Distal radius # teaching

Question 1

History questions for wrist injury

Answer 1

• Explore pain
• High energy vs low energy (fall from standing height)
• Any other injuries?
• Nerve symptoms? - median nerve commonly involved
• PMH- previous #, known OP? steroid use? co-morbids?
• SH - hand dominance, hobbies/occupation (impact of injury)

High energy - worried about other injuries and soft tissue

Question 2

Examination of hand

Answer 2

• Look
• Feel
• Move

Question 3

Look

Answer 3

• Open wounds
• Deformity
• Swelling
• Bruising

Sometimes need to stop here if obvious deformity which suggests #

Question 4

Feel

Answer 4

• Bony prominences around wrist
• Scaphoid palpation - FOOSH injury

Question 5

Wrist imaging

Answer 5

• PA and lateral radiograph

Question 6

Lateral view

Answer 6

• Radius
• Lunate
• Capitate

Should be all in line - colinear
In # may be zig zag

Question 7

Parameters for discussing distal radial #

Answer 7

• Radial height
• Volar tilt
• Radial inclination

Question 8

Normal radial height

Answer 8

• Radial styloid should be taller than ulna head
• 12mm usually between the two
• Line should be paralell if drawn

Question 9

Volar tilt

Answer 9

• Line across radial styloid
• Line across articular surface
• Usually points anterior
• 12 degrees usually

Dorsal angulation will decrease volar tilt

Question 10

Radial inclination

Answer 10

• Normal 22-24 degrees
• Across ulna head and line across articular surface of radius

Question 11

Treatment of #

Answer 11

• Displaced - reduce hold rehabilitate
• Undisplaced - hold and rehabilitate (eg below elbow plaster, keeping thumb free and should not go beyond distal palmar crease to allow MCPJ flexion)

Question 12

Manipulation anaesthesia distal radius

Answer 12

• Local haematoma block - local anesthetic inside joint # haematoma - aspirate and want to see blood
• Biers block - LA into a vein with tourniquet on arm, inflate above systolic BP - prevent arterial and venous circulation in arm

Prilocaine said to not be cardiotoxic - concerns re Biers block often

Question 13

Cast on moulding

Answer 13

• Mould cast
• Distal radius often displaces dorsally
• Mould cast to create pressure - 3 point moulding
• Apex of moulding on volar side
• Two pressure points the other side each side of the #

Takes a curved plaster to make a bone straight

Question 14

When is surgery needed for DR #

Answer 14

• Unable to reduce by manipulation alone
• Displaced and unstable - won’t reduce in plaster
• Intra-articular displaced #

Question 15

Surgery for DR

Answer 15

• External fixation - wires, scaffold like to hold bone in position
• Internal fixation - volar locking plate and screws

Question 16

What is a Colles #?

Answer 16

• Extra-articular distal radius #
• Shortening and dorsal angulation
• Dinner fork deformity
• Often elderly in OP bone

Often don’t use the name Colle’s just describe the #

Question 17

Hack in working out direction in lateral view x-ray of wrist

Answer 17

• Thumb always sits volarly
• Look at thumb

Question 18

Smith’s #

Answer 18

• Extra-articular distal radius #
• Volar displacement
• Unstable - ALWAYS - often need surgery
• Often fall onto back of hand

Question 19

Problems with reducing in elderly

Answer 19

• Skin tear and soft tissue injury
• Due to fragility of skin

Question 20

Follow up after plaster placement to assess if # stayed in place

Answer 20

• See in 1 week
• Repeat x-ray
• Every week for 3 weeks - if still undisplaced unlikely to displace further
• Then at 6 weeks to remove cast

Question 21

Incision for internal fixation

Answer 21

• Flexor carpi radialis
• Go down to pronator quadratas and reflect ulnarly