Pathology
Wrist Fractures, or breaks in the wrist, are the most frequent fractures seen in the emergency room. Distal Radius Fractures with and without a distal ulnar fracture is second only to hip fractures in frequency.
Wrist fractures have a bimodal distribution, with peak ages between 6-10 years and between 60-69 years old, often occurring after a fall at ground level.
Higher energy injuries occur more frequently with a fall from a height, a sports injury or a motor vehicle accident.
Over 50 % of distal radius fractures extend into the joint surface (intra-articular), involving the radio-carpal joint or the radio-ulnar joint.
This type of fracture requires the anatomic restoration of the joint surface.
Fractures not involving the joint surfaces (extra-articular) are frequently unstable, despite an acceptable initial reduction and casting. This is because of the poor bone quality or high level of fragmentation occurring in elderly individuals.
Treatment
Many distal radius fractures, particularly in the elderly, have been undertreated because of the poor results initially achieved with an open reduction and internal fixation (ORIF).
However, with more rigorous scrutiny of the personality of the fracture, the trend is now leaning towards fixing many of the fractures previously treated in a cast.
Nonsurgical Fractures are:
- Not separated (displaced)
- Significantly shortened or angulated
- Able to be reduced to an acceptable position with a high likelihood of maintaining the position
These kinds of fractures can often be treated initially with a splint that includes the elbow, called a sugartong splint. This is followed by a short arm cast 3 weeks later, and early controlled motion exercises when the cast is removed around 6 weeks after injury, if x-rays demonstrate sufficient healing has occurred.
The consultation of a therapist will assist in preventing the wrist and hand from becoming stiff and will guide the therapy protocol until the best level of activity is achieved.
Surgical Fractures are:
- Separated
- Significantly shortened
- Angulated
- Extend into the joint
- There are multiple small fragments (comminution)
These findings alone or in combination can result in an unstable fracture which means if the fracture is reduced and casted, the likelihood of holding position until healed is unlikely.
In this instance, surgery is indicated. Different Methods of Fracture Fixation
- Pins
- Headless screws
- External fixation
- Plates & screws
Recently, distal radius fracture fixation has had improved results due to newer plates and screws that lock to each other, consequently providing an improved hold on the fragments until the fracture heals.
This newer plate and screw systems are placed on the palmar side of the wrist where there is improved padding due to the muscles on this side of the forearm. This causes less plate prominence, often eliminating the need for their removal in the future after the fracture has healed.
The locking plates increase the rigidity of the fixation, which allows earlier motion of the wrist and digits even if poor bone quality exists. In turn, this minimizes the stiffness often associated with these injuries and delivers improved and earlier return of normal function.
Severe fractures often have associated conditions like acute carpal tunnel syndrome (compression of the median nerve due to severe swelling about the wrist) demanding release of the nerve on same surgical setting.
Ligament injures associated with distal radius fractures must also be considered.
Injury to the distal radial ulnar joint as occurs when an ulnar styloid fracture is present.
After fracture fixation, the patient can start immediate active motion of the fingers and wrist to prevent stiffness.
A removable wrist splint is used during the perioperative period to provide psychological confidence for elderly patients concerned about losing their balance.
The patients are evaluated 1 week after surgery for an initial wound check and for the initiation of formal therapy. The patient is given a protective brace that is removable for hygiene and wrist and hand exercises.
It takes up to 3- 4 months to obtain about 75% functionality. It may take a full year to obtain maximal improvement. The timeframe depends on the severity of the fracture, associated injuries and the age of the patient.