Wrist Fracture


Article Author:
Hunter Hsu


Article Editor:
Shivajee Nallamothu


Editors In Chief:
Andrew Sherman
Richard Kaplan


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/17/2019 6:50:21 PM

Introduction

A distal radius fracture, commonly known as a wrist fracture, is defined by the involvement of the metaphysis of the distal radius. The fracture may or may not involve the radiocarpal joint, distal radioulnar joint, and/or the distal ulna.[1] This injury is commonly associated with high-energy mechanisms in younger patients and lower energy mechanisms or falls in older patients.[2] The fracture results in acute wrist pain and swelling, and if left untreated, it can result in significant morbidity. Treatment can involve both non-operative and operative management and ultimately depends on multiple factors.[3]

Etiology

The mechanism of injury in a distal radius fracture is an axial force across the wrist with the pattern of injury determined by bone density, the position of the wrist, and the magnitude and direction of the force. Most distal radius fractures result from falls with the wrist extended and pronated.[1] This places a dorsal bending moment across the distal radius. This type of injury is often referred to as a "fall onto an outstretched hand" or FOOSH. The relatively weaker, thinner dorsal bone collapses under compression; whereas, the stronger volar bone fails under tension resulting in a characteristic “triangle” of bone comminution with the apex volar and greater comminution dorsal. Cancellous impaction of the metaphysis compromises dorsal stability, and shearing forces impact the injury pattern which often involves the articular surface.[4] High-energy injuries may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

Common mechanisms in younger individuals

  • Falls from height
  • Motor vehicle accident
  • Injuries sustained during athletic participation

Common mechanisms in elderly individuals

  • Simple falls from standing height

Epidemiology

A distal radius fracture is the most common fracture of the upper extremity.[1] These fractures happen in all patient populations and are the most common orthopedic injury with a bimodal distribution. More than 450,000 fractures occur annually in the United States, and that number continues to rise. Fractures of the distal radius represent approximately one-sixth of all fractures treated in emergency departments. Younger patients tend to be involved in higher energy trauma mechanisms, whereas older patients tend to be involved with lower energy falls. The incidence in the elderly population correlates with osteopenia and rises in incidence with increasing age which corresponds to the increased incidence of hip fractures.[5]

Risk factors in the elderly

  • Decreased bone mineral density
  • Female gender
  • White race
  • Family history
  • Early menopause

History and Physical

Patients will typically present with variable wrist deformity and displacement of the hand in relation to the wrist. The wrist is typically swollen with ecchymosis, tenderness, and painful range of motion. The mechanism of injury should be investigated to assist in assessing the energy and level of destruction. It is important to establish the patient’s functional status before the injury as well as occupational demands as these may aid in determining treatment direction. Document co-existing medical conditions that may affect healing such as osteoporosis, diabetes, and/or tobacco use.

The physical examination should include careful attention to the following:

  • Condition of the surrounding skin and soft tissue
  • Quality of vascular perfusion and pulses
  • Integrity of nerve function
  • Sensory 2-point discrimination
  • Motor function of intrinsic, thenar, and hypothenar muscles of the hand
  • Careful attention to median nerve function as acute carpal tunnel syndrome can occur up to 20% of the time[6]

Associated injuries include:

  • Ipsilateral elbow
  • Ipsilateral shoulder
  • Distal radial ulnar joint
  • Radial styloid fracture
  • Triangular fibrocartilage complex
  • Scapholunate ligament
  • Lunotriquetral ligament

Evaluation

Imaging confirms fracture severity, determines stability and guides the treatment approach. Plain radiographs should be obtained before and after reduction, if necessary. The standard radiographs include posteroanterior and lateral views of the wrist, as well as oblique views for further fracture definition. Oblique views are useful to help evaluate articular involvement, particularly the lunate fossa fragment. Contralateral wrist views may evaluate the patient’s normal ulnar variance and scapholunate angle. Computed tomography scan may demonstrate the extent of intraarticular involvement. It is important to know normal radiographic measurements of the distal radius because it is useful in identifying distal radius fractures. These measurements are also useful in determining treatment.

