University of Groningen
Grip on prognostic factors after forearm fractures
Ploegmakers, Joris Jan Willem
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Publication date: 2019
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Ploegmakers, J. J. W. (2019). Grip on prognostic factors after forearm fractures. Rijksuniversiteit Groningen.
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J.J.W. Ploegmakers B. The
M. Brutty T.R. Ackland W.A. Wang
Chapter 6
The effect of a Galeazzi fracture on the strength of pronation
and supination two years after surgical treatment
ABSTRACT
Purpose: The aim of this study was to determine the effect of a Galeazzi fracture on the strength
of pronation and supination at a mean of two years after surgical treatment.
Methods: The strength of pronation and supination was measured in varying rotational positions
of the forearm of ten male patients (mean age 38.9 years (21 to 64)) who had undergone plate fixation for a Galeazzi fracture. The stability of the distal radioulnar joint was assessed, and a clinical assessment using the quick-Disabilities of the Arm Shoulder and Hand (qDASH) questionnaire and patient-related wrist examination (PRWE) scores was undertaken. In addition, the strength of pronation and supination was measured in a male control group of 42 healthy volunteers (mean age 21.8 years (18 to 37)).
Results: The mean absolute loss of strength of supination in the injured compared with the non-
injured arm throughout all ranges of forearm rotation was 16.1 kg (SEM 5.3), corresponding to a relative loss of 12.5% (95% confidence interval (CI) 3.6 to 21.4). For the strength of pronation, the mean loss was 19.1 kg (SEM 4.5), corresponding to a relative loss of 27.2% (95% CI 14.2 to 40.1). Loss of strength of supination following a Galeazzi fracture correlated with poor qDASH (p = 0.03) and PRWE scores (p < 0.01).
Conclusions: Loss of strength of pronation (27.2%), and of supination (12.5%) in particular,
after a Galeazzi fracture is associated with worse clinical scores, highlighting the importance of supination of the forearm in function of the upper limb.
INTRODUCTION
Galeazzi fractures involve a fracture of the middle to distal third of the diaphysis of the radius, associated with a dislocation or instability of the distal radioulnar joint (DRUJ).1,2 They comprise about 3% of all fractures of the forearm.3 The typical mechanism of injury is a fall with the wrist in hyperextension and pro- nation.1 They are usually treated surgically, with good to excellent functional results in 80% to 95% of patients.4,5,6
Modern standards of clinical research demand the use of validated subjective outcome measures, however, using clinical scoring systems for Galeazzi fractures might not be specific enough. For example, clinical scoring systems might not be able to detect the long-term effects of injury to the DRUJ.
Measuring the decrease of the strength of pronation and supination of the forearm is a non-in-vasive and sensitive alternative measure of the outcome of treatment of a Galeazzi fracture, since these parameters reflect the function of the forearm and wrist.7-11 Some residual disability might also be revealed by measuring strength in different positions of rotation of the forearm.
The aim of this study is to relate the outcome in patients who have undergone surgery for a Ga-leazzi fracture to the strength of pronation and supination in varying rotational positions of the forearm in comparison with the normal situation.
PATIENTS AND METHODS
We identified 24 patients who had undergone surgical treatment for a Galeazzi fracture between 2009 and 2011. Two patients had the plate removed for persistent symptoms, four were not willing to participate and eight could not be contacted, leaving ten patients in the study. All were male and right-hand dominant, of whom six had a fracture affecting the right arm (Table 1). The mean age of the patients was 32.9 years (21 to 64) and their mean body mass index (BMI) was 25.2 kg/m2 (22.8 to 27.3). Six patients had an associated dorsal displacement of the ulna; in three there was a neutral position resulting in an ulna plus variance and in one there was volar displacement of the ulna.
