Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management

Background

To evaluate the functional and radiographic outcomes, as well as the treatment costs, of closed displaced intra-articular distal radius fractures treated with either open reduction internal fixation (ORIF) with volar locking plates or nonoperative treatment with plaster cast immobilisation.

Materials and methods

A total of 60 patients (32 receiving ORIF, 28 receiving nonoperative treatment) with closed intra-articular distal radius fractures were included. The mean age was 52.1 and 57.4, respectively. Functional and radiographic assessments were carried out at 12 months post-injury. Patients’ treatment costs, median salaries and lengths of medical leave were obtained.

Results

DASH and MAYO wrist score in the ORIF group did not differ significantly from those in the nonoperative group. Apart from superior ulnar deviation in the ORIF group (p = 0.0096), differences in the range of motion of the injured wrists were not significant. Similarly, there were no significant differences in grip strength and visual analog scale for pain. Volar tilt (p = 0.0399), radial height (p = 0.0087), radial inclination (p = 0.0051) and articular step-off (p = 0.0002) were all significantly superior in the ORIF group. There was a 37-fold difference in mean treatment costs between ORIF (SGD 7951.23) and nonoperative treatment (SGD 230.52).

Conclusion

Our study shows no difference in overall functional outcomes at 12 months for closed displaced intra-articular distal radius fractures treated with either ORIF with volar locking plates or plaster cast immobilisation, and this is independent of radiographic outcome. A longer follow-up, nevertheless, is needed to determine whether the development of post-traumatic arthritis will have an effect on function. The vast difference in treatment costs should be taken into consideration when deciding on the treatment option.

Level of evidence

Level 3.

     

Neuronal ceroid lipofuscinosis diagnosed via skin biopsy

We aim to report that skin biopsy, a non-invasive test by neurological standards, may lead to a diagnosis. A 4-year-old male presented with a 2-year history of epilepsy and progressive developmental regression. The patient had a mildly elevated ammonia level; however, evaluation for the accumulation of excess serum amino acids and evaluation of urine for organic acids was negative. MRI revealed cerebral atrophy, and an electroencephalogram demonstrated multifocal sharp and slow waves. Due to the progressive degenerative neurologic presentation, a neurologic storage disease was favored. An axillary skin biopsy was performed, revealing eosinophilic intra-cytoplasmic inclusions within the eccrine glands. A periodic acid-Schiff stain also highlighted these inclusions. Electron microscopic studies demonstrated characteristic multiple membrane-bound inclusions within the eccrine epithelial cells, containing curvilinear inclusion material characteristic of neuronal ceroid lipofuscinosis. The clinical, histological, electron microscopic and enzymatic studies were diagnostic of late-infantile onset neuronal ceroid lipofuscinosis.     

METHANOL-INDUCED OPTIC NEUROPATHY: TREATMENT WITH INTRAVENOUS HIGH DOSE STEROIDS

The aim of this study was to find the potential benefit of intravenous high dose steroids in the treatment of patients with methanol optic neuropathy. Four patients complaining of diminution of vision after taking methylated spirit presented to us within a variable period of its consumption. The systemic features of methanol poisoning were absent in these patients. Raised blood levels of methanol confirmed the diagnosis of methanol optic neuropathy. All these patients received high doses of intravenous steroids for three days, followed by oral steroids, 1 mg/kg body weight, for 11 days. The administration of high doses of intravenous steroids led to an improvement of visual status in all four patients. Intravenous high dose steroids benefit the visual status of patients with methanol-induced optic neuropathy, provided the interval between the consumption of methanol and starting treatment is short. Further studies should be undertaken to document the role of intravenous steroids in this context.     

Anästhesie in der Augenheilkunde

Narkosen in der Augenheilkunde bieten zahlreiche Besonderheiten. Die Patienten geh?ren aufgrund ihres Alters und/oder ihrer Begleiterkrankungen h?ufig zu den ASA-Risikogruppen III und IV. Operative Manipulationen am Auge und die eingesetzten Ophthalmika k?nnen gravierende systemische Effekte v.a. im Bereich des kardiovaskul?ren Systems aufweisen. Umgekehrt beeinflussen zahlreiche an?sthesiologische Ma?nahmen und Pharmaka den intraokularen Druck, dessen unkontrollierter Anstieg zum Visusverlust führen kann, wenn eine Netzhautisch?mie auftritt oder intraokul?re Strukturen aus operativ angelegten oder traumatischen Perforationsstellen herausgepresst werden. Am Auge wird eine Vielzahl verschiedener operativer Verfahren durchgeführt, die sich grob in extraokul?re und intraokul?re Eingriffe unterteilen lassen. W?hrend bei den intraokul?ren Eingriffen aufgrund der Er?ffnung des Auges die Kontrolle des Augeninnendrucks und die Akinesie des Bulbus von entscheidender Bedeutung sind, steht bei extraokul?ren Eingriffen die Vermeidung bzw. die Therapie des okulokardialen Reflexes im Vordergrund. Durch Kenntnis der Anatomie, (Patho-)Physiologie und Pharmakologie des Auges kann der An?sthesist wesentlich zum Gelingen der operativen Verfahren beitragen.

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Prolonged survival of GalT‐KO swine skin on baboons

Weiner J, Yamada K, Ishikawa Y, Moran S, Etter J, Shimizu A, Smith RN, Sachs DH. Prolonged survival of GalT‐KO swine skin on baboons. Xenotransplantation 2010; 17: 147–152. © 2010 John Wiley & Sons A/S. Abstract: Background: Allogeneic skin is currently the best alternative to autologous skin as a temporary treatment for severe burns, but it has several drawbacks. As a potential alternative, we have evaluated GalT‐KO swine skin, which lacks expression of the Gal epitope, to investigate the effect of eliminating this epitope on survival of pig‐to‐baboon skin grafts. Methods: Two adult baboons that had fully recovered from previous T cell depletion received simultaneous skin grafts from: (i) GalT‐KO swine, (ii) Gal‐positive swine, (iii) a third‐party baboon, and (iv) self (control skin). Recipients were treated with cyclosporin for 12 days and the survival, gross appearance, and histology of the grafts were compared. Results: In both baboons, the GalT‐KO skin survived longer than either the Gal‐positive swine skin or the allogeneic skin. Early rejection of the Gal‐positive skin appeared to be mediated by cytotoxic preformed anti‐Gal IgM antibodies, while the rejection of GalT‐KO skin appeared to result from cellular mechanisms. Conclusions: GalT‐KO skin may have potential clinical benefits as an alternative to allogeneic skin as a temporary treatment for severe skin injuries.