Distal Radius fracture

Hand

What is a distal radius fracture?

A fracture of the distal radius is one of the most common types of injuries to the skeletal system, and is treated using a variety of different techniques, from casting to pinning to open surgery with plates and screws.

There are a wide variety of fracture patterns, and no single form of treatment applies for all of these fractures. The nature and location of this fracture, compounded by the multidirectional forces we exert on this joint in our daily lives, often requires surgery to achieve proper healing and restore anatomic alignment of this important bone.

There are two common variants of distal radius fractures that are characterized by the direction of forces applied to the wrist during a fall:
 

• Colles' fractures, the most common type of distal radius fractures, which occur when falling on an outstretched hand, where the hand is extended backward on the wrist, and
   
• Smith fractures, which are caused by the opposite mechanism, that is, when the hand is flexed forward under the wrist.
  
   

Many other fracture types exist in addition to these two most common types. Available treatment options depend on the type and severity of the fracture as well as the needs and health of the injured patient, and these options need to be carefully individualized by the treating physician to achieve a satisfactory functional outcome.
 

Diagnosing distal radius fractures of the wrist

A proper diagnosis begins with proper imaging, including initial and follow-up X-rays and possible advanced 3D imaging. Computed tomography (CT) may be employed on occasion to assess the alignment or fragmentation of the joint surface and, less frequently, magnetic resonance imaging (MRI) may be required to rule out concurrent injuries to ligaments or injuries to other bones in the wrist, such as the scaphoid.

It is now our practice to recommend to all women over the age of fifty with a fracture of the distal radius that they consider bone densitometry (DEXA) measurement to assess for the presence of osteoporosis.

A fracture that is displaced, meaning the fracture fragments are out of normal alignment, will require a "reduction," which refers to an attempt to manipulate the fracture fragments back into alignment. If the reduction is deemed acceptable, periodic images will be taken to ensure that the position or alignment of the fracture fragments does not change during the early phase of healing.

Fractures that are felt to be unstable – due to osteoporotic bone or extensive fragmentation – may be vulnerable to "settling" or loss of reduction, and follow-up imaging may be necessitated as often as every week. More stable fractures may require less frequent follow-up radiographs over the six to eight weeks required for healing.

If the fracture cannot be reduced within an acceptable degree of alignment, or it is deemed grossly unstable and likely to re-displace in plaster immobilization, the physician may recommend surgery to reduce and stabilize the fractured fragments under anesthesia.
 

Treatment for distal radius fractures: Closed reduction, casting, surgery, fixation and biologics
 

The scope of treatment for distal radius fractures has changed considerably in recent years. Methods of treatment include casting as well as percutaneous or open surgery, and new and exciting surgical options have developed over the past decade.

Treatment always begins with a closed reduction of a displaced fracture, generally done under local anesthesia and a light sedative, in the emergency department of a hospital.

 

Closed reduction

Using various forms of anesthesia to minimize discomfort, the physician manipulates the fracture fragments into proper alignment (reduces the fracture) without making an incision or directly exposing the fracture.

A plaster splint or cast is applied and molded to the patient’s forearm and hand. Often, the plaster may extend above the elbow to help provide additional stability and neutralize the extensive forces that can be generated by natural movements of the arm and forearm.

Following closed reduction, subsequent treatment will be recommended based on an array of patient-related and radiographic factors. The condition and needs of the patient are of paramount importance when considering treatment options, and include the patient’s general medical status, activity level, age, and bone quality.?

If a patient’s medical condition permits, the goals of treatment are relatively straightforward: restoration of bony alignment, attainment of a smooth joint surface, and provision of stability until healing.

After determining the mechanism and type of distal radius fracture, its stability can be predicted to some extent based on five important factors:
 

• The degree of fragmentation of the bone.
• The amount of displacement that occurred at the time of injury.
• The integrity of the three columns of the wrist, including the ulna bone.
• The age of the patient (a relative barometer for osteoporosis), and
• The integrity of the joint surface.
   