Important normal radiographic relationships include:[7][8]

  • Radial inclination: Average of 23 degrees
  • Radial height: Average of 11 mm
  • Volar tilt: Average of 11 degrees

Treatment / Management

Distal radius fractures may be treated non-surgically or surgically. Non-surgical treatment necessitates acceptable fracture displacement, angulation, and shortening. Should these criteria not be met, surgical treatment is recommended.

Acceptable criteria for distal radius fractures include:

  • Radial height: Less than 5 mm shortening
  • Radial inclination: Less than 5-degree change
  • Articular step off: Less than 2 mm step off
  • Volar tilt: Dorsal angulation less than 5 degrees or within 20 degrees of contralateral distal radius

Displaced fractures must undergo a closed reduction in an attempt to achieve an anatomic or acceptable reduction. Adequate anesthesia or analgesia, such as conscious sedation or hematoma block, are necessary for closed reduction.[9] Following the closed reduction, the arm should be immobilized in a long-arm, sugar-tong splint acutely, as opposed to a cast. A long-arm, sugar-tong splint prevents pronation, supination, and elbow flexion, thereby eliminating the brachioradialis as a deforming force. The splint will allow for swelling as opposed to a cast.[10] Post-reduction radiographs must be obtained to evaluate the quality of the reduction. If the fracture reduction meets the acceptable criteria, the patient may remain in the splint and follow up with an orthopedic surgeon where weekly radiographs will be obtained for the first 2 weeks. If the reduction is not maintained and is no longer acceptable, surgical intervention should be recommended. If the reduction is maintained, the splint may be converted to a cast and immobilized for a total of 6 weeks.

Non-displaced fractures are treated without surgery in a long-arm splint acutely and transitioned to a short-arm cast in the office for a total of 6 weeks with serial radiographs to monitor for fracture displacement and healing.

For fractures that do not meet acceptable alignment, surgical intervention is recommended.[3] The goal of surgical treatment is to achieve acceptable alignment and stable fixation for early motion. There are various methods of fixation including pins, external fixators, dorsal plates, and a volar plate. Percutaneous pinning is useful in maintaining sagittal length and alignment in extra-articular fractures with a stable volar cortex. It is unacceptable when the volar cortex is comminuted, and therefore unstable, as there is not enough bony fixation to maintain reduction. Good outcomes have been reported up to 90% of the time if used appropriately. External fixation is often used in conjunction with percutaneous pin or plate fixation as it does not reliably restore the volar tilt on its own. This technique relies on ligamentotaxis to maintain fracture reduction. It is essential to limit the duration of external fixation to a maximum of 8 weeks and to perform aggressive hand therapy to maintain range of motion of the hand. Good outcomes have been reported up to 90% of the time if used appropriately. Open-reduction internal fixation with volar plating is much more common than dorsal plating. Volar plating is associated with irritation of both flexor and extensor tendons and flexor pollicus longus tendon rupture may be seen.[11][12] Volar plating offers support to the subchondral bone to help maintain fracture reduction. Dorsal plating is associated with extensor tendon irritation and rupture. It is typically indicated for displaced intra-articular fractures with dorsal comminution.

Differential Diagnosis

Radiographs confirm diagnosis; however, the following must be considered.

  • Associated and contributory injuries should always be considered.
  • Pathologic fracture
  • Associated injuries to the carpus

Staging

Multiple Classification Systems of Distal Radius Fractures

Frykman Classification 

Based on the pattern of intraarticular involvement

  1. Extraarticular distal radius fracture
  2. 1 + distal ulna fracture
  3. Intraarticular distal radius fracture involving radiocarpal joint
  4. 3 + distal ulna fracture
  5. Intraarticular distal radius fracture involving distal radioulnar joint
  6. 5 + distal ulnar fracture
  7. Intraarticular distal radius fracture involving radiocarpal and distal radioulnar joint
  8. 7 + distal ulna fracture

Fernandez Classification

Based on the mechanism of injury

  1. Metaphyseal bending fracture with the inherent problems of loss of volar tilt and radial shortening relative to the ulna
  2. Shearing fracture requiring reduction and often buttressing of the articular segment
  3. Compression of the articular surface without the characteristic fragmentation; also the potential for significant interosseous ligament injury
  4. Avulsion fracture or radiocarpal fracture dislocation
  5. Combined injury with significant soft tissue involvement owing to high-energy injury

