A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and swelling of rapid onset. The wrist may be deformed. The ulna bone may also be broken.
In younger people, these fractures typically occur during sports or a motor vehicle collision. In older people, the most common cause is falling on an outstretched hand. Specific types include Colles, Smith, Barton, and Hutchinson fractures. The diagnosis is generally suspected based on symptoms and confirmed with X-rays.
Treatment is with casting for six weeks or surgery. Surgery is generally indicated if the joint surface is broken and does not line up, the radius is overly short, or the joint surface of the radius is tilted more than 10% backwards. Among those who are casted, repeated X-rays are recommended within three weeks to verify that a good position is maintained.
Distal radius fractures are common. They represent between 25 and 50% of broken bones. They occur most commonly in young males and older females. A year or two may be required for healing to occur.
Video Distal radius fracture
Signs and symptoms
People usually presented with a history of fall on outstretch hand with complaint of pain and swelling around the wrist, sometimes with deformity around the wrist. Any paresthesia or numbness should be asked to exclude median and ulnar nerve injuries. Any pain in the limb of the same side should also be investigated to exclude associated injuries to the same limb.
Examination
Swelling, deformity, tenderness, and loss of wrist motion are normal features on examination of a person with a distal radius fracture. Dinner fork deformity of the wrist is caused by dorsal displacement of the carpal bones (Colle's fracture). Reverse deformity is seen in volar angulation (Smith's fracture). The wrist may be radially deviated due to shortening of the radius bone. Examination should also rule out a skin wound which might suggest an open fracture, usually at the side. Checking for loss of sensation, loss of circulation to the hand, and more proximal injuries to the forearm, elbow and shoulder is imperative. The most commonly associated neurological finding is decreased sensation over the thenar eminence due to associated median nerve injury.
A classic "dinner fork" deformity may be seen in dorsally angulated fractures due to dorsal displacement of the carpus. The reverse deformity may be seen in volarly angulated fractures.
Maps Distal radius fracture
Mechanism of injury
The most common cause of this type of fracture is a fall on an outstretched hand from standing height although some will be due to high energy injury. People who fall on the outstretch hand are usually fitter and have better reflexes when compared to those with elbow or humerus fractures. The characteristics of distal radius fractures are influenced by the position of the hand at the time of impact, the type of surface it contact, speed of the impact, and the strength of the bone. Distal radius fracture would most probably occur with the wrist bend back to 60 to 90 degrees. Radial styloid fracture would occur if the wrist is ulnar deviated and vice versa. If the wrist is bend back less, then proximal forearm fracture would occur, but if the bending back is more, then the carpal bones fracture would occur. With increasing bending back, more force is required to produce a fracture. Besides, more force is required to produce a fracture in males than females. Risk of injury increases in those with osteoporosis.
Common associated injuries with distal radius fractures are interosseous intercarpal ligaments injury especially scapholunate (4.7 to 46% of the cases) and lunotriquetral ligaments (12% to 34% of the cases) injuries. There is an increased risk of interosseous intercarpal injury if the ulnar variance (the difference in height between the distal end of ulna and the distal end of radius) is more than 2 mm and there is fracture into the wrist joint. Triangular fibrocartilage complex (TFCC) injury occurs in 39% to 82% of the cases. Ulnar styloid process fracture increases the risk of TFCC injury by the factor of 5.1. However, it is unclear that whether intercarpal ligaments and triangular fibrocartilage injuries are associated with long term pain and disability for those who are affected.
Injuries to the elbow, humerus, and shoulder are also common after a fall on outstretched hand. Swelling and displacement can cause compression on the median nerve across the wrist, an acute carpal tunnel syndrome. Very rarely is pressure on the muscle components of the hand or forearm sufficient to create a compartment syndrome.
Diagnosis
Diagnosis may be evident clinically when the distal radius is deformed, but should be confirmed by X-ray. The differential diagnosis includes scaphoid fractures and wrist dislocations, which can also co-exist with a distal radius fracture. Occasionally, fractures may not be seen on X-rays immediately after the injury. Delayed X-rays, X-ray computed tomography (CT scan), or Magnetic resonance imaging (MRI) can confirm the diagnosis.
