Determining the Borderline Anatomical Parameters for Better Functional Outcome of Colles Fracture: A Prospective Study

Panigrahi, Tapasa Kumar; Ray, Satyajeet; Mallik, Manoranjan; Maharaj, Ramesh Chandra; Khatua, Jugaratna; Nanda, Debi Prasad

doi:10.1055/s-0041-1726062

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Original Article • Rev. bras. ortop. 57 (04) • Jul-Aug 2022 • https://doi.org/10.1055/s-0041-1726062 copy

Determining the Borderline Anatomical Parameters for Better Functional Outcome of Colles Fracture: A Prospective Study^* * Work developed at the Department of Orthopedics, S.C.B. Medical College and Hospital, Cutack, Odisha, India.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

The treatment of Colles fracture can deform the wrist. Some studies claim the resulting deformity rarely hinders daily activities, whereas others report the opposite; thus, anatomical reduction is desirable. Our objective was to analyze the anatomical and functional results of Colles fracture to find out the values of individual parameters corresponding to the best functional outcome.

Methods

The present prospective study included 70 elderly patients with Colles fracture. All patients were managed conservatively. The anatomical parameters were evaluated by measuring dorsal angulation, radial inclination, and radial height, and they were assessed as per Stewart et al. The functional result was assessed by the Mayo wrist score. The results were analyzed using the chi-squared test of association, and a p-value < 0.001 was considered statistically significant and to examine strengths of associations; we computed odds ratios (ORs) with 95% confidence intervals (CI).

Results

Excellent and good results were obtained in 68.5% of the cases anatomically and 78.5% functionally, which was statistically significant (p= 0.0009). Out of the three anatomical parameter dorsal angulation < 10° and loss of radial inclination < 9° showed statistically significant association with functional results (p= 0.0006), but loss of radial height < 6 mm did not (p= 0.0568), which became significant when loss of radial height was kept < 4 mm (p= 0.00062).

Conclusion

Fractures with anatomical reduction have better functional results. The acceptable borderline anatomical parameters for obtaining excellent or good functional results are dorsal angulation < 10°, loss of radial inclination < 9°, and loss of radial height < 4 mm.

Keywords
Colle's fracture; conservative treatment/methods; aged

Scoring system	Dorsal angle (degree)	Loss of radial length (mm)	Loss of radial angle (degree)	Score	Rating
1.1 Anatomical assessment of treatment results of radial bone fracture in a typical zone (Stewart et al.)	Neutral	0-3	0-4	0	[Rating: combined score dorsal angle, radial length, and radial angle; Excellent = 0; Good = 1-3; Fair = 4-6; Poor = 7-12)
	1-10	4-6	5-9	1
	11-14	7-11	10-14	2
	> 15	> 12	> 15	4
1.2 Functional score by the Mayo wrist score	Category	Score	Finding		Points
	Pain (25 points)	25 20 20 15 10 5 0	No pain Mild pain with vigorous activities Pain only with weather changes Moderate pain with vigorous activity Mild pain with activities of daily living Moderate pain with activities of daily living Pain at rest		[*Total points 90-100 = Excellent; 80-89 = Good; 65-79 = Fair; < 65 = poor]
	Satisfaction (25 points)	25 20 10 0	Very satisfied Moderately satisfied Not satisfied, but working Not satisfied, unable to work
	Range of motion (25 points)	25 20 10 5 0	100% of normal 75-99%of normal 50-74% of normal 25-49% of normal 0-24% of normal
	Grip strength (25 points)	25 15 10 5 0	100% of normal 75-99% of normal 50-74% of normal 25-49% of normal 0-24% of normal