We recruited 42 right-hand dominant male volunteers with no history of upper limb injury to form a control group. The mean age of the controls was 21 years (18 to 37) and their mean BMI was 23 kg/m2 (19.8 to 29.9). They underwent the same measurements of the strength of pronation and supination protocol as the study group. The differences in strength between the dominant and non-dominant arm were also recorded and used for correction of the comparison between the injured and non- injured arm of those in the study group. In order to calculate the relative loss of strength, we used the maximum values for pronation and supination in the control group as baseline values. In other words, these values substituted the pre-injury values for the study group, which could not be obtained retrospectively.
All the patients and controls underwent a single session of testing. The strength of pronation and supination was assessed using a Baseline hydraulic dynamometer (BHD; Fabrication Enterprises, White Planes, New York). The BHD was fitted with a ‘shovel handle’ grip and was mounted on a frame with the ability to rotate and lock the device in varying degrees of pronation (60°, 40°, 20°) and supination (60°, 40°, 20°) and in neutral (0°). Each participant grasped the handle with the elbow at 45° of flexion and resting on the thigh 5 cm proximal to the patella for stability.
Table 1. Characteristics of the two groups.
Patients (n=10) Controls (n = 42)
Median age in yrs (range) 33 (21 to 64) 21 (18 to 37)
Mean body mass index in kg/m2 (median; range) 25.2 (25.4; 22.8 to 27.3) 23.4 (23.3; 19.8 to 29.9) Male n, (%) 10 (100) 42 (100) Fractured side (n) Right 6 Left 4 -Dislocation side Dorsal 6 Volar 1 Neutral 3
-Median ulnar variance in mm (range) 3.5 (-3.3 to 7.5) -Median radial translation in mm (range) 26 (19 to 66)
-The forearm was positioned horizon- tally in line with the axle of the handle and BHD, the chair and table allowed the seated height to be adjusted for correct positioning (Fig. 1).
Each participant performed two pre-test maximal isometric contractions, one of pronation and one of supination, with the verbal prompt “contract as hard as you can without moving your wrist, elbow or shoulder”. The subject then repeated two trials for the assessment at each angle of rotation using the same prompts. If the position of the wrist, elbow or shoulder was compromised during testing, the trial was repeated. Both left and right arms were assessed at the same angle and the assessment sequence was such that at an angle of ‘-60°’, the left hand measured 60° in a supine position and the right hand measured 60° in a prone position. There was approximately one minute of rest before testing commenced at the next angle.
Instability was graded in the study group by assessment of the DRUJ in 60° pronation, neutral and 60° supination, and compared with the non-injured site. The testing-position was with the upper arm placed against the chest and the elbow flexed at 90°. The DRUJ was scored as ‘stable’, ‘partially unstable’ or ‘unstable’ according to the criteria described by Nicolaidis et al.12 The range of active pronation and supination was also recorded. The level of the fracture of the radius, the direction of dislocation and the presence or absence of ulnar variance was recorded.
Scores for pain, function and general health using the Quick-Disability of the Arm Shoulder and Hand (quickDASH)13 and the Patient Rated Wrist Evaluation (PRWE)14 were recorded. quickDASH and PRWE have scores ranging from 0 to 100 points, where a lower score denotes less impairment. Health, function and pain were scored using a visual analogue scale (VAS) from 0 to 100. For health and function, 100 indicated the best result and 0 the worst; for pain, 0 denoted no pain and 100 extreme pain.
Figure 1. Strength measurement setup.
Statistical analysis
Strength curves for both the study group and the controls were constructed. In the study group, the measurements of strength in the injured arm were compared to those in the uninjured arm. Data from the control groups were used to calculate differences in strength between the dominant and non-dominant sides.
The absolute loss (in kg) of strength of pronation and supination, as well as the relative loss (percentage of the baseline strength measurements from the controls) were calculated. Correlations between loss of the maximum strength of supination or pronation and the decrease in clinical scores were assessed.
All statistical analyses were performed using SPSS v20.0 (SPSS Inc., Chicago, Illinois). Statistical significance was set at a p-value of < 0.05.
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RESULTS
The study had ethical approval and all patients and controls gave informed consent.