Medical imaging
X-ray of the affected wrist is required if a fracture is suspected. Anteroposterior, lateral, and oblique views can be used together to describe the fracture. X-ray of the uninjured wrist should also be taken to determine if any normal anatomic variations exist. Investigation of a potential distal radial fracture includes assessment of the angle of the joint surface on lateral X-ray (volar/dorsal tilt), the loss of length of the radius from the collapse of the fracture (radial length), and congruency of the distal radioulnar joint. Displacement of the articular surface is the most important factor affecting prognosis and treatment. CT scan is often performed to further investigate the articular anatomy of the fracture, especially if surgery is considered. MRI can be considered to evaluate for soft tissue injuries, including damage to the TFCC and the interosseous ligaments.
Classification
In medicine, classifications systems are devised to describe patterns of injury which will behave in predictable ways, to distinguish between conditions which have different outcomes or which need different treatments. Most wrist fracture systems have failed to accomplish any of these goals and no consensus about the most useful one has been reached.
At one extreme, a stable, undisplaced extra-articular fracture has an excellent prognosis. However, an unstable, displaced intra-articular fracture is difficult to treat and has a poor prognosis without operative intervention.
Eponyms such as Colles', Smith's, and Barton's fractures are discouraged.
An anatomic description of the fracture is the easiest way to describe the fracture, determine treatment, and assess stability.
- Articular incongruity
- Volar or dorsal tilt
- Radial inclination
- Radial length and ulnar variance
- Comminution of the fracture (the amount of crumbling at the fracture site)
- Open (compound fracture) vs. closed injury
- Associated ulnar styloid fracture
- Associated soft-tissue injuries
Treatment
Treatment options for distal radius fractures include nonoperative management, external fixation, and internal fixation. Indications for each depend on a variety of factors such as patient's age, initial fracture displacement, and metaphyseal and articular alignment, with the ultimate goal to maximize strength and function in the affected upper extremity. Surgeons use these factors combined with radiologic imaging to predict fracture instability, and functional outcome to help decide which approach would be most appropriate. Treatment is often directed to restore normal anatomy to avoid the possibility of malunion, which may cause decreased strength in the hand and wrist. The decision to pursue a specific type of management varies greatly by geography, physician specialty (hand surgeons vs. orthopedic surgeons), and advancements in new technology such as the volar locking plating system.
Nonoperative
The majority of distal radius fractures are treated with conservative nonoperative management, which involves immobilization through application of plaster or splint with or without closed reduction. The prevalence of nonoperative approach to distal radius fractures is around 70%. Nonoperative management is indicated for fractures that are undisplaced, or for displaced fractures that are stable following reduction. Variations in immobilization techniques involve the type of cast, position of immobilization, and the length of time required in the cast.
The length of time in the cast varies with different ages. Children heal more rapidly, but may ignore activity restrictions. Three weeks in a cast and 6 weeks off sports may be appropriate for certain fractures. In adults, the risk of stiffness of the joint increases the longer it is immobilized. If callus is seen on x-ray at 4 weeks, the cast may be replaced by a removable splint. However, many hand surgeons leave the patients in the cast for up to 6 weeks. In general, the X-rays will not show any callus until about a month after the fracture is healed; therefore, the cast is removed before the X-rays confirm that it is healed.
During the period of follow-up, repeating x-rays at about 1 week is common practice to make sure the position is still acceptable. Further followup is needed to determine when the fracture has healed and when rehabilitation is complete. The critical time during the period of attempted treatment with casting is the first 3 weeks. The swelling will reduce during this time and the fracture can displace. If the displacement becomes unacceptable, closed treatment may need to be abandoned and surgery pursued. More than 3 weeks after injury, the fracture will start to heal and further displacement becomes less likely.
Undisplaced stable fractures
Where the fracture is undisplaced and stable, nonoperative treatment involves immobilization. Initially, a sugar tong splint is applied to allow swelling and subsequently a cast is applied. Depending on the nature of the fracture, the cast may be placed above the elbow to control forearm rotation. For torus fractures, a splint may be sufficient and casting may be avoided.
