropped out due to death, lack of follow-up or incomplete documentation. The remaining 46 patients represented 50 wrists (4 bilateral) effectively evaluated. From these patients, 26 were male and 20 female, the age ranging from 20 to 88 years old (average 51.9 years). Regarding the affected side, 27 were at the dominant side and 15 at non-dominant side, and 4 were bilateral (8 wrists).

The most common cause was falling form standing position (24 cases, or 48%), followed by motorcycle accident (8 cases, 16%), fall from high (five cases, 10%), automobile accident (four cases, 8%) and running over (two cases, 4%). Seven cases (14%) resulted of other kinds of traumatism, generally by direct agent such as aggression with a stick or industrial machinery accident. Other body systems were affected in 21 patients (45.5%) including twelve injuries in other parts of the limbs, nine brain injury and four in other organs.

The retrospective analysis of the X-ray examinations included: 1) Fracture classification according to Frykman ⁽¹⁵⁾ (Table 1); 2) study of angle deviations (radial and dorsal deviation angles) and radial shortening according to Frykman's anatomical criteria as modified by Lidström ^{(22, 29)}; and 3) signs of carpal instability according to X-ray exams performed on the first assistance and at the last routine visit (Figure 1).

Patients re-evaluation

In the second part, all 46 patients whose files were previously evaluated were recalled. Thirty-two came and undergone roentgen, functional and clinical evaluation in a total of 35 wrists with a mean follow-up of 46.6 moths (range from 9 to 105 months).

During the clinical evaluation patients were inquired regarding complaints such as pain (at rest, during movement, at changes of temperature), activity restrictions, parestesias, and the degree of satisfaction with the result of the treatment. Following, they undergone local clinical examination regarding skin conditions (edema, color, trophism) and possible aesthetic changes, and range of movement of the wrist, the elbow and the shoulder through goniometry. Additionally, patients undergone an upper limb functional evaluation according to Carazatto's protocol ⁽⁹⁾, complemented by measurement of the strength of grip and thumb/index strength using a hand dynamometer (Jamar) and a thumb/index dynamometer.

Roentgen analysis of the wrists was performed by usual anterior-posterior and lateral views, with addition of a posterior-anterior view with an ulnar-radial angulation of the ampoule by 10º in order to evaluate connections between scaphoid, lunatus and eventually display carpal bone instability. ^{(4, 17)} In the radiographic exams, it was evaluated: 1) radial angle; 2) volar angle; 3) rádio-ulnar length discrepancy; 4) scapholunate diastasis; 5) scapholunate angle; 6) lunocapitate angle; 7) scaphoid ring sign; e 8) signs suggesting arthrosis and degeneration (Figure 1).

Operative Technique

The technique used was the indicated by AO group. Under general or regional anesthesia, the affected limb was prepared as usual for an open surgery. A pneumatic tourniquet was installed only in these cases when open reduction was anticipated. Manual traction was applied for 10 minutes and maneuvers of digital compression of the fracture area, and flexion and extension of the wrist aiming to release impacted fragments. Then the external fixator was applied. In all cases an specific made in Brazil external wrist fixator was applied (Biomecanica).

Initially two Shanz nails were placed in dorso-radial aspect of radius and two in the second metacarpal with a 45º orientation in regard to frontal and sagital forearm views. The nails were placed transversally to the bone surface and parallel to each other in the two bones, with a distance among them of about 3 cm in radius, and 1.5 cm in the metacarpal, according to the standard of the fixation platform. For the radius, were used wires of 3 mm diameter, and for the metacarpals of 2.5 mm. All of them were 80 mm long. Shanz nail were inserted manually using a ''T'' driver and preceded by a bone perforation by a drill with a diameter 0.5 mm smaller than the nail (respectively 2.5 and 2.0 mm). This procedure avoids premature loosening of the nails.

