Demerit Point System Research Articles

Dorsally comminuted fractures of the distal end of the radius: osteosynthesis with volar fixed angle locking plates.

Background. Dorsally comminuted distal radius fractures are unstable fractures and represent a treatment challenge. The objective of this study was to evaluate the functional and radiological outcome of dorsally comminuted fractures of the distal radius fixed with a volar locking plate. Patients and Methods. Thirty-three consecutive patients with dorsally comminuted fractures of the distal end of the radius were treated by open reduction and internal fixation with AO 2.4 mm (n = 19)/3.5 mm (n = 14) volar locking distal radius plate (Synthes, Switzerland, marketed by Synthes India Pvt. Ltd.). There were 7 type A3, 8 type C2, and 18 type C3 fractures. The patients were followed up at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Subjective assessment was done as per Disabilities Arm, Shoulder, and Hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist; the radiological determinants were radial angle, radial length, volar angle, and ulnar variance. The final assessment was done as per Demerit point system of Saito. Results. There were 23 males and 10 females with an average age of 44.12 ± 18.63 years (18–61 years). Clinicoradiological consolidation of the fracture was observed in all cases at a mean of 9.6 weeks (range 7–12 weeks). The average final extension was 58.15° ± 7.83°, flexion was 54.62° ± 11.23°, supination was 84.23° ± 6.02°, and pronation was 80.92° ± 5.54°. Demerit point system of Saito yielded excellent results in 79% (n = 26), good in 18% (n = 6), and fair in 3% (n = 1) patients. Three patients had loss of reduction but none of the patients had tendon irritation or ruptures, implant failure, or nonunion at the end of an one-year followup. Conclusion. Volar locking plate fixation for dorsally comminuted distal radius fractures results in good to excellent functional outcomes despite a high incidence of loss of reduction and fracture collapse.

English

BACKGROUND: Fractures of distal end radius are the most common fractures of the upper extremity, encountered in orthopaedic practice. The goal of treatment has always been to restore the anatomy of the radius i.e. length, tilt, inclination and joint surface. Fixation of these fractures by volar plating provides restoration of distal radial anatomy and most consistent correction of displacement. The purpose of this study was to evaluate the functional outcome of patients with distal end radius fractures managed operatively by volar plating. METHODS: Between August 2007 and March 2012, eighty patients with distal end radius fractures were treated with volar fixed-angle locking plate. Fractures were classified according to the AO/ASIF classification system as type A(n = 16), B(n = 12) and C(n = 52). Anatomical evaluation was done by Sarmiento’s modification of Lind Storm criteria while clinical and functional outcome was done by demerit point system of Gartland and Werley with Sarmiento et al’s modification. RESULTS: The average follow up of patients was 62.5 weeks. On anatomical evaluation at final follow up we found that 68 patients (85%) had excellent restoration of anatomy, 8 (10%) had good and 4 (5%) had fair restoration of anatomy. Functionally 60 patients (75%) had excellent, 12 (15%) had good and 8 (10%) had fair results. Poor function correlated with residual displacement and poor patient compliance. 9 patients had joint stiffness and 3 had paresthesia in median nerve distribution and 2 had reflex sympathetic dystrophy. CONCLUSION: The treatment of intra and extra-articular fractures of the distal radius with a volar plating system have an excellent to good anatomical restoration of anatomy and excellent functional outcomes. This treatment is associated with a very small and statistically insignificant loss of volar tilt, radial inclination and radial length upon comparison of immediate postoperative alignment with that seen after more than 1 year follow-up. These results suggest that stabilizing the fracture with volar plating is a very effective method.

Volar long locking compression plate fixation for distal radius fractures with metaphyseal and diaphyseal extension