Displaced stable fractures
In displaced fractures, the fracture may be manipulated under anaesthesia and splinted in a position to minimize the risk of re-displacement. Typically, this involves injecting local anesthesia into the fracture (hematoma block) possibly combined with intravenous medication. A manual reduction is performed to reposition the displaced distal radius into its preinjury position and maintain this position in a well-formed splint or cast.
Displaced fractures in the elderly or those physiologically unable to undergo surgery are treated differently. When the fracture is displaced and no plans for a surgery are made, a short arm cast is placed for only 4 weeks or until the tenderness resolves. A larger cast placed for an extended period of time only slows down recovery in this group of patients.
Following healing and cast removal, a period of rehabilitation for recovery of strength and range of motion is necessary. Patients will continue to improve after the fracture for 4 to 12 months.
Closed reduction of distal radius fractures is indicated if nonsurgical management is predicted to be successful, and radiographic imaging demonstrates measurements outside the acceptable limits listed below:
- 2-3 mm positive ulnar variance
- No carpal malalignment, less than 2-mm gap or step deformity in joint
- Neutral dorsal tilt if carpus malaligned, less than 10° dorsal tilt if carpus aligned
- Radial inclination less than 10°
Closed reduction of a distal radius fracture involves first anesthetizing the affected area with a hematoma block, intravenous regional anesthesia (Bier's block), sedation or a general anesthesia.
Manipulation generally includes first placing the arm under traction and unlocking the fragments. The deformity is then reduced with appropriate closed manipulations (depending on the type of deformity) reduction, after which a splint or cast is placed and an X-ray is taken to ensure that the reduction was successful. The cast is usually maintained for about 6 weeks.
Distal radius fractures are often associated with distal radial ulnar joint (DRUJ) injuries, and the American Academy of Orthopaedic Surgeons recommends that postreduction lateral wrist -rays should be obtained in all patients with distal radius fractures in order to preclude DRUJ injuries or dislocations.
Closed treatment is frequently unsuccessful in maintaining a good position in adults, because there is frequently comminution of the fracture. Re-displacement and deformity can reoccur with an unacceptable ultimate result.
The American Academy of Orthopaedic Surgeons suggests surgical management for distal radius fractures if postreduction radiographic imaging demonstrates:
- Radial shortening >3 mm
- Dorsal tilt >10°
- Intra-articular displacement
- Step-off >2 mm
Risks of nonoperative treatment
Failure of nonoperative treatment leading to functional impairment and anatomic deformity is the largest risk associated with conservative management. Prior studies have shown that the fracture often redisplaces to its original position even in a cast. Only 27-32% of fractures are in acceptable alignment 5 weeks after closed reduction. In the long term, this increases the risk of stiffness and posttraumatic osteoarthritis leading to wrist pain and loss of function. Because of these findings, many surgeons recommend operative intervention if the fracture is displaced enough to consider a reduction. Ultimately, the fractures that have a closed reduction may return to the position before the reduction is attempted.
Other risks specific to cast treatment relate to the potential for compression of the swollen arm causing carpal tunnel syndrome or compartment syndrome. Carpal tunnel syndrome may be related to the position of the wrist (i.e. excessive flexion) or excess distraction if the wrist is placed in an external fixator. Compartment syndrome is swelling in the muscle compartments, usually in the forearm, leading to severe pain, loss of nerve function, and a contracture. Finally, complex regional pain syndrome (reflex sympathetic dystrophy) is a serious complication following injury and is thought to be more common after cast immobilization than after surgery. The provoking factors for regional pain syndromes, however, are very complex, but the condition often leads to chronic pain and stiffness.
Despite these risks with nonoperative treatment, more recent systematic reviews suggest that when indicated, nonsurgical management in the elderly population may lead to similar functional outcomes as surgical approaches. In these studies, no significant differences in pain scores, grip strength, and range of motion in patients' wrists occurred when comparing conservative nonsurgical approaches with surgical management. Although the nonsurgical group exhibited greater anatomic misalignment such as radial deviation, and ulnar variance, these changes did not seem to have significant impact on overall pain and quality of life. These results suggest that as decreased functional demands of the wrist exist in the elderly population, and therefore fewer symptoms from malunion, maintaining normal anatomy to avoid postoperative complications may be of lower priority.