When a satisfactory and stable reduction of the several fragments was not obtained, a percutaneous fixation with Kirschner wires was performed, using a scan or even an open reduction with multiple Kirschner wires fixation. This procedure did not follow a fixed pattern, but changed according to number and position of the fragments. Open reduction was performed through a dorsal longitudinal approach, a more recently a tri-radiated approach ⁽⁶⁾. Twenty-one patients (42%) needed open reduction, one of them in consequence of loosing the initial reduction. (Figure 2)

The time between the traumatism and the surgery ranged from 1 to 28 days (average: 10.5 days). The time under external fixation ranged from 3 to 11 weeks (average 7.8 weeks). During this time, patients underwent a rehabilitation protocol comprising active mobilization of the shoulder, elbow, forearm and fingers, with an weekly follow-up by a physiotherapist. Removal of the fixator was usually performed at the ambulatory followed by immediate start of wrist physiotherapy.

RESULTS

Clinical Evaluation

From the 35 wrists evaluated in 32 patients, 27 (77%) had no symptom. Among the eight remaining wrists, one had chronic edema, one had dystrophic skin, six were painful at rest and at movement, or with changes in temperature. Daily activity restriction was found in 3 wrists.

Range of movement was separately evaluated, by plans using as standard the normal values described in the literature ^{(13, 18)} , since eight patients had history of counter-lateral wrist fracture, making impossible making comparisons. So, extension was equal or superior to 80% of the normal in ten wrists, ranging from 60 to 80% in 14, from 40 to 60% in 11 and under 40% in six.

Flexion was equal or superior to 80% of the normal in four wrists, ranging from 60 to 80% in 15, from 40 to 60% in 11 and under 40% in five.

Radial inclination was equal or superior to 80% in 18 wrists, ranging from 60 to 80% in five, from 40 to 60% in another five, and under 40% in seven. Ulnar inclination was equal or superior to 80% in 18 wrists, between 60 and 80% in 13, between 40 and 60% in one and under 40% in three.

Pronation was equal or superior to 80% in 25 wrists, between 60 and 80% in four, between 40 and 60% in three and under 40% in another three. Supination was equal or superior to 80% in 20 wrists, ranging from 60 to 80% in nine, between 40 and 60% in three and under 40% in another three.

Regarding aesthetic evaluation, 20 wrists had normal appearance, however 11 had a salient ulnar head, three had a light ''fork back'' appearance; two had radial deviation and two ulnar deviation. According to the opinion of the patients, the results were excellent in 15 wrists, good in 13, fair in six and bad in only one.

Regarding functional evaluation according to Carazatto's criteria ⁽⁹⁾, function was superior to 95% of the normal in 34 wrists, equal to 85% of the normal in only one. Grip strength and thumb/index power were analyzed in comparison to counter-lateral side. For this reason, four patients were not evaluated, three of them due to bilateral fracture and one for amputation of thumb and index of counter-lateral hand. From the remaining 28 wrists, 16 had hand grip superior to 80%, 8 between 60 and 80%, and four under 60% of the counter-lateral normal. Regarding thumb/index power tip to tip, in 26 wrists it was superior to 80% and in only two was between 60 and 80% of counter-lateral normal.

Radiographic Evaluation

Involved the analysis of final radiography of all selected patients, including those who did not come for clinical and radiographic reevaluation. For these, only scapholunate diastasis was not evaluated, due to the need of a special radiographic exposure obtained at this additional visit. The analysis of the recorded data demonstrated an average radial angle of 23º (range from 6º to 30º), average volar angle was 0.5º (range from -16º to 20º) and radio-ulnar length discrepancy averaged 2.75 mm (range from 0 to 26 mm). Average scapholunate angle was 44º (range: 30º - 61º) and average lunocapitate angle was 10º (range: 0 a 45º).

Scapholunate diastasis, evaluated only in those patients who returned for re-evaluation, ranged from 1 to 3 mm (average 1.4 mm) and scaphoid ring sign was present in 8 wrists. Signs suggesting degeneration and arthrosis were observed in 11 wrists.

For all selected patients, independently of their return for re-evaluation, according to Frykman as modified by Lidstrom^{(22, 29)}, excellent results were obtained in 21 wrists, good in another 21, fair in five, and bad in three. Were also found 7 wrists with signs of VISI and 8 with signs of DISI.