Common Eponyms for Distal Radius Fractures

Colles fracture

  • Low energy, intraarticular and extraarticular distal radius fracture demonstrating dorsal angulation, dorsal displacement, and radial shortening
  • Clinically, described as a “dinner fork” deformity

Smith fracture

  • Low energy, extraarticular distal radius fracture demonstrating volar angulation

Barton fracture

  • Fracture-dislocation or subluxation of the wrist. The dorsal or volar rim of the distal radius is displaced with the hand and carpus
  • Volar involvement is more common

Chauffeur’s fracture

  • Avulsion fracture of the radial styloid

Die-punch fracture

  • A depressed fracture of the lunate fossa of the articular surface of the distal radius

Prognosis

Overall good to excellent results can be expected in over 80% of patients regarding a range of motion, strength, and outcomes scoring with open-reduction internal fixation and volar plating. Studies comparing volar fixation to other forms of fixation have revealed similar if not superior results. Results appear to be superior in the early recovery period with the outcome yielding equivalent results among all fixation groups. Some studies suggest better maintenance with volar plating in overall reduction compared to other forms of fixation.[1]

Complications

Median Nerve Neuropathy (Carpal Tunnel Syndrome)[6]

  • Most frequent neurologic complication
  • One percent to 12% of low-energy fractures and up to 30% of high-energy fractures
  • Treat with acute carpal tunnel release in progressive paresthesias, weakness in thumb opposition if symptoms do not respond to closed reduction, and if they last greater than 24 to 48 hours

Extensor Pollicus Longus Tendon Rupture[11][12]

  • Nondisplaced distal radius fractures have a higher rate of spontaneous rupture of the extensor pollicus longus tendon

Radiocarpal Arthrosis

  • Reported incidence up to 30%
  • Ninety percent of young adults will develop symptomatic arthrosis if articular step off is greater than 1 to 2 mm
  • May be asymptomatic
  • Malunion and nonunion

Compartment Syndrome

Complex Regional Pain Syndrome

Postoperative and Rehabilitation Care

Postoperative care for open-reduction internal fixation with volar plating includes immediate volar splinting following surgery. The patient is instructed to perform active range of motion exercises for the digits and elevate their wrist above heart level to prevent stiffness and aid in edema control. The splint is removed 1 to 2 weeks after surgery for a wound check. A removable splint should be fabricated by a hand therapist to help with edema and worn at all times to protect fracture fixation. The patient should remain non-weight bearing of the upper extremity but may begin active range of motion exercises of the wrist after the first post-operative visit. At 4 to 6 weeks putty and grip exercises may be added. At 6 to 8 weeks the splint is discontinued, and progressive strengthening exercises are advanced. The patient will typically be discharged to activities as tolerated at the 10 to 12-week mark.

Enhancing Healthcare Team Outcomes

Wrist fractures are complex because of the number of anatomical structures that may be involved. The majority of these patients are seen by the nurse practitioner or emergency department physician. However, asides from pain control and stabilization, these patients are best referred to a hand or orthopedic surgeon. Mild fractures may be managed with closed reduction but severely displaced fractures may require ORIF.

The outlook for most patients is fair but a significant number do have chronic pain and limited range of motion after treatment. Physical therapy is a must to regain muscle function and strength.[13][14]


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Wrist Fracture - Questions

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A patient has pain focally to the dorsal wrist on exam and so x-rays are ordered. The lateral view shows a small chip dorsally that is not well visualized on any other view. Which of the following bones was likely fractured?



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Which of the following nerves is at risk using the Thompson approach to a radial fracture?



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Select the most effective method to decrease edema of the hand after a wrist fracture has healed?



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A patient has been casted for a wrist fracture for 6 weeks. Which of the following would not be expected?



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A patient falls and fractures the left hip and left wrist. The patient is to be non-weight bearing for the left upper extremity and partial weight bearing for the left lower extremity. What is the most appropriate assistive device?