Surgery
The techniques of surgical management include open reduction internal fixation (ORIF), external fixation, percutaneous pinning, or some combination of the above. The choice of operative treatment is often determined by the type of fracture, which can be categorized broadly into three groups: partial articular fractures, displaced articular fractures, and metaphyseal unstable extra- or minimal articular fractures.
Significant advances have been made in ORIF treatments. Two newer treatment are fragment-specific fixation and fixed-angle volar plating. These attempt fixation rigid enough to allow almost immediate mobility, in an effort to minimize stiffness and improve ultimate function, no improved final outcome from early mobilization (prior to 6 weeks after surgical fixation) has been shown. Although restoration of radiocarpal alignment is thought to be of obvious importance, the exact amount of angulation, shortening, intra-articular gap/step which impact final function are not exactly known. The alignment of the DRUJ is also important, as this can be a source of a pain and loss of rotation after final healing and maximum recovery.
An arthroscope can be used at the time of fixation to evaluate for soft-tissue injury. Structures at risk include the triangular fibrocartilage complex and the scapholunate ligament. Scapholunate injuries in radial styloid fractures where the fracture line exits distally at the scapholunate interval should be considered. TFCC injuries causing obvious DRUJ instability can be addressed at the time of fixation.
Prognosis varies depending on dozens of variables. If the anatomy (bony alignment) is not properly restored, function may remain poor even after healing. Restoration of bony alignment is not a guarantee of success, as soft tissue contributes significantly to the healing process.
Little joint involvement
These fractures are the most common of the three groups mentioned above that require surgical management. A minimal articular fracture involves the joint, but does not require reduction of the joint. Manipulative reduction and immobilization were thought to be appropriate for metaphyseal unstable fractures. However, several studies suggest this approach is largely ineffective in patients with high functional demand, and in this case, more stable fixation techniques should be used.
Surgical options have been shown to be successful in patients with unstable extra-articular or minimal articular distal radius fractures. These options include percutaneous pinning, external fixation, and ORIF using plating. Patients with low functional demand of their wrists can be treated successfully with nonsurgical management; however, in more active and fit patients with fractures that are reducible by closed means, nonbridging external fixation is preferred, as it has less serious complications when compared to other surgical options. The most common complication associated with nonbridging external fixation is pin tract infection, which can be managed with antibiotics and frequent dressing changes, and rarely results in reoperation. The external fixator is placed for 5 to 6 weeks and can be removed in an outpatient setting.
If the fractures are unlikely to be reduced by closed means, open reduction with internal plate fixation is preferred. Although major complications (i.e. tendon injury, fracture collapse, or malunion) result in higher reoperation rates (36.5%) compared to external fixation (6%), ORIF is preferred, as this provides better stability and restoration of the volar tilt. Following the operation, a removable splint is placed for 2 weeks, during which time patients should mobilize the wrist as tolerated.
Displaced intra-articular fractures
These fractures, although less common, often require surgery in active, healthy patients to address displacement of both the joint and the metaphysis. The two mainstays of treatment are bridging external fixation or ORIF. If reduction can be achieved by closed/percutaneous reduction, then open reduction can generally be avoided. Percutaneous pinning is preferred to plating due to similar clinical and radiological outcomes, as well as lower costs, when compared to plating, despite increased risk of superficial infections. Level of joint restoration, as opposed to surgical technique, has been found to be a better indicator of functional outcomes.
Prognosis
Nonunion is rare; almost all of these fractures heal. Malunion, however, is not uncommon, and can lead to residual pain, grip weakness, reduced range of motion (especially rotation), and persistent deformity. Symptomatic malunion may require additional surgery. If the joint surface is damaged and heals with more than 1-2 mm of unevenness, the wrist joint will be prone to posttraumatic osteoarthritis. Half of nonosteoporotic patients will develop posttraumatic arthritis, specifically limited radial deviation and wrist flexion. This arthritis can worsen over time. Displaced fractures of the ulnar styloid base associated with a distal radius fracture result in instability of the DRUJ and resulting loss of forearm rotation.