Comminuted distal radial fractures with metaphyseal and diaphyseal extension are uncommon and remain a challenge to treat. The purpose of this study was to assess the radiographic and functional outcomes of treatment with the volar long locking compression plate (LCP) system for distal radius fractures with metaphyseal and diaphyseal extension. This retrospective study was performed on 22 consecutive patients who were treated with open reduction and internal fixation with the application of a 2.4-mm-extra-long LCP volar distal radius plate. Patients were evaluated based on clinical signs and radiography studies. The average time to fracture union was 16 weeks. The volar tilt was restored to a mean of 10.1°. The radial length and radial inclination were restored to a mean of 12.8 mm and 23.6° at final follow-up, respectively. The mean loss of radial length was -1.0 mm at final follow-up as compared with the contralateral extremity. The average ulnar variance was positive 0.1 mm at final follow-up with a congruent distal radioulnar joint. The degree of collapse after fixation between immediate postoperative and final follow-up visit was -0.1 mm. Using the demerit-point system of the Gartland and Werley rating system, 14 results were rated as excellent, 5 as good and 1 as fair. DASH scores averaged 10.1 points. Based on our experience, the volar long LCP is useful in the management of comminuted fractures of the distal radius, in which there is proximal extension into the diaphysis and can avoid or minimize the complications of external fixation or dorsal bridging distraction plate.

A Radical Change in Traffic Law: Effects on Fatalities in the Czech Republic

This study examines short- and long-run effects of a new—stricter—road traffic law on traf- fic accident-related fatalities in the Czech Republic. The law introduced tougher punishments through the introduction of a demerit point system and a manifold increase in fines, together with augmented authority of traffic police. Identification is based on difference-in-differences methodology, with neighbouring countries serving as a control group. I find a sharp, 33.3%, decrease in accident-related fatalities during the first three post-reform months. This trans- lates into 127 saved lives (95% confidence interval: 51, 204). The decline was, however, temporary; the estimates of the effects going beyond the first year are around zero. Unique data on traffic police activity reveal that police resources devoted to traffic law enforcement gradually declined. Tougher penalties have significant, but often short-lived effects. Weaker enforcement in the aftermath of such reforms may explain the absence of long-run effects.

LOCKING PALMAR PLATE FIXATION FOR DORSALLY DISPLACED FRACTURES OF THE DISTAL RADIUS: A PRELIMINARY REPORT

We reviewed a series of 62 consecutive patients with dorsally displaced fractures of the distal radius, including 20 extra-articular and 42 intra-articular fractures. All patients were treated with palmar locking plate systems at our institution between 2002 and 2006. After a minimum follow-up time of 12 weeks, the fractures had healed with satisfactory radiographic and functional results. According to the demerit point system of Gartland and Werley, 35 patients were rated excellent, 26 good, and one fair. In the good and fair groups, the demerit points were almost all for ulnar wrist pain. Our results suggest that palmar locking plate systems enable early functional mobilization with good reproducible radiographic and clinical outcomes. Since nine out of 62 patients had residual ulnar wrist pain at the final follow-up evaluation, further investigation of the pathogenesis of ulnar wrist pain is necessary to obtain better functional outcomes.

Conductores infractores, ¿Un perfil de conducta desviada?: Análisis de las diferencias y similitudes con una muestra de conductores de la población general

Con las últimas modificaciones del Código Penal en materia de seguridad vial determinados comportamientos del conductor han adquirido la consideración de delito y pueden ser castigados con penas de prisión. Esta medida ha supuesto un complemento al llamado “permiso de conducción por puntos” y ha propiciado un incremento en la investigación sobre las variables relacionadas con el comportamiento infractor del conductor. En esta línea, el objetivo de este trabajo ha sido comprobar si existen diferencias entre los conductores de la población general y los infractores en una serie de características de personalidad y en el modo en que experimentan y manifiestan sus emociones al volante. Además, también hemos querido analizar sus hábitos de conducción y su historial de multas y accidentes con el fin de determinar si existe un perfil infractor y desviado en los conductores condenados por delitos contra la seguridad vial. Para ello se ha realizado una encuesta a un grupo de conductores condenados por delitos de tráfico y a un grupo de conductores de la población normal. Este último lo componían 647 conductores de la población gallega con edades comprendidas entre los 19 y los 74 años, siendo el 52% mujeres y el 48% varones. Los infractores fueron seleccionados de entre aquellos que participaron en un curso de reeducación impartido por psicólogos del COP Galicia. Los resultados muestran que los penados puntúan más alto en Impulsividad que los conductores de la población general y que suelen manifestar su ira al volante mediante conductas de agresión física. Además, los condenados por delitos de tráfico consumen más alcohol, infringen más las normas de circulación y se ven implicados en más accidentes sin víctimas. Estos resultados tienen importantes implicaciones prácticas a la hora de diseñar programas de prevención e intervención en el campo de la seguridad vial.