The fracture of the radius in the study group united with normal radial alignment in all the pa-tients. There were no ulnar dislocations or residual subluxations and all had normal ulnar vari-ance.12-14 The differences between the dominant and non-dominant arm and the curves for the strength of pronation and supination in both groups are summarised in Figure 2; the curves are similar, although the study group shows reduced peak strength in every position of the forearm. The relative loss of strength in the study group is summarised in Table 2 and the clinical scores for these patients are shown in Table 3 and stability values in Table 4.
Table 2. The strength of supination and pronation at different angles of rotation of the forearm in the two
groups demonstrating the relative loss (CI = confidence interval)
Position Mean baseline (kg) (SEM) Mean loss Relative loss (%, 95% CI) after Galeazzi (kg) (SEM)
Strength of supination 60° supination 84.1 (3.0) 10.4 (6.3) 12.4 (-2.5 – 27.2) 40° supination 103.6 (3.4) 11.1 (6.0) 10.7 (-0.8 – 22.2) 20° supination 118.1 (3.0) 9.8 (4.1) 8.3 (1.4 – 15.2) neutral 127.6 (3.3) 16.5 (5.5) 12.9 (4.4 – 21.5) 20° pronation 140.3 (3.5) 19.6 (4.9) 14.0 (7.1 – 20.9) 40° pronation 150.4 (3.5) 24.2 (5.9) 16.1 (8.3 – 23.9) 60° pronation 161.0 (3.6) 21.0 (4.7) 13.0 (7.3 – 18.8) Overal 126.4 (1.6) 16.1 (5.3) 12.5 (3.6 – 21.4) Strength of pronation 60° supination 162.8 (3.7) 29.4 (6.6) 18.1 (10.0 – 26.1) 40° supination 142.1 (3.5) 22.3 (5.3) 15.7 (8.3 – 23.1) 20° supination 115.6 (3.1) 18.5 (5.0) 16.0 (7.4 – 24.6) neutral 87.1 (2.6) 22.7 (4.7) 26.1 (15.4 – 36.8) 20° pronation 61.1 (2.3) 19.6 (4.4) 32.1 (17.8 – 46.4) 40° pronation 38.1 (1.9) 11.0 (2.9) 28.8 (13.8 – 43.9) 60° pronation 19.2 (1.5) 10.3 (2.6) 53.5 (26.8 – 80.3) Overal 89.4 (2.3) 19.1 (4.5) 27.2 (14.2 – 40.1)
Table 3. The range of movement and clinical scores for the study group
Median (range)* injured arm non-injured arm Control
Range of movement flexion 80° (65°-90°) 80° (65°-90°) 78° (52°-105°) extension 70° (60°-90°) 80° (45°-90°) 68° (43°-89°) pronation 73° (55°-90°) 88° (65°-90°) 80° (47°-102°) supination 80° (65°-90°) 90° (55°-95°) 95° (76°-121°) quickDASH 21 (15-34) PRWE 15 (0-48) Health 85 (35-95) Function 90 (73-100) Pain 9 (0-30)
* quickDASH = quick disability arm shoulder and hand score; PRWE, patient related wrist evaluation
Table 4. Stability values
Stability 60° pronation 4 3 3 10 0 0 Stability neutral 4 4 2 10 0 0 Stability 60° supination 3 4 3 10 0 0
Stable Moderate Unstable Stable Moderate Unstable unstable unstable
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The loss of strength of supination in comparison with the uninjured side (with application of the correction factor for differences between the dominant and non-dominant sides), was correlated with the change in the clinical scores. A clear correlation was found between a reduced strength of supination and worse qDASH scores (p = 0.03), and an even stronger correlation with worse PRWE scores (p < 0.01). However, the analysis of correlations between the strength of pronation and the clinical scores revealed a much weaker correlation (Fig. 3).
Figure 2. Overall strength curves for both the 42 healthy subjects (2a) and the Galeazzi group (2b).