Sl.no	Parameters for comparison	2 × 2 tables			Results	Statistical significance
3.1	Anatomical outcome with functional outcome	Anatomical result	Functional result (no. of patients)		Chi-square = 10.99, DF = 1, p< 0.001 (0.0009). Odds ratio = 7.17(95% CI 2.01-25.01)	Significant
		Anatomical result	Excellent/Good	Fair/Poor
		Excellent/Good	43	5
		Fair/Poor	12	10
3.2	(< 10°) loss of dorsal angulation with functional outcome	Dorsal angulation	Functional result (no. of patients)		Chi-squared = 11.75, DF = 1, p< 0.001(0.0006) Odds ratio = 7.67(95% CI: 2.18-26.92)	Significant
		Dorsal angulation	Excellent/Good	Fair/Poor
		< 10°	46	6
		> 10°	9	9
3.3	(< 9°) loss of radial inclination with functional outcome	Loss of radial angle	Functional results (nr. of patients)		Chi-squared = 11.77, DF = 1, p< 0.001(0.0006). Odds ratio = 7.67 (95% CI, 2.18-26.92)	Significant
		Loss of radial angle	Excellent/Good	Fair/Poor
		< 9 °	41	4
		> 9 °	14	11
3.4	(< 6 mm.) loss of radial height with functional outcome	Loss of radial height	Functional result (nr. of patients)		Chi-squared = 6.62, DF = 1, P> 0.001(0.01). Odds ratio = 4.57 (95% CI, 1.33-15.33)	Not significant
		Loss of radial height	Excellent/Good	Fair/Poor
		< 6 mm	44	7
		> 6 mm	11	8
3.5	(< 4 mm.) loss of radial height with functional outcome	Loss of radial height	Functional result(no of patients)		Chi-squared = 11.70, DF = 1, p< 0.001 (0.00062) odds ratio = 8.94 (95%CI: 2.23-35.84)	Significant
		Loss of radial height	Excellent/Good	Fair/Poor
		< 4mm	38	3
		> 4mm	17	12

Source	Radial inclination	Palmar inclination	Radial bone length	Ulnar variance
Campbell 13 ^th ed. 2017 (p.2993)¹⁶16 Perez EA. Fractures of the shoulder, arm and forearm. In: Azar FM, Canale ST, Beaty JH. editors. Campbell's operative orthopaedics. 13th ed.. Philadelphia: Elsevier; 2017: 2993	20°	11°	12 mm	± 2 mm
Green operative hand surgery 7^th ed. (2017)¹¹11 Wolfe SW. Distal Radius Fractures. In: Wolfe SW, Pederson WC, Cohen Mark S. editors. Green's Operative Hand Surgery. 7th ed.. Philadelphia: Elsevier; 2017: 530	23°	11°		-1 mm
Mishra et al. (2016)¹⁷17 Mishra PK, Nagar M, Gaur SC, Gupta A. Morphometry of distal end radius in the Indian population: A radiological study. Indian J Orthop 2016; 50 (06) 610-615	23.27 ± 7.42° (11.3-42.1°)	10.7 ± 5.28° (1-16.9°)	11.31 ± 4.9 mm (7.1-30.4 mm)	0.66 ± 2.46 mm (-2.4 + 4.1 mm)
Dario et al. (2014)¹⁸18 Dario P, Matteo G, Carolina C. et al. Is it really necessary to restore radial anatomic parameters after distal radius fractures?. Injury 2014; 45 (Suppl. 06) S21-S26	21-25°	7-15°	10-13 mm	0.7- 4.1 mm
Present study	25.6 ± 2.8°(20-30°)	7.9 ± 4.2°(0-15°)	13.4 ± 1.7 mm (8-18 mm)