Evaluating impact of demerit points system on speeding behavior of drivers

The objective of this research was to evaluate the immediate impact of the demerit points system on speeding behavior of drivers in Al Ain. Al Ain is the fourth largest city in the United Arab Emirates, located about 120 Km from Dubai. The spot speed data of randomly selected vehicles using speed guns was collected from three major arterial urban roads.The data was collected three months before and three months after the implementation of the demerit points system. The free flow conditions were considered during the data collection. The data was analyzed using SPSS program. The results revealed that the demerit points system has statistically no significant impact on the speeding behavior of drivers in Al Ain. One of the plausible reasons for insignificance affect of the demerit point system could be the lack of effective traffic monitoring system. This study recommends that to influence the drivers’ behavior an effective traffic monitoring system should be provided to achieve the desired outcomes of introducing tougher laws such as demerit point system. The study also recommends to collect more data to investigate the changes in the speeding behavior of drivers.

Rational Drivers, Irrational Enforcers, and Road Safety

Using Italian data, this article presents an econometric investigation of the effects on infractions and accidents of the introduction of a demerit point system (DPS), as an additional sanctioning mechanism for traffic infringements. Our main finding is that the coming into force of the DPS produced only a temporary and weak effect, while the announcement of the decision of the Italian government to introduce the new penalty system (occurred more than two years before the introduction of the new penalty system) exerted a stronger deterrent effect on the behavior of drivers, and thus on the number of recorded infractions. The evidence on this sort of announcement effect together with that on the implemented level of enforcement, which remained constant during the overall examined period, suggests that the Italian DPS has been prevented by exerting a lasting deterrent effect because drivers have rationally responded to incentives through a learning mechanism. Precisely, once Italian drivers learned that, neither after the government's announcement nor subsequently the coming into force of the DPS, the probability of being detected and thus the perceived expected sanction increased, they re-adapted their degree of compliance with the traffic law to the previous lower levels. Thus, further changes in the implementation of the Italian DPS appear desirable in order to make the new system effectively works.

Fragment-specific fracture fixation and double-column plating of unstable distal radial fractures using AO mini-fragment implants and Kirschner wires

To evaluate the efficacy of AO mini-fragment implants and 1.25-mm Kirschner wires using fragment-specific fracture fixation and double-column plating for displaced or unstable distal radial fractures. prospective and consecutive. level II trauma hospital. 28 people with 30 fractures and an average follow-up of 21.1 (range 12-41) months, treated with fragment-specific fracture fixation. anatomical assessment using anteroposterior and lateral radiographs, graded according to Sarmiento's modification of Lidstrom's scoring system. CLINICAL OUTCOME ASSESSMENT: DASH and Modified Gartland and Werley scores. There were 24 excellent and 6 good radiological results. Final mean grip strength was 83% of uninjured side, and mean wrist range of motion was 61 degrees dorsiflexion, 54 degrees palmar flexion, 85 degrees supination and 83 degrees pronation. Gartland and Werley's demerit point system revealed 13 (43%) excellent, 12 (40%) good, 5 (17%) fair and no poor results. The mean DASH score was 18, with a standard deviation of +/-18. This fixation method is a reliable and low-cost alternative with good clinical and anatomical results, particularly useful in open reduction and internal fixation of comminuted intra-articular distal radial fractures.

Cancellous Allograft versus Autologous Bone Grafting For Repair of Comminuted Distal Radius Fractures: A Prospective, Randomized Trial

Distal radius fractures with a large metaphyseal defect often need defect filling. We assessed the reliability of a new allogenic transplant as a bone-graft substitute in comparison to autologous iliac crest bone-grafting. This prospective, randomized study included 90 patients. Fracture-osteosynthesis was done with 2.7 mm quarter-tube plates. Tutoplast-cancellous-chips were used as allografts. Clinical and radiologic parameters were determined at three and 12 months after surgery. Overall outcomes were assessed according to the Demerit Point System: There were 71% good-to-excellent results in the "Tutoplast"; group and 75% good-to-excellent in the "iliac crest" group. Radiologic parameters were comparable and within normal range. Complications deriving from iliac bone harvesting were notably more frequent in the iliac crest group. Operation time was significantly shorter in the Tutoplast group. By the use of the investigated allograft no adverse effects were detected on the outcome of the treated radius fractures. Therefore, this new allograft could be a desirable alternative to autologous bone grafting from the iliac crest, as operating and anesthetics times are shortened and complications of iliac crest bone grafting avoided.