Peak str
ength (K
g)
Healthy controls Galeazzi
Forearm position 200 150 100 50 0 60 40 20 0 20 40 60 supination pronation 60 40 20 0 20 40 60 supination pronation Supination (dominant) Supination (non-dominant) Pronation (dominant) Pronation (non-dominant)
Pronation strength loss Supination strength loss PRWE
quickDASH
Spearman corr. coefficient: -0.27 p-value: 0.46
Spearman corr. coefficient: 0.94 p-value: < 0.01
PR
WE
PR
WE
Pronation strength loss Supination strength loss
Pronation strength loss Supination strength loss
Spearman corr. coefficient: -0.17
p-value: 0.63 Spearman corr. coefficient: 0.68p-value: 0.03
quickD ASH quickD ASH 50 40 30 20 10 0 50 40 30 20 10 0 50 30 20 10 0 35 30 25 20 0 -20.00 0.00 20.00 40.00 60.00 80.00 100.00 -20.00 0.00 20.00 40.00 60.00 80.00 100.00 0.00 20.00 40.00 60.00 0.00 20.00 40.00 60.00
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DISCUSSION
The aim of this study was to quantify the effects of a Galeazzi fracture on the strength of rotation of the forearm using a simple method of measurement in order to detect potentially clinically relevant sequelae of this injury.
We performed isometric testing of the strength of pronation and supination in different posi-tions of rotation of the forearm. To our knowledge, this is the first study to assess patients with a Galeazzi fracture in this way.8-11, 15-20We found persisting changes at a mean of two years after surgical treatment. The mean absolute loss of strength of supination of the injured compared with the non-injured arm throughout all positions of rotation of the forearm was 16.1 kg (SEM 5.3), corresponding to a relative loss of 12.5% (95% confidence interval (CI) 3.6 to 21.4) and the mean loss of the strength of pronation was 19.1 kg (SEM 4.5), corresponding to 27.2% (95% CI 14.2 to 40.1). Although the loss of strength was greater for pronation, the loss of the strength of supination showed a much stronger correlation with deterioration of clinical scores. This finding may be explained by the fact that the loss of the strength of pronation can be partially compen-sated for by a combination of abduction and internal rotation of the shoulder, while loss of the strength of supination cannot be as easily compensated for.
We found that the loss of strength of supination was highly correlated with deterioration in both qDASH and PRWE scores and highlights the importance of the strength of supination in the per-formance of daily activities. In our patients, no additional treatment for the DRUJ was added after fixation of the fracture. Temporary immobilisation of the DRUJ is commonly undertaken using k-wires if instability persists after fixation of the fracture, but this was not deemed to be necessary in any of our patients.6, 21
A limitation of this study is the lack of MRI or arthroscopic evaluation of the DRUJ and triangular fibrocartilageneous complex. This would have provided a pathoanatomical basis for the loss of rotational strength of the forearm.9 Also the study group was small. Only ten of the 24 patients identified with a Galeazzi fracture were available. We can only assume that those who were lost to follow-up, would be broadly represented by the ten who were studied.
We did not have pre-injury strength data in the study group, and the sample size was too small to extract reliable baseline values. Fortunately, data from the control group provided us with much larger numbers to provide reliable baseline measurements of strength; and this group could be used to measure the difference in strength between the dominant and non-dominant arm, which enabled us to correct for this in the calculations of the loss of strength in the study group. We conclude that two years after the surgical treatment of a Galeazzi fracture, the mean absolute loss of strength of supination in the injured compared with the non-injured arm throughout all positions of rotation of the forearm was 16.1 kg (SEM 5.3), corresponding to a relative loss of 12.5% (95% CI 3.6 to 21.4) and the mean loss of the strength of pronation was 19.1 kg (SEM 4.5), corresponding to 27.2% (95% CI 14.2 to 40.1). Loss of the strength of supination in particular is associated with worse clinical scores.
DISCLOSURES
One of the authors received a stipend in support of his clinical fellowship from Synthes and Smith and Nephew. The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive benefits or a commitment or agreement to provide such benefits from a commercial entity. No writing assistance was utilized in the pro-duction of this manuscript.
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