| Objective: Distal radius fracture refers to the fracture that happens in 3cm near the wrist articular. It is one of the most common fractures in clinical work,and may account for one sixth of the total amount of fracture. Rayback classified the distal radius fracture into four types according to the dislocation and the articular involvement. Type I, II and III can be treated conservatively, but there is controversy on the treatment of type IV fracture. In this study, we make an effort to compare of the clinical outcome after conservative treatment and operative treatment.Method: From October 2010 to October 2013, patients who were diagnosed as Rayback IV distal radius fracture and treated in Central hospital of Petro China and Waldkrankenhaus Germany were included. Including criteria:(1) No former operation on involved arm, and can act as normal;(2) No secondary osteoporosis and metabolic osteopathy;(3) No severe systematic disease. Conservative treatment: close reduction and cast, local anaesthesia was applied if necessary. First, traction along the axial of the involved arm, and then reduction of the fracture was performed, finally, plaster cast was made. X ray examination was performed after treatment. After the acceptable reduction, routine follow-up were made on 1st, 3rd, 7th, 14 th, 21 st, 28 th,42nd days and 3rd, 6th, 12 th,18th months. X ray examination were performed on the 7th day and 14 th day, and reduction was made again if necessary. Plaster cast was removed after 4 to 6 weeks. Rehabilitation was performed under the guidance of doctors. Operative treatment:(1)Approach: a 5cm to 8cm incision was made, and then went between radius artery and flexor carpi radialis, the pronator quadratus and capsular of wrist joint was split, the distal part of radius was exposed.(2) Fixation: Locking compress plate was placed and fixed with Kirschner wire, X ray examination was performed to make sure the position of the bone and plate was correct. And then locking screws were placed. Postoperative rehabilitation was performed under the guidance of doctors according to the result of follow-up. X-ray examination and function of wrist joint was tested at the 3rd, 6th, 12 th, 18 th months.Gartland-Werley score and Patient-Rated Wrist Evaluation(PRWE) score were used to evaluate the result of treatment. Gartland-Werley scoring system is widely used in the evaluation of the function of the wrist joint, four aspects are included, appearance, self-evaluation of patient, evaluation of doctors, complications. The the four parts scores sum to 100, and classified into four grade. Excellent(0-2), Good(3-8),normal(9-20) and bad(more than 21). PRWE scoring system is used to evaluate the wrist pain and dysfunction of patients’ daily life, and is composed of two parts. There are five items in the evaluation of pain, each has 10 points(0 refers to no pain and 10 refers to the most severe imaginable pain); function evaluation is composed of 10 items(special actions and normal actions), each item has 10 points; the final result is calculated as A+B/2, 0 refers to no problem with wrist and 100 refers to the most severe pain and dysfunction. Some studies concluded that age had big influences on the recovery of the function. So the patients were divide into two groups according to their age(older than 65 or not). At the same time the incidence of complications were also observed and recorded, such as the injury of median nerve, delayed rupture of tendon, nonunion of fracture and apparent dislocation of fracture. SPSS 18.0 was used to perform the statistical work. Two independent sample t-test, Mann-Whitney test and Chi-square test were used according to the type of the data, if P<0.05, statistically significant difference was considered to be found.Result: For the patients who were under 65 years old, operative treatment had a better effect than conservative treatment according to the Gartland-Werley score and PRWE score at the time point 3rd, 6th, 12 th, 18 th months and this superiority was confirmed by statistically significant difference. The superiority became more and more apparent during the follow-up.For patients who were older than 65 years old, operative treatment also had a better effect than conservative treatment at each follow-up point, but the superiority became less and less apparent during the follow-up. There was no statistically significant difference at 18 th month follow-up. For the complications, there were no statistically significant difference when comparing the incidence of median nerve injury, delayed rupture tendon, nonunion of fracture; but the incidence of apparent dislocation of fractures was more common in conservative treatment group, which was confirmed by statistically significant difference.Conclusion: For Rayback IV distal radius fracture patients who are under 65 years old, operative treatment can yield better result than conservative treatment in both short-term and long-term follow-up. But for patients who are older than 65 years old, operative treatment can yield better result than conservative treatment in short-term follow-up, but no difference could be found in long-term follow-up. There is no difference in the incidence of median nerve injury, delayed rupture of tendon and nonunion of fracture. But the incidence of apparent dislocation of fracture is higher in conservative treatment group than operative treatment group. |