The Use of Tricorticocancellous Bone Graft in Severely Comminuted Intra-Articular Fractures of the Distal Radius

We report the results of a retrospective study of the use of tricorticocancellous iliac crest bone graft in 12 patients with acute AO type C3.2 or type C3.3 fractures of the distal radius who were followed up for at least 1 year. Twelve of 17 patients treated with the protocol were available for follow-up evaluation. All fractures were treated with open reduction and combined internal and external fixation. Five fractures were plated dorsally, 1 volarly, and 5 volarly and dorsally. Five patients had AO type C3.2 fractures and 7 had AO type C3.3 fractures. Nine of 10 radiographic parameters that were restored to near-normal values during the surgery were maintained at near-normal levels at the final follow-up evaluation at a mean of 28 months after surgery. Nine fractures had less than 2 mm of articular step-off of the distal radius and 8 had less than 3 mm of total articular incongruity (gap plus step-off). In 10 patients the radial length was restored to at least 10 mm. The mean arc of flexion-extension was 67% and the mean grip strength was 57% of that of the uninjured side. According to the Gartland and Werley demerit-point system 5 of the patients had good or excellent results. According to the modified Green and O'Brien clinical rating system 2 patients had good or excellent results. Poor results for 2 patients according to the demerit-point system and for 6 patients according to the Green and O'Brien clinical rating system were associated with severe ipsilateral soft-tissue and osseous injuries of the wrist, forearm, and arm. The total articular incongruity had a moderately strong correlation with the outcome as assessed by the demerit-point system. Tricorticocancellous bone grafting in conjunction with combined internal and external fixation is a satisfactory treatment that can lead to a high rate of return to work and sports, a high level of patient satisfaction, and a low rate of complications. Therapeutic, Level IV.

PALMAR PLATING FOR AO/ASIF C3.2 FRACTURES OF THE DISTAL RADIUS WITH ARTHROSCOPICALLY ASSISTED REDUCTION

We performed a retrospective study of 15 patients with AO/ASIF C3.2 fracture of the distal radius. All patients were treated with arthroscopically assisted reduction of the radiocarpal joint followed by palmar plating with autologous bone graft, with a follow-up evaluation of 24 months. According to the demerit point system of Gartland and Werley, five patients had excellent results and 10 had good results. Grade 1 arthritic changes were found in 10 patients even though with no step-off on radiographs. In the current study, this combined treatment was challenging and useful for AO/ASIF C3.2 fractures.

骨粗しょう症性とう骨遠位端骨折に対する小切開掌側ピンを追加したＤｅｓｍａｎｅｔ変法

Increasingly higher functional results are reguired in the treatment of distal radius fractures with osteoporosis and surgical procedures must be selected carefully in case of inadequate reduction of the fracture. Of these surgical procedures, pinning using K-wire is widely used for ease and minimum invasion, however, complications are occasionally seen. To solve these problems, we have been using modified Desmanets intrameddullary pinning in recent years. In some cases, we experience over collection, and add the volar pin for better results. From 2003 to 2004, 10 patients with osteoporotic distal radius fractures were treated at our hospital. The clinical results were satisfactory according to the demerit point system of Saito; six were assessed as excellent and four as good. Dorsal 2 pins aid reduction of the fracture and maintain reduction by 3 point support. Moreover, the added volar pin acts as to prevent over-reduction. This technique minimizes morbidity by successfully handling the osteoporotic bone allowing early return to function and provides good final results.