Complications

Analysis of the complications also included the patients who did not come for reevaluation. They were observed in 11 wrists, and the most frequent was superficial infection around the nails, found in five wrists, followed by loosing the reduction, found in three wrists. Infection was well solved in all cases by means of cleaning and antibiotics. Loosing the reduction made necessary to re-manipulate the fracture and the fixator in all wrists, and in two it was necessary additional percutaneous Kirschner wire fixation. Another case needed open reduction and additional internal fixation with Kirschner wires. The third most frequent complication was loosening of a single nail, found in two wrists, however without need of replacement or removal before the expected time. One case of Reflex Sympathetic Dystrophy was also found, which lead to the worst result.

DISCUSSION

Comminuted fractures of distal radius, particularly those rated as 7 and 8 according Frykman⁽¹⁵⁾, are usually difficult to treat through usual methods ^{(1, 3, 4, 5, 13, 14, 15, 16, 24, 28, 30, 31)}. They generally involve more than three fragments, which are virtually impossible to manipulate in order to get a good reduction. Besides this, these fractures are usually instable, and keeping the reduction eventually obtained is very difficult by using the conventional resources. On the other hand, open reduction and internal fixation of these fractures by AO method²³ is very difficult to perform, mainly when the size of the fragments is considered, since they are generally too small to be screwed, and osteoporosis is common in elder patients.

Combination of wires and cast as proposed by Boehler and several other authors ^{(5, 8, 16, 18, 19, 25, 27, 30, 31)}, is a reasonable solution, however this method is frequently joined by a number of complications, especially infection due to the impossibility of viewing and cleaning the wires. And the method is not practical when it is the case of a re-manipulation due to a lost reduction ⁽¹⁰⁾. So, evolution of external fixators was imperative, since they are lighter and more comfortable for the patient, allowing daily cleaning of the skin around the nails, and periodic re-manipulations when needed. In the case of the model of fixator used (Biomecanica), it is worthy to stress that its conception is not the ideal, since the rigid bars are connected directly to the screws that adjust and fix the Shanz nail fixating platforms. This connection is not mobile, making that when re-manipulations are need it is necessary release all the system and sometimes even to place new Shanz nails in more suitable placement. This kind of problem can be avoided by the use of more modern conception fixators, as the AO mini-fixator and others, which use independent platforms of fixation and much more versatile connecting bars.

In the retrospective phase of this work, the analysis of the files and the initial radiographies of each patient revealed that most of them had had a good evolution, with low complication rates, and those observed were almost always of minor importance and easy to manage. Only one case of Reflex Sympathetic Dystrophy happened, that could have been triggered by the traction, that was not excessive, or by the 10 weeks time of immobilization. It is convenient to remember that, regarding this issue, adequate reduction of the fragments is only obtained under a certain degree of articular distraction, which, however, should only be kept by about two weeks, and after this traction should be alleviated allowing contact between articular surfaces of radius and carpal bones be restored without danger of loosing the reduction. Additionally, the fixators should be placed for no more than 8 weeks, when should be removed and replaced by cast or orthesis made of thermo-moldable plastic, may immobilization is still needed.

Late functional results seen in patients' reevaluation were in general good, mainly when considering the severity of the fractures. Recovery of 60% or more of the movements in several plans was obtained in more than one half of the patients, and the most restricted movement was flexion, since only 19 of the 35 re-evaluated wrists recovered more than 60% of the normal range of movement. Radial inclination followed, limited to 60% or more in its range in 23 of the 35 re-evaluated wrists. The best recovering movement was ulnar inclination, equal or superior to 60% of normal in 31 of the 35 re-evaluated wrists. Global function of upper limb was quite normal (95% of the possible performance) in 34 of the re-evaluated wrists, and was below 90% in only one. Hand grip measured in 28 wrists was below 60% of the normal in only four wrists, and above 80% in 16. The remaining eight wrists were between these limits. The power of thumb/index grip tip to tip was above 80% of the normal in 26 of the 28 evaluated wrists.