Nerve injury, especially of the median nerve and presenting as carpal tunnel syndrome, is commonly reported following distal radius fractures. Tendon injury can occur in people treated both nonoperatively and operatively, most commonly to the extensor pollicis longus tendon. This can be due to the tendon coming in contact with protruding bone or with hardware placed following surgical procedures.
Complex regional pain syndrome is also associated with distal radius fractures, and can present with pain, swelling, changes in color and temperature, and/or joint contracture. The cause for this condition is unknown.
No surgery
In children, the outcome of distal radius fracture treatment in casts is usually very successful with healing and return to normal function expected. Some residual deformity is common, but this often remodels as the child grows. In the elderly, distal radius fractures heal and may result in adequate function following nonoperative treatment. A large proportion of these fractures occur in elderly people that may have less requirement for strenuous use of their wrists. Some of these patients tolerate severe deformities and minor loss of wrist motion very well even without reduction of the fracture. In this low-demand group, only a short period of immobilization is indicated as rapid mobilization improves functional outcome.
In younger patients, the injury requires greater force and results in more displacement, particularly to the articular surface. Unless an accurate reduction of the joint surface is obtained, these patients are very likely to have long-term symptoms of pain, arthritis, and stiffness.
Epidemiology
Distal radius fractures are the most common fractures seen in adults, which accounts for 17.5% of all adult fractures with approximate rate of 23.6 to 25.8 per 100,000 per year. Incidences in females outnumbering incidence in males by a factor of two to three. Average age of occurance is between 57 to 66 years. Men who sustain distal radius fractures are usually younger, generally in their 40s (vs. 60s in females). Low energy injury (usually fall from standing height) is the cause of distal end radius fracture (66 to 77% of the cases). High energy injuries accounts for 10% of the wrist fractures. About 57 to 66% of the fractures are extra-articular fractures, 9 to 16% are partial-articular fractures, and 25 to 35% are complete articular fractures. Unstable metaphyseal fractures are ten times more common than the severe articular fractures. In older people with osteoporosis who are still active, they are at an increased risk of getting distal radius fractures.
History
Before the 18th century, distal radius fracture was believed to be due to dislocation of the carpal bones or the displacement of the distal radioulnar articulation. In the 18th century, Petit first suggested that these types of injuries might be due to fractures rather than dislocations. Another author, Pouteau, suggested the common mechanism of injury which leads to this type of fractures - injury to the wrist when a person fell on outstretched hand with dorsal displacement of the wrist. However, he also suggested that volar displacement of the wrist was due to the ulnar fracture. His works received skepticism from his colleagues and little recognition because the article was published after he died. In 1814, Abraham Colles described the characteristics of distal end radius fracture. In 1841, Guilaume Dupuytren acknowledged the contributions by Petit and Pouteau, agreeing that the distal end radius fracture is indeed a fracture, not a dislocation. In 1847, Malgaigne described mechanism of injury for distal end radius fractures which can can be caused by falling on the outstretched hand or on the back of the hand, and also the consequences if the hand fracture is not treated adequately. After that, Robert William Smith, professor of surgery in Dublin, Ireland, first described the characteristics of volar displacement of distal radius fractures. In 1895, with the advent of X-rays, the visualisation of the distal radius fracture become more apparent. Lucas-Champonnière first described the management of fractures using massage and early mobilization techniques. Anaesthesia, aseptic technique, immbolization, and external fixation all have contributed to the management of fixation of distal radius fracture. Ombredanne, a Parisian surgeon in 1929, first reported the use of nonbridging external fixation in the management of distal radius fractures. Bridging external fixation was first introduced by Roger Anderson and Gordon O'Neill from Seattle in 1944 due to poor results in conservative management (using orthopaedic cast) of distal end radius fractures. Raoul Hoffman of Geneva has designed orthopaedic clamps which allow adjustments of the external fixator to reduce the fractures by closed reduction. In 1907, percutaneous pinning was first used. This was followed by the use of plating in 1965.
References
External links
- Orthopaedic Trauma Association Fracture Classification Radius and Ulna
- Wheeless' Textbook of Orthopaedics Fractures of the Radius
Source of the article : Wikipedia
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