Modified Desmanet’s intramedullary pinning for fractures of the distal radius

The purpose of this article is to present the results of Desmanet’s intramedullary pinning for distal radius fractures, and also to present modifications of the cut-end management of pins; the cut-ends were shaped like a tear-drop for the radial pin and like a curtain-hook for the ulnar pin. One hundred and two operated patients (23 men and 79 women; mean age at operation, 61.0 ± 17.5 years) were followed up for 9.6 ± 12.9 months. The clinical results were satisfactory according to the demerit point system of Saito; 83 were assessed as excellent and 19, as good. On the X-ray measurements, the mean values for radial inclination angle, volar tilting angle, and ulnar variance were 23.5° ± 5.1°, 8.8° ± 7.1°, and 1.0 ± 1.6 mm, respectively. Eighty-three patients (81.4%) showed no deformities. The results of 23 aged patients (older than 75 years) were also satisfactory, and this method thus appears to be a good choice for aged patients with osteoporosis. Modifications of the cut-ends of pins reduced the extensor tendon complications that occur with Desmanet’s original method. The present method is also good for extraarticular Colles’ fracture. Concerning intraarticular Colles’ fractures, the undisplaced type and the ulnar split type are good indications for this method. This method can also be used for the dorsal split depression type, but the ulnodorsal split type is not a good indication.

Treatment of the unstable distal radius fracture with external fixation and a hydroxyapatite spacer.

A prospective study was performed on 25 patients (15 women, 10 men) with unstable fractures of the distal radius selectively treated with a dynamic type of external fixation combined with a hydroxyapatite spacer. The fractures ranged from type VI to type VIII according to Frykman's classification. The patients' mean age at surgery was 49 years (range, 19-75 years). The mean follow-up period was 2.5 years, and overall outcome was assessed using Gartland and Werley's demerit point system as modified by Sarmiento. Radial inclination was 26 degrees +/- 4 degrees at the time of reduction and 26 degrees +/- 5 degrees at follow-up, palmar tilt was 9 degrees +/- 2 degrees at reduction and 8 degrees +/- 3 degrees at follow-up, and ulnar variance was 1.4 +/- 0.6 mm at reduction and 2.1 +/- 0.9 mm at follow-up. The mean range of motion at follow-up was 80 degrees +/- 10 degrees in flexion, 80 degrees +/- 10 degrees in extension, 85 degrees +/- 10 degrees in supination, and 80 degrees +/- 5 degrees in pronation. The outcome in 24 of 25 patients was evaluated as excellent. In the surgical treatment of unstable fractures of the distal radius using external fixator, the fracture reduction should be supported with bone graft or a bone substitute, and a hydroxyapatite spacer was considered to be a useful substitute for a bone graft.

Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation.

Severely comminuted AO type-C3 intra-articular fractures of the distal end of the radius are difficult to treat. Failure to achieve and maintain nearly anatomic restoration can result in pain, instability, and poor function. We report the results of a retrospective study of the use of a standard protocol of open reduction and combined internal and external fixation of these fractures. Seventeen of twenty-five patients treated with the protocol were available for follow-up evaluation. Six had an AO type-C3.1 fracture; eight, type-C3.2; and three, type-C3.3. Eleven fractures required a dorsal buttress plate and/or a volar buttress plate, and eleven required bone-grafting. The mean time until the external fixator was removed was seven weeks. At a mean of thirty months postoperatively, the mean arc of flexion-extension was 72% of that on the uninjured side and the mean grip strength was 73% of that on the uninjured side. The mean articular step-off was 1 mm, the total articular incongruity (the gap plus the step-off) averaged 2 mm, and the radial length was restored to a mean of 11 mm. Thirteen patients had less than 3 mm of total articular incongruity. Arthritis was graded as none in three patients, mild in ten, moderate in three, and severe in one. According to the Gartland and Werley demerit-point system, ten of the patients had a good or excellent result. According to the modified Green and O'Brien clinical rating system, five had a good or excellent result. One patient had a fracture collapse requiring wrist fusion, one had reflex sympathetic dystrophy, and three had minor Kirschner-wire-related problems. Total articular incongruity immediately postoperatively had a moderately strong correlation with the outcome as assessed with both clinical rating systems (r = 0.70 and 0.74 for the Gartland and Werley system and the Green and O'Brien system, respectively; p<0.05). Open reduction and combined internal and external fixation of AO type-C3 fractures can restore radiographic parameters to nearly normal values, maintain reduction throughout the period of fracture-healing, and provide satisfactory functional results.