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Which of the following structures may be better visualized by ordering a carpal tunnel view with a set of x-rays?



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A 72-year-old female falls on her outstretched left hand and develops sudden pain. She is unable to move her wrist, which is now slightly swollen. A dinner fork deformity is obvious on the exam. Injury to which of the following structures is commonly associated with this type of fracture?



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A 69-year-old female is 3 months post right distal fracture treated conservatively. She returns to the office with the new complaint of inability to extend her thumb or lift it off the table. What is the most likely diagnosis?



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A 25-year-old male presents with a comminuted, displaced intra-articular distal radius fracture. It subsequently is closed, reduced, and appropriately splinted in a long arm sugar-tong splint. What deforming force is eliminated by choosing to use a long arm sugar-tong splint versus a regular sugar-tong splint?



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Wrist Fracture - References

References

Risk Factors for Osteoporosis in Postmenopausal Women - from The Point of View of Primary Care Gynecologist., Franic D,Verdenik I,, Zdravstveno varstvo, 2018 Mar     [PubMed]
Incidence of tendon rupture following volar plate fixation of distal radius fractures: A survey of 2787 cases., Sato K,Murakami K,Mimata Y,Doita M,, Journal of orthopaedics, 2018 Mar     [PubMed]
Fixation of unstable distal radius fractures by using expandable Intramedullary nailing system in adult patients., Calbiyik M,, Pakistan journal of medical sciences, 2018 Jan-Feb     [PubMed]
Prospective study of comminuted articular distal radius fractures stabilized by volar plating in the elderly., Martinez-Mendez D,Lizaur-Utrilla A,de Juan-Herrero J,, International orthopaedics, 2018 Apr 7     [PubMed]
Dual Radial Styloid and Volar Plating for Unstable Fractures of the Distal Radius., Garner MR,Schottel PC,Thacher RR,Warner SJ,Lorich DG,, American journal of orthopedics (Belle Mead, N.J.), 2018 Mar     [PubMed]
Above-versus below-elbow casting for conservative treatment of distal radius fractures: a randomized controlled trial and study protocol., Okamura A,de Mendonça GM,Raduan Neto J,de Moraes VY,Faloppa F,Belloti JC,, BMC musculoskeletal disorders, 2018 Mar 27     [PubMed]
Systematic review and pooled analysis of the rate of carpal tunnel syndrome after prophylactic carpal tunnel release in patients with a distal radius fracture., Al-Amin Z,Senyürek SA,Van Lieshout EMM,Wijffels MME,, Hand surgery & rehabilitation, 2018 Mar 23     [PubMed]
Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?, Tseng PT,Leu TH,Chen YW,Chen YP,, Journal of orthopaedic surgery and research, 2018 Mar 27     [PubMed]
[Rupture of the extensor pollicis longus secondary to distal radius fracture repaired with partial tendineous graft from the extensor carpi radialis longus with good functional result]., Nkaoui M,Yazidi AE,, The Pan African medical journal, 2017     [PubMed]
Effect of decrease in radial inclination of distal radius fractures on distal radioulnar joint stability: a biomechanical study., Bessho Y,Nakamura T,Nishiwaki M,Nagura T,Matsumoto M,Nakamura M,Sato K,, The Journal of hand surgery, European volume, 2018 Jan 1     [PubMed]
Evidence-Based Review of Distal Radius Fractures., Mauck BM,Swigler CW,, The Orthopedic clinics of North America, 2018 Apr     [PubMed]
Corsino CB,Sieg RN, Distal Radius Fractures 2018 Jan;     [PubMed]
Nasser JS,Huetteman HE,Shauver MJ,Chung KC, Older Patient Preferences for Internal Fixation after a Distal Radius Fracture: A Qualitative Study from the Wrist and Radius Injury Surgical Trial. Plastic and reconstructive surgery. 2018 Jul;     [PubMed]
Weinstock-Zlotnick G,Page C,Ghomrawi HM,Wolff AL, Responsiveness of three Patient Report Outcome (PRO) measures in patients with hand fractures: A preliminary cohort study. Journal of hand therapy : official journal of the American Society of Hand Therapists. 2015 Oct-Dec;     [PubMed]

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