Distal Radial Fractures ("Wrist Fractures") Flashcards
Outline the most common mechanism/aetiology of distal radius fractures (“wrist fractures”).
- Most low energy injuries e.g. fall on out-stretched
hand (FOOSH), especially elderly/osteoporotic
(often female) - High energy injuries e.g. RTA/sporting injuries (often
in young male patients)
Outline important features of history taking in wrist fractures.
• Mechanism of injury (e.g. how they fell & landed) • Hand dominance • Occupation/career plans • Hobbies activities • Smoking status/med Hx/DHx
Outline important components of examining a wrist fracture.
• Neurovascular assessment – Median, radial, ulna – Cap refill +/- pulses • Open/closed injury • Check for other sites of injury – elsewhere in the same limb, other arm, or multiple injuries as in high energy injuries – Don’t miss scaphoid fracture or scapholunate ligament injury in the same wrist
Which imaging modalities are appropriate in a wrist fracture?
• X-rays
–wrist: AP & lateral
–Or if scaphoid suspected, do scaphoid views (out
of cast)
–Always x-ray after “doing something “ e.g.
manipulation or cast application
What is meant by the term ‘reduction’?
Restoration of normal anatomical position.
Expand upon the phrase ‘reduce, stabilise, rehab’.
Reduce:
- Restore radial length, radial inclination and
volar tilt.
Stabilise (immobilise):
- Cast, percutaneous K-wires, internal fixation,
(external fixation rare).
Rehabilitate:
- Physiotherapy
Outline the ‘11, 11, 22’ rule in assessing the placement of the distal radius.
The rule of “11, 11, 22” confirms the distal radius to be undisplaced
- Radial inclination (on AP view): The distal radial articular surface should be at 22 degrees angulation from the perpendicular to the long axis on the AP view
- Radial length (on AP view) The radial styloid should be 11mm distal the the ulna at the DRUJ
- Volar tilt (on lateral view). The distal radial articular surface should be tilted 11 degrees volarly (i.e. towards the palm).
What placement is acceptable/unacceptable upon closed reduction?
- Volar tilt is preferable
- Neutral position on lateral (i.e. 0 degrees volar tilt) is often acceptable
- Loss of radial length (shortening) or dorsal tilt are generally unacceptable except in frail/unwell patients with very low functional requirements.
What is important about intra-articular fractures in regards to reduction?
• Intra-articular fractures must have NO displacement/loss of alignment in the articular surface
– Harder to achieve & maintain in non-surgical treatment (therefore often require open reduction internal fixation/ORIF)
How are stable injuries managed?
• Maintain in acceptable position for 6 weeks in short-arm cast
– Undisplaced/minimally displaced fractures are
often stable injuries
– Casts require moulding during the first 2-3 weeks of
treatment to minimise the risk of fracture
displacement, even if initially undisplaced.
– X-ray at 1, 2, 3 & 6 weeks to check for displacement (&
treat if displacement does arise)
How are unstable injuries managed?
• Unstable injuries unlikely to remain in an
acceptable position with just a moulded cast
e.g. may need surgical stabilisation
List the 3 key wrist fracture patterns.
- Colle’s fracture
- Smith’s fracture
- Barton’s fracture
Describe the typical mechanism and deformity seen in a Colle’s fracture.
- FOOSH (usually low energy)
- May be high energy FOOSH in sporting injury
- Dinner fork deformity
Outline how a Colle’s fracture is defined.
- A fracture within 2.5 cm of the wrist joint.
- EXTRA-ARTICULAR
- Dorsal displacement.
- Dorsal angulation.
- Radial displacement.
- Radial angulation
- Impaction (i.e. shortening).
- Osteoporotic bone
- Frequently associated with an ulnar styloid
fracture.
How are Colle’s fractures most often managed?
- Often displaced
- Required closed reduction with sedation/block (manipulation under sedation = MUS)
- Maintained with moulded short arm cast
- Adequate analgesia +/- sedation
Opioids, entonox, local anaesthetic block (e.g.
haematoma block), midazolam, or combination as
per patient’s medical history - X-RAY FOLLOWING REDUCTION!
How are Colle’s fractures managed if still displaced upon closed reduction (manipulation under sedation)?
• Use general anaesthetic for closed reduction
(manipulation)
i.e. manipulation under anaesthetic (MUA)
• Difficulty in achieving initial reduction can mean
difficulty in maintaining acceptable position too
– e.g needs percutaneous wires (Kirschner-wires) for
stabilisation
- if STILL displaced after X-ray –> open reduction internal fixation (ORIF).
Again, outline the important caveat to INTRA-ARTICULAR Colle’s fractures (not a true Colle’s fracture).
- Intra-articular fractures difficult to reduce using closed reduction technique.
- Low-threshold for ORIF over MUA/K-wires
- ALWAYS attempt closed reduction urgently regardless in order to minimise tension of soft-tissues , nerves, blood vessels; even if ORIF required.
Outline the mechanism/aetiology of a Smith’s fracture.
- Falling on the back of the hand
- Usually while carrying/holding something/handlebars
- Causes displacement and angulation VOLARLY (rather than dorsally)
Describe a Smith’s fracture.
- Often referred to as a ‘reverse Colle’s fracture’
- Extra-articular
- Volar angulation
- VERY unstable
- Often requires ORIF but always attempt closed reduction to protect soft tissues
Describe a Barton’s fracture.
“Partial articular fracture-subluxation” where
part of the articular surface is still attached to
the shaft, & the carpus is subluxed with the
broken fragment due to strong ligamentous
attachment
• Usually displaced volarly, therefore often called
“volar Barton’s” fractures
How are Smith’s/Barton’s fractures managed?
- Attempt initial closed reduction to protect soft-tissues
- ORIF
Outline wrist fracture follow-up management (non-operative/K-wired wrists/ORIF).
- Non-operative: review at 1, 2, 3 & 6 weeks with x-rays (to identify & treat any new displacement). Remove cast & mobilise at 6 weeks (often with physio)
- K-wired wrists: Pinsite check & x-ray at 1 week, wires removed & x-ray at 3 weeks &, cast until 6 weeks, then mobilise (often with physio)
- ORIF: Wound check at 1-2 weeks, then usually change to removable splint to gradually wean out of over next 2-4 weeks (if patient compliant)
List complications of wrist fractures.
- Pain, stiffness, & arthritis if intra-articular
- N/V damage
- Carpal tunnel syndrome
- Volkmann’s ischaemic contracture (shortening of forearm muscles resulting in claw formation at wrist, hand, and fingers).
- Complex regional pain syndrome (CRPS)
Outline common patterns of wrist fractures in children.
- Most are buckle or greenstick pattern.
- These have mild angulation/displacement.
- Potential for remodelling in children.
- Usually stable (3 weeks in a cast)
NOTE TO SELF: PLEASE LOOK AT IMAGES OF COLLE’S/SMITH’S/BARTON’S FRACTURES!
Please do that.