小児とう骨遠位端骨折に対するＩｎｔｒａｆｏｃａｌ ｐｉｎｎｉｎｇ（ＩＦＰ）法の検討

Twenty-three children with fracture or epiphyseal separation of the distal radius were treated with intrafocal pinning (IFP). Fifteen were boys and eight were girls. The age at surgery ranged from 8 to 15 years (mean age: 11.3 years). There were 14 extra-articular fractures and 9 epiphyseal separations (Salter-Harris type II in 8 and type III in 1). Follow-up ranged from 2 months to 42 months. The results were evaluated according to the radiographical measurements of the palmar tilt, radial inclination and ulnar variance, and were evaluated by Saito's demerit point system. The palmar tilt was reduced within the normal range in 22 of the 23 patients. The radial tilt was reduced within normal range in 21 of the 23 patients. Zero variance was achieved in 21 patients. These reductions were maintained through the end of the follow-up. All of the 11 patients who visited us for evaluation were classified as excellent. The IFP method is not only minimally invasive but also stable enough to enable early ROM exercise. We can conclude that IFP is useful for distal radius fracture and epiphyseal separation in children.

創外固定器を用いたＢｅｎｎｅｔｔ骨折・Ｒｏｌａｎｄｏ骨折の治療経験

Two important fractures of the trapeziometacarpal joint are Bennett's fracture and Rolando's fracture. There are many treatments for these fractures, amongst which closed reduction and percutaneous pinning have become the treatment of choice for these fractures these days.We report on our treatment with an external fixator in 7 cases of Bennett's fracture and Rolando's fracture between 1995 and 1998. Four cases are Bennett's fractures and 3 cases are Rolando's. All cases could be followed, and the follow-up period varied from 6 months to 2 years.The policy of our department has been towards the reconstruction of the articular surface with closed reduction applying external fixator. If the fracture is not reducible, an open reduction is recommended.Clinical results were assessed using Saito's demerit point system for Bennett's fracture and roentgenographic findings were analysed. There were 6 excellent, 1 good, and no fair or poor. Roentgenographically, there was only 1 case with shortening of the metacarpal shaft. By using an external fixator, reduction can be maintained without difficulty.

高齢者Ｃｏｌｌｅｓ骨折に対するｉｎｔｒａｆｏｃａｌ ｐｉｎｎｉｎｇ法の工夫

Intrafocal pinning first described by Kapandji was originally indicated for extra-articular fractures of the distal radius in young patients. We Modified the procedure for application to elderly patients. Three Kirschner wires were inserted through small incisions. The dorsal intramedullary pin was inserted first through the fourth dorsal compartment. The radial pin was then inserted between the first and second dorsal compartments.Finally the palmar pin was inserted from the radial side of the radial artery. The ends of the Kirschner wires were bent and impacted to the cortex to avoid skin irritation.We observed 27 (16 original procedures and 11 modified procedures) patients aged over 65. The number of patients within the normal range of the palmar tilt (0 to 22 degrees) was 7 for the original procedure and 10 for the modified procedure. That within the normal range of the radial inclination (16 to 22 degrees) was 7 and 11 respectively. 11 patients were evaluated by the Saito's demerit point system. There were 1 excellent and 5 good for the original procedure and 5 excellent for the modified procedure. The number of patients with complications caused by the Kirschner wires was 8 for the original procedure and 1 for the modified procedure. The results suggest modified intrafocal pinning method maintains better reduction and reduces complications by the Kirschner wires.

A more practical approach to integrate low voltage distribution system into the electrical engineering curriculum

This paper describes the author's new attempt to introduce a 10-hour lecture on low voltage (LV) distribution system with a 5-hour design exercise and a 5-hour project work for all electrical engineering students. It is felt that most of the electrical engineering graduates will possibly encounter more applications in the LV system rather than the traditional power system analysis. The system earthing and the associated electrical parts for the LV network can be easily implemented in a laboratory for students to test and operate. In the design exercise, the PC-based integrated tool not only guides the students in a step-by-step approach and provides a CAD tool to automate the repetitive design process, it also evaluates the student's performance in the design exercise by using error log and a demerit point system. In the guided project work, the students are exposed to a physical LV simulator identical to an industrial installation to carry out inspection, testing, turn-on supply, fault diagnosis and restoration of supply. In a survey from 600 students, 24% strongly agreed, and 52% agreed that this 10-hour design and project works are useful and challenging. Many students expressed that they are interested in their first exposure to a power engineering project.