Radiographic reevaluation revealed that in average a reasonable restoration of normal parameters was obtained. The radial angle was around 23º, however the volar angle averaged 0.5º. Length discrepancy between radius and ulna was 2.75 mm, corresponding to an insufficient correction of volar angle and an important shortening of the radius. Besides average values, it is necessary to take into consideration the range of variation, since there were cases where radial angle was barely above 0º or volar angle was negative (-16º). Even though this was observed in isolated cases, it is worthy to remember that these figures correspond to very bad results, confirming that not always the external fixation technique works efficiently.

As in the literature ⁽⁴⁾, some carpal changes were observed, being 7 VISI e 8 DISI, however in no case were observed complaints or functional changes due to them. Also degenerative changes were found in 11 wrists, most of them of a light or mild degree, not yet leading to important symptoms. These changes, however, are anyway related to the severity of the fractures, and not to the method of treatment.

CONCLUSIONS

Considering the severity of most of the studied fractures, the final results observed (good clinical results in 85% of the wrists, functional in 97% and anatomical in 84%) and that only one severe complication was observed, the authors conclude that the external fixation method for treatment of comminuted fractures of the distal radial end not always restores the bone anatomy, but also allows an adequate functional recovery. It is so to be understood as the option of choice for this kind of fractures.

REFERÊNCIAS

Trabalho recebido em 13/04/2000. Aprovado em 05/08/2000

• 1. Abbaszadgan, H., Jonsson, U.& von Silvers, K.: Prediction of instability of Colles fractures. Acta Orthop. Scand. 60: 646-650, 1989.
• 2. Anderson, R.& O'Neil, G.: Comminuted fractures of the distal end of the radius. Surg.Gynecol.Obstet. 78: 434-440, 1944.
• 3. Axelrod, T.S. & McMurtry, R.Y: Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J. HandSurg. 15A(1): 1-11, 1990.
• 4. Barbieri, C.H., Mazzer, N. & Santiago, G.R.: Avaliação tardia das fraturas da extremidade distal do rádio, com particular atenção para as instabilidades carpais associadas. Rev. Brasil. Ortop.29(8): 591-596, 1994.
• 5. Barbieri, C.H., Yamashita, J.L., Yoshida, J.K. & Barbieri P.H.P.: Fraturas cominutivas da extremidade distal do rádio: avaliação tardia de tração-fixação bipolar pelo método de Green. Rev. Bras. Ortop. 19: 73-80, l984.
• 6. Barbieri, C.H. & Mazzer, N.: Triradiate skin incision for dorsal approach to the wrist. J. Hand Surg. 21B: 21-23, 1996.
• 7. Bartosh R.A. & Saldana, M.J.: Intraarticular fractures of the distal radius: A cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J. Hand Surg. 15A(1): 18-21, 1990.
• 8. Böhler, L.: The treatment of fractures, 3rd. Ed., New York, Grune & Stratton, 1932, pp 90-96.
• 9. Carazatto, J.G.: Teste de função motora da mão. Pesquisa em 200 pessoas normais. Dissertação de Mestrado, Área Ortopedia e Traumatologia, FMUSP, 1978.
• 10. Chapman, D.R., Bennet, J.B., Bryan, W.J. & Tullos,H.S.: Complications of distal radius fractures: pins and plaster treatment. J. Hand Surg. 7:509-512, 1982.
• 11. Charnley, J.: The closed treatment of common fractures. London,Churchill Livingstone, 1972.
• 12. Cooney, W.P.: External Fixation of Distal Radial Fractures. Clin. Orthop 180: 44-49, 1983.