After considering these factors, as well as the general health and needs of the patient, a surgeon will decide whether a fracture is likely to be stable or unstable following reduction, and will recommend one or more of the following treatment options:
 

Casting

Casting provides external stability to the forearm and hand by the application of gentle pressure to the skin and underlying soft tissues. This provides a rigid mold and contains the reduction in proper alignment during the healing period. If the fracture is stable and has been successfully realigned by the reduction, casting may be the only treatment necessary.

Casts will need to be removed and replaced several times during the healing period to insure snug and secure support of the fracture. Casts may be applied either "above elbow" or "below elbow" and may include the thumb or not, depending on the particular type of injury and physician preference.

Casts are generally made from plaster early in the treatment, which allows for some degree of swelling, and the more rigid and lighter-weight fiberglass material during later stages of healing.

 

Surgery

When surgery is necessary, there is usually a two week window of opportunity before early bone healing begins. Patients may seek a second opinion during this period to explore their options.
 

Internal fixation (plates, screws, pins)

A common form of internal fixation involves an open surgical technique in which an incision is made over the fracture and a stainless steel plate with screws is placed to align the bone ends and prevent displacement or loss of reduction.

Advantages of internal fixation include:
 

• Increased stability
• Strategic placement of implants
• The lack of a need for an external device
• Less obtrusive casting and potential earlier use of the hand
   

This may not be suitable for all fractures – possible complications of this technique include:
 

• loss of fixation
• improper positioning of the plate or screws
• infection
• the need for hardware removal
• nerve injury
• tendon injury or rupture
• stiffness

 

Percutaneous fixation with pins and casting

Some types of fractures, while unstable in a cast alone, require only the addition of one or more pins to create a stable situation and enable treatment with a cast. The pins can be placed without the need for an incision and are done in the operating room under a regional anesthetic. The wrist is then placed in a cast until healing, at which time the pins are removed and therapy begun.
 

Advantages of percutaneous pin fixation include:

• adequate stability for closed treatment
• no need for permanent hardware implantation
• minimal soft tissue or bony complications
• less painful procedure
• minimal scarring and no surgical incision
   

This may not be suitable for all fractures – possible complications of this technique include:

• loss of fixation
• settling / loss of reduction
• pin infection
• re-operation
• nerve injury
• tendon injury
• stiffness
   

Biologics

New biologic agents which enhance bone healing hold much promise in treating fractures when used along with one of the treatments mentioned above.

On the near horizon, researchers, scientists, and clinicians expect biologic agents to augment the bone healing process to such a degree that a four-week recovery period may be realized for distal radius fractures, substantially shortening the current 6 to 8 week outlook. This may enhance the future applicability of some of the percutaneous methods of fracture treatment.
 

Postoperative recovery

Casting

The rule for bone healing in general is to expect a six-week period to ensure proper bone strength. After that, it is generally advised to include an additional week or two of support in a removal plastic splint. A stable fracture may be treated with a combination of casting and splinting throughout this healing period.
 

Internal Fixation

In most cases, a patient who has undergone internal fixation surgery for a distal radius fracture may begin gentle wrist range of motion within 1 to 2 weeks of surgery, after which time a removable splint is used to support the hand.

The plate that was surgically placed inside the arm/wrist at the time of surgery may be left in place or removed at a later date.

 

External Fixation

The external frame and pins are usually removed sequentially, beginning 3 to 6 weeks after surgery, followed by a few additional weeks of removable splint wear.

An individualized treatment plan for distal radius fractures

Fractures of the distal radius are very common, and are treated using either casting or surgical techniques such as internal and external fixation. There are nearly as many ways to treat a distal radius fracture as there are distal radius fractures.

In other words, there is no one treatment that is effective for all types of fractures. Each fracture requires individual treatment customized to deal with the specific characteristics of the fracture.