Wrist Fractures Flashcards by Kati Saylor

Colles’ fracture

complete fracture of the distal radius with dorsal displacement of the distal fragment and radius shortening (from hyperextension of the wrist)

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Smith’s fracture

complete fracture of the distal radius with volar displacement of the distal fragment (from hyperflexion of the wrist))

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Barton’s fracture

fracture-dislocation of rim of radius along the carpus caused by shearing forces from the proximal carpus translating across the radius

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Chauffeur’s fracture

fracture of distal radial styloid

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Salter-Harris fracture

fracture of the growth (epiphyseal) plate of children and teens

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Galeazzi’s fracture

unstable fracture of radial shaft and DRUJ disruption (usually the result of a FOOSH and most common in males)

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Monteggia’s fracture

unstable fracture of ulnar shaft and radial head dislocation (usually the result of a FOOSH or blunt trauma)

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Greenstick fracture

incomplete fracture common in children

concave side of bone may be intact or buckled with convex side fractured

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Torus (buckle) fracture

incomplete fracture common in children

concave side of bone compresses (buckles) with convex side intact

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Primary healing

when the bone fragments are secured using plates and/or screws where there is essentially no movement and good vascularity of the fracture site
*will bypass the three typical phases of bone healing

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Secondary healing

process of bone tissue repair and reorganization

consists of the inflammatory phase, repair phase, remodeling phase

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Triangular Fibrocartilage Complex (TFCC)

hammock-like structure composed of cartilage and ligaments, suspends the ulnar carpus and acts as both a force distributor between the ulna head and triquetrum, and a primary stabilizer for the DRUJ

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Central portion of TFCC

consists of articular disc which provides smooth gliding surface for the ulnar carpus
has no blood supply so will not heal if torn

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Peripheral portions of TFCC

ligamentus and capable of bearing tensile loads generated during gripping or weight bearing on the wrist

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% of load traveling through the carpal bones and transferred to the radius by TFCC

80%

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% of load traveling through the carpal bones and transferred to the ulna by TFCC

20%

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FOOSH

fall on out-stretched hand
44% of UE fractures
15% of all adult fractures in US

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Most common distal forearm fracture

Colles’ fracture

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2nd most common distal forearm fracture

Smith’s fracture

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Categories of forearm fractures (3)

extra-articular fracture
intra-articular fracture
comminuted

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Extra-articular fracture

fracture did not cross into the joint space

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Intra-articular fracture

fracture did cross into the joint space

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Comminuted fracture

bone breaking into multiple segments

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Types of fixation for distal radius fracture (4)

cast
external fixation
dorsal plating
volar fixed angle plating

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How do you control edema in a patient who has a cast?

use positioning (elevation of extremity), retrograde massage, and AROM of uninvolved joints

How long does a cast typically stay on?

4-6 weeks

What happens after the cast is removed?

client wears orthosis for comfort and support for the next 2-4 weeks

How do you address joint contracture/muscle -tendon tightness following the removal of a cast?

static progressive splinting after 6 weeks

What do you need to make sure to address that is unique to an external fixation?

pin site care

What ROM do you initially need to address with an external fixation?

immediate AROM of uninvolved joints

What AROM is limited with external fixation?

limited/difficult forearm rotation | AROM of wrist not possible

How do you address irritated RSN with an external fixation?

desensitization program

What do you address following the removal of external fixation hardware?

A/PROM to wrist and forearm

What ROMs should you focus on following the removal of external fixation hardware? (4)

1. digital flexion 2. wrist extension 3. ulnar deviation 4. supination

What type of orthosis can be introduced to regain ROM following an external fixation?

static progressive orthosis as needed

At what rate do you advance activity and ADLs following the removal of an external fixation?

as tolerated

What needs to be addressed early on following dorsal plating?

edema control and scar management

What type of orthosis is used with dorsal plating?

resting static wrist orthosis between exercise sessions for 4-6 weeks

What ROM is addressed with dorsal plating?

immediate AROM of all joints

What may be necessary if EDC integrity is compromised by dorsal plating?

guarded early active wrist motion (place and hold for wrist extension) for 4-6 weeks

What type of orthosis is used to regain wrist motion once the fracture is adequately healed with dorsal plating?

static progressive wrist orthosis

When can you advance activities and ADLs following dorsal plating?

after 6 weeks

What needs to be addressed early following volar fixed angle plating?

edema control and scar management

What ROM is addressed with volar fixed angle plating?

immediate AROM of wrist and uninvolved joints allowed

When can you address ADLs with volar fixed angle plating?

initially light ADLs to tolerance out of orthosis | advance activities and ADLs after 6 weeks

What orthosis is initially used following volar fixed angle plating?

wrist extension immobilization orthosis is slight extension for 4-6 weeks for comfort and protection

What type of orthosis is used to regain wrist and forearm motion after the fracture has adequately healed with volar fixed angle plating?

static progressive wrist orthosis

Treatment concepts for distal radius fractures (7)

1. monitor shoulder movement, strength, and function 2. some casting positions are with moderate wrist flexion - monitor for CTS 3. encourage finger movement 4. edema control 5. watch for extensor and intrinsic tightness 6. educate on signs of infection 7. modalities as appropriate

Complications following distal forearm fractures(8)

1. Complex Regional Pain Syndrome (CRPS) 2. Negative Ulnar Variance 3. Positive Ulnar Variance 4. Ulnocarpal abutment syndrome (ulnar impaction syndrome) 5. malunion 6. non-union 7. teninopathy and tendon rupture 8. DRSN compression or irritation

Watson's test

scaphoid shift test tests for SL ligament injury forearm supinated with slight wrist extension place pressure on volar distal pole of scaphoid move wrist from ulnar to radial deviation + when painful “clunk” with radial deviation

Non-operative management of non-displaced scaphoid fracture

6 weeks or more of immobilization

Healing time - scaphoid distal pole fracture

8-10 weeks

Healing time - scaphoid waist fracture

12 weeks

Healing time - scaphoid proximal pole fracture

12-24 weeks

Non-operative management of scaphoid waist or proximal pole fracture

6 weeks in long arm thumb spica followed by 6 weeks in a short arm thumb spica (some in thumb spica orthosis for 2 weeks after a cast)

Operative management of scaphoid fracture

- needed if fracture is displaced, comminuted, or associated with soft tissue injures - may need graft - pinning - screwing

Trapezium fracture

3-5% of carpal fractures tender at base of thumb pain with resisted wrist flexion CTS may be present

Trapezoid fracture

Capitate fracture

1-2% of carpal fractures largest carpal bone AVN can occur

Hamate fracture

2-4% of carpal fractures one of the larger carpal bones hook is most common fracture site

Pisiform fracture

1-3% of carpal fractures sesamoid bone attachment of FCU and origin of ADM

Triquetrum

2nd most common carpal fracture | small irregular shape

Lunate fracture

moon shape fracture more likely from repeated compression AVN (Keinbock's disease)

Non