• 13. Cooney, W.P., Dobyns, J.H. & Linscheid, R.L.: Fractures and dislocations of the wrist. In Rockwood, C.A., Green, D.P. & Bucholz, R.W. (Eds.): Fractures in Adults, Philadelphia, J.B.Lippincott, 1991, pp 563-678.
• 14. Forgon, M. & Mammel, E.: The external fixateur in the management of unstable Colles' fractures. Int. Orthop 5: 9-14, 1981.
• 15. Frykman, G.: Fractures of the distal radius, including sequelae shoulder-hand-finger syndrome, disturbance of the distal radio-ulnar joint and impairment of the nerve function. A clinical and experimental study. Acta Orthop. Scand. (Suppl.108),1967.
• 16. Green, D.P.: Pins and plaster treatment of comminuted fractures of the distal en of the radius. J. Bone Joint Surg.57A: 304-310, 1975.
• 17. Green, D.P.: Carpal dislocations and instabilities. In Green, D.P. (Ed.) Operative Hand Surgery, New York, Churchill Livingstone, 1993, pp 861-928.
• 18. Hoppenfeld, S.: Exame da mão e do punho. In: Propedeutica Ortopédica. Coluna e Extremidades, Rio de Janeiro, Livraria Ateneu, 1987, pp 59-107.
• 19. Ledoux, A., Ravis, A., Vanderghinst, M.: L'embrochage des fractures inférieures du radius. Rev.Chir.Orthop59: 427-438, 1973.
• 20. Leung, K.S., Shen, W.Y., Tsang, H.K., Chiu, K.H., Leung, P.C., & Hung, L.K.: An effective treatment of comminuted fractures of the distal radius. J. Hand Surg 15A(1): 11-15, 1990.
• 21. Leung, K.S., Shen, W.Y., Leung, P.C., Kinninmonth, A.W.G., Chang, J.C.W. & Chan, G.P.Y.: Ligamentotaxis and bone grafting for comminuted fractures of the distal radius. J.Bone Joint Surg. 71B(5): 838-842, 1989.
• 22. Lidström, A.: Fractures of the distal end of the radius. A clinical and statistical study of the end results. Acta Orthop Scand (Suppl. 4),1959.
• 23. Müller, M.E., Allgöwer, M., Schneider, R. & Willenegger, H.: Manual of Internal Fixation (3^rd Ed.), Berlin, Spriger-Verlag, 1991, pp 476-478.
• 24. Mazzer, N., Barbieri, C.H., Lemos, F.G.P. & Moya, S.P.: Correlação anatomo-funcional dos resultados finais das fraturas da extremidade distal do rádio. Rev. Bras. Ortop 29(10): 759-766, 1994.
• 25. McFarlane, J.A. & Thomas, R.H.: Fixed skeletal traction in the treatment of certain fractures of the wrist. Can. Med. Assoc. J. 186: 417-428, l976.
• 26. Nakata, R.Y., Chand, Y., Matiko, J.D., Frykman, G.K. & Wood, V.E.: External fixators for wrist fractures: A biomechanical and clinical study. J. Hand Surg 10A(6): 845-851, 1985.
• 27. Palmer, A.K.: Fractures of the distal radius. In Green, D.P. (Ed.) Operative Hand Surgery, New York, Churchill Livingstone, 1993, pp 929-972.
• 28. Ravis, A., Ledoux, A., Thiebault, A. & Vanderghinst, M.: Bipolar fixation of fractures of the distal radius. Int. Orthop 3: 89-96, 1979.
• 29. Reis, F.B., Faloppa, F., Saone, R.P., Boni, J.R. & Corvelo, M.C.: Fraturas do terço distal do rádio: Classificação e tratamento. Rev. Bras. Ortop 29(5): 326-330, 1994.
• 30. Sarmiento, A., Pratt, G.W., Berry, N.C & Sinclair, W.F.: Colles' Fracture. Functional bracing in supination. J. Bone Joint Surg 57A: 311-316, 1975.
• 31. Scheck, M.: Long term follow-up of treatment of comminuted fractures of the distal end of the radius by fixation with Kirschner wires and cast. J. Bone Joint Surg 44A: 337-351, 1962.

Publication Dates

• Publication in this collection
  13 Oct 2005
• Date of issue
  Dec 2001

History

• Received
  13 Apr 2000
• Accepted
  05 Aug 2000