Table Of ContentFractures of the Distal Radius
Springer
New York
Berlin
Heidelberg
Barcelona
Budapest
Hong Kong
London
Milan
Paris
Santa Clara
Singapore
Tokyo
Diego L. Fernandez, M.D.
Orthopaedische Chirurgie FMH
Jesse B. Jupiter, M.D.
Associate Professor, Orthopaedic Surgery
Harvard Medical School, and
Director, Orthopaedic Hand Service
Massachusetts General Hospital
Fractures of the
Distal Radius
A Practical Approach to Management
With 371 illustrations in 698 parts
Springer
Diego L. Fernandez
Orthopaedische Chirurgie FMH
Mittelstr. 54
3012 Bern, Switzerland
Jesse B. Jupiter
Director, Orthopaedic Hand Service
Massachusetts General Hospital
ACC 527, 15 Parkman Street
Boston, MD 02114 USA
Library of Congress Cataloging-in-Publication Data
Jupiter, Jesse B.
Fractures of the distal radius I Jesse B. Jupiter, Diego L. Fernandez.
p. em.
Includes bibliographical references and index.
ISBN-13: 978-1-4684-0480-7 e-ISBN-13: 978-1-4684-0478-4
DOl: 10.1007/978-1-4684-0478-4
1. Radius - Fractures. I. Fernandez, Diego L. II. Title.
[DNIM: WE 820 J95f 1995J
RD557 J68 1995
6171'57 - dc20
DNIMIDLC
for Library of Congress 94-45533
Printed on acid-free paper
© 1996 Springer-Verlag New York, Inc.
Softcover reprint of the hardcover 1st edition 1996
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Dedicated to our Fathers
Leoncio Diego Fernandez, MD.
Samuel Jacob Jupiter
"There is a dead medical literature and there
is a live one. The dead is not all ancient and the
live is not all modern."
Oliver Wendell Holmes
Foreword
by Henry j. Mankin
At first glance at this volume, it is easy to ask "why so much about so little?"
After all the distal radius is only a small part of the body and its fractures,
although common, are really not exactly a life- or limb-threatening issue.
Admittedly it is a fracture that we often do not deal with well, but is that really
worth an entire volume? How wrong one would be with that attitude! How
truly inappropriate is such a view of this truly spectacular and well-written
compendium of important technology and information!
Fractures oj the Distal Radius is truly a remarkable effort and one that by all
standards offers the reader a practical guide to the diagnosis and management
of distal radius fractures and their sequellae. Each of the management chapters
provide the reader with methods of identifying the injury, techniques of
anesthesia, reduction, fixation, immobilization, aftercare, potential complica
tions and their management and expected and achieved outcomes. All types of
injuries are detailed, and all methods of treatment including closed techniques
are described. This it would seem would be sufficient for a book about an
injury, especially one as frequently encountered and as seemingly prosaic as
fractures of the radius. A~ important as that goal is, however, it is not alone the
purpose, nor in this essayist's opinion, the principal achievement of this
remarkable volume.
The book has been written by two outstanding surgeons who not only
describe the lesions and the best treatment on the basis of their own
experience, but in addition provide the readers with a broad panoply of
methodology for the management of the injuries based not just on what is
successful in their own hands, but on a careful assessement of an extraordi
narily voluminous body of literature. No stone lies unturned by Drs. Fernandez
and Jupiter in providing the reader with every recorded classification system
and their strengths, weaknesses and difficulties of application. At the same time
they offer as their choice the new Fernandez approach which to this reader
seems to make sense out of potential chaos and confusion. This alone is
perhaps worth the price of the volume and is a truly valuable contribution.
Of perhaps greater interest to some of us is the evident fact that the authors
display for this day and age, a rather astounding reverence for history. The first
chapter clearly demonstrates this point and despite its lack of direct application
to management of the injured patient (which after all is what the book
is about) is for some of us, the most edifying and entertaining section. It
describes in remarkably clear fashion the extraordinary, centuries-old struggle
since the time of ancient Greece to define and describe this very common
injury. Faced with the complex anatomy of the wrist, lack of anatomical
specimens of the fractures (very few autopsies were done then or even now
for injuries about the wrist), and of course the absence of imaging studies, the
ancients were appropriately puzzled by the injury and the ensuing deformities.
Fractures and dislocations were confused with one another and the putative
viii Foreword
site of injury (as in the eponymically immortalized Abraham Colles' case) was
often far from the place which we now know is the actual location of
the fracture. It is amazingly evident that Smith, Barton, Colles, Dupuytren,
Malgaigne, Goyrand, Petit, Cotton and the rest (including Velpeau ...
presumbably of shoulder immobilization fame, who gave the deformity the
name of "talon de fourchette" or the "silver fork deformity") all described
x
features of these often eponymously immortalized injuries prior to the first
ray picture taken by Wilhelm Conrad Roentgen just about 100 years ago (and
appropriately for this volume of his wife's hand and wrist!). The struggle for
definition of the fact of these injuries is eloquently described by the authors, in
many cases by direct quotes from thsee ancient sources and in fact, really
paraphrases the development of modern medicine throughout the centuries.
Seminal observations by ancient scholars using the tools of their day add a bit
to knowledge. Others in the next generation, or even next century, build on
these data with new observations until with modern technology and systems of
study we come upon what passes for current-day "truth." This is true until
another generation extends these observations and establishes yet another
plateau of knowledge. This then is the way of learning about disease, and no
more careful assessment of the role of such a process can be encountered than
is found in the exposition of the diagnosis, classification, and management of
fractures of the distal radius in this very book. We are indebted to the authors
for this remarkable and stunning exposition of the history of what has been
mistaken by many modern clinicians to be a straight-forward problem, but has
been clearly shown by them to be a tangled and sometimes confusing web of
fact and fancy surrounding a series of complex anatomical and functional
problems.
Henry J. Mankin, M.D.
Chief of the Orthopedic Service
Massachusetts General Hospital;
Edith M. Ashley Professor of Orthopaedics
Harvard Medical School
Foreword
by Maurice E. Mitller
This outstanding book on the fractures of the distal radius has been written by
two surgeons famous for their expertise in this area. Diego Fernandez began
to contribute to our knowledge in this area in the late 1970s in Berne where
he was responsible for the surgical care of all wrist and hand injuries at the
University Orthopaedic Department. It was during this time that he began to
formulate the gUidelines for the classification and treatment of fractures of the
distal radius. During the years that followed, fractures of the distal radius were
almost always among the subjects of his lectures given on the occasion of AO
courses and Meetings of Hand Surgery Societies, in both North and South
America. The many discussions held on these occasions with world authorities
gave him the opportunity to broaden and mature his concepts. Publications on
the classification and treatment of these injuries as well as on the treatment of
complications of hand fracture followed. This brought him international
acceptance and greatly accelerated his academic career in Switzerland. On this
occasion he has collaborated with his close friend Jesse Jupiter who is equally
world famous for his many contributions to the pathomechanics and treatment
of fractures of the distal radius. Jesse Jupiter is the chief of the Upper Extremity
Service at the Massachusett's General Hospital in Boston. In this position he is
involved not only in clinical care of extremely difficult upper extremity
problems, but also in related clinical and basic research. The close collabora
tion of the two experts has resulted in a book which is destined to become a
milestone in the literary contributions of this subject.
The two authors discuss not only their own experience but make frequent
references to English, European, and particularly to French literature. Unques
tionably one of the main features of this book is the authors' extensive
discussion of over 20 published classification systems of injuries to the distal
radius and of the correlation between the diagnosis, the surgical treatment,
and the prognosis. The authors point out that in metaphyseal fractures an
appreciation of the mechanism of injury is usually enough to effect a successful
closed treatment. The open treatment of fractures, on the other hand, places
much greater demands on the surgeon. Here the authors have chosen the
methodology of the Comprehensive Classification of Fractures (CCF)* in which
the classified fractures are organized in a hierarchical system of triads, in an
ascending order of severity of the prognosis, be it for the type (or family),
group or subgroup. In order to give the injury full expression, they had in
many instances to utilize as well the qualifications giving information on the
associated lesion of the ulna and radio-ulnar joint. The authors evaluated the
classification as being easily reprodUCible and reliable. The detailed morpho
logical categorization of the fractures made it possible to establish an exact
* Muller M.E., Nazarian S., Koch P., Schatzker ].: The Comprehensive Classification of Fractures of
Long Bones, Springer-Verlag Heidelberg-New York, 1990.
x Foreword
diagnosis and clear guidelines to treatment correlated with the prognosis of
the outcome, In evaluating the CCF, the authors found that although the system
of classification was designed for all fractures of the long bones, it gave them
the best practical guide to the selection of either closed or open treatment of
fractures of the distal radius,
I recommend this book very strongly to all those concerned with the care of
fractures of the distal radius, The text contains well over 400 illustrations which
clearly describe the authors' concepts and make it easy for the reader to
master most of the recommended procedures, The book appeals to the
expert in this area because the authors describe many very specialized
procedures including the arthroscopically aided reduction and fixation of the
difficult C2 and C3 fractures, It will also serve well as a reference book because
of its scope and superb bibliography,
Maurice E. Muller, M.D.
Berne, 1st of July 1995