Author	Study	Results	Conclusion
Chung et al. (2020)¹⁵15 Chung KC, Cho HE, Kim Y, Kim HM, Shauver MJ. WRIST Group. Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2020; 3 (01) e1919433	Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial	Data of 166 patients analyzed with 2-phase multivariable regression models only 2 of the 84 correlation coefficients calculated were statistically significant; grip strength with radial inclination and MHQ ADL score with ulnar variance.	They conclude that precise restoration of the wrist anatomy is not associated with better functional outcome.
Kong et al. (2019)²²22 Kong L, Kou N, Wang Y, Lu J, Tian D, Zhang B. The Necessity of Restoration of Radiologic Parameters by Closed Reduction in Elderly Patients with Distal Radius Fractures. Med Sci Monit 2019; 25: 6598-6604	The Necessity of Restoration of Radiologic Parameters by Closed Reduction in Elderly Patients with Distal Radius Fractures	0ut of 96 patients 75 (78.1%) got acceptable reduction and 21 (21.9%) got poor reduction. A significant correlation was found between ulnar positive variance with grip strength (r = 0.35, p= 0.03) and dorsal angulation with wrist flexion (r = 0.31, p= 0.02)	They concluded that satisfactory reduction is the first choice as malalignment leads to decreased grip strengths, unsatisfactory appearance and certain limitation of wrist movements.
Finsen et al. (2013)¹⁰10 Finsen V, Rod O, Rød K, Rajabi B, Alm-Paulsen PS, Russwurm H. The relationship between displacement and clinical outcome after distal radius (Colles') fracture. J Hand Surg Eur Vol 2013; 38 (02) 116-126	The relationship between displacement and clinical outcome after distal radius (Colles) fracture	Reviewed 260 patients. Though there exist a statistically significant association between functional and anatomical results by Bivariate analysis however multiple regression showed dorsal angulation, ulnar variance and radial inclination accounts only 11% of variability.	They concluded that final radiological alignment of distal radius fracture has minor influence on clinical outcome of Colles fracture.
Arrora et al. (2011)¹⁹19 Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011; 93 (23) 2146-2153	A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older	Prospectively analyzed 73 patients the range of motion, the level of pain, and the Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were not different between the operative and nonoperative treatment groups	Thus achieving anatomic reconstruction did not convey any improvement in range of motion or better ability of daily leaving activities in elderly.
Anzarut et al. (2004)²⁰20 Anzarut A, Johnson JA, Rowe BH, Lambert RG, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am 2004; 29 (06) 1121-1127	Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures	Out of 74 patients 47 (69%) had acceptable radiographic outcome and 44 (59%) had satisfied functional result at 6 months.	Concluded that acceptable radiographic reduction was not associated with better functional outcome.
Young and Rayan et al. (2000)²¹21 Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg Am 2000; 25 (01) 19-28	Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years	Got 88% excellent or good functional results and 68% excellent or good anatomical results	Radiographic outcome did not correlate with the functional outcome.
Slogaard et al. (1988)²³23 Solgaard S. Function after distal radius fracture. Acta Orthop Scand 1988; 59 (01) 39-42	Function after distal radius fracture	Functional results were excellent or good with dorsal angulation below 10° and loss of radial height < 7 mm.	Function was influenced by radiographic results. It is rational to improve the function results by better reduction technique of the fracture and prevention of secondary displacements.
Jenkins et al. (1988)²⁴24 Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles' fracture. J Hand Surg Br 1988; 13 (03) 291-293	Mal-union and dysfunction-in Colles fracture	Results of 61patients. The anatomical parameters at union were: mean dorsal angulation of 9° (SD 12.1), mean loss of radial inclination 7.8° (SD 7.2°) and mean radial shortening of 4 mm (SD 3.9 mm). Loss of grip strength and loss of flexion were taken as the functional parameter. A multilinear regression analysis showed statistically significant correlation between grip strength and loss of radial inclination and dorsal angulation and same with loss of flexion but did not reach level of significance.	Final recovery of the grip strength was related to the inclination of the articulate surface of healed radius both coronal and sagittal plane. Loss of radial length appears to become important determinant of long-term pain.
Garland and Werely (1951)⁶6 Gartland Jr JJ, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am 1951; 33-A (04) 895-907	Evaluation of healed Colles fractures	Good functional results (68.3%) achieved despite of poor radiological appearances.	The residual dorsal tilt more strongly associated with poor outcome than the loss of radial inclination or radial height or ulnar variance. However Cases showing more accurate reduction have best outcome.
Present study	Determining the borderline values of anatomical parameters for better functional outcome of Colles fracture. A prospective study	Of 70 patients excellent to good functional results was seen in 55 (78.55) and anatomically in 48 (68.5%) with a statistically significant correlation between them p< 0.001(0.0009)	Concludes anatomical reduction and maintaining the reduction is priority for better functional outcome.

Author	Study	Dorsal angulation	Loss of radial inclination	Loss of radial height	Ulnar variance	Remarks
Stewart et al. (1984)¹³13 Stewart HD, Innes AR, Burke FD. Functional cast-bracing for Colles' fractures. A comparison between cast-bracing and conventional plaster casts. J Bone Joint Surg Br 1984; 66 (05) 749-753	Functional cast-bracing for Colles fractures: a comparison between cast-bracing and conventional plaster casts	< 10°	< 9°	< 6 mm		The anatomic results were not influenced by methods of immobilization but was related to efficacy of reduction.
Altimissi et al. (1986)²⁵25 Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the distal radius. Clin Orthop Relat Res 1986; (206) 202-210	Long term results of conservative treatment of fractures of the distal radius	> 15°	< 5°		> 5 mm (radio ulnar index)	No statistically significant relation between the final results and type of fracture. However unsatisfactory results reported with extreme values three radiographic parameters as mentioned.
Slogaraad et al. (1988)²³23 Solgaard S. Function after distal radius fracture. Acta Orthop Scand 1988; 59 (01) 39-42	Function after distal radius fracture	< 10°		< 7 mm		Functional results were excellent or good with dorsal angulation below 10° and loss of radial height < 7 mm.
Salmon & Patrick et al. (1999)²⁶26 Salmon JM, Pattern S. Prevention of malunion of distal radius fracture. J Bone Joint Surg Br 1999; 81 (01) 5	Prevention of malunion of distal radius fracture	> 10°	≤ 17°	> 3 mm	> 1 mm	They have taken these radiographic measurements to define malunion in distal radius fracture.
Fuji k et al. (2002)²⁷27 Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T, Terai T. Fractures of the distal end of radius in elderly patients: a comparative study of anatomical and functional results. J Orthop Surg (Hong Kong) 2002; 10 (01) 9-15	Fractures of the distal end of radius in elderly patients: a comparative study of anatomical and functional results	3°		4 mm		Minor deformities as mentioned did not affect functional outcome. However radial shortening of more than 6 mm may result in poor functional outcome.
Smilovic et al. (2003)²⁸28 Smilovic J, Bilic R. Conservative treatment of extra-articular Colles' type fractures of the distal radius: prospective study. Croat Med J 2003; 44 (06) 740-745	Conservative treatment of extra-articular Colles type fractures of the distal radius: prospective study	≤ 9°	≤ 3°	≤ 2 mm		There was significant association between anatomical and functional results. And borderline values for better functions were as mentioned.
Campbell 13^th ed. 2017 (p.2993)¹⁶16 Perez EA. Fractures of the shoulder, arm and forearm. In: Azar FM, Canale ST, Beaty JH. editors. Campbell's operative orthopaedics. 13th ed.. Philadelphia: Elsevier; 2017: 2993	Acceptable reduction of distal radius fracture	Neutral (0°)	No less than 10°		No more than 2mm of shortening relative to ulnar head
Present study	Determining the borderline anatomical parameters for better functional outcome of Colles' fracture. A prospective study	< 10°	< 9°	< 4 mm		Recommends anatomic reduction of the fracture with in the borderline limits of the individual parameters as mentioned for achieving excellent to good functional results.

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E-mail: rbo@sbot.org.br

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[1] Address for correspondence Ramesh Chandra Maharaj, MBBS, M.S., Room no-13, SR Hostel, S. C. B. Medical College and Hospital, Cuttack, Odisha, India (e-mail: rameshchandramaharaj@gmail.com).

Patients (n)	70
Mean age (years)	66.3 ± 3.2 (60-80 years.)
Female patients	42 (60%)
Male patients	28 (40%)
Female: Male	3:2
Affected side: • Unilateral, dominant hand • Unilateral, non-dominant hand	42 28
Radiological parameter of control hand: • Radial inclination • Palmar angulation • Radial length	20-30° (25.6 ± 2.8 degree) 0-15° (7.9 ± 4.2 degree) 8-18 mm (13.4 ± 1.7 mm)

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Determining the Borderline Anatomical Parameters for Better Functional Outcome of Colles Fracture: A Prospective Study* * Work developed at the Department of Orthopedics, S.C.B. Medical College and Hospital, Cutack, Odisha, India.

Abstract

Objective

Methods

Results

Conclusion

Determining the Borderline Anatomical Parameters for Better Functional Outcome of Colles Fracture: A Prospective Study^* * Work developed at the Department of Orthopedics, S.C.B. Medical College and Hospital, Cutack, Odisha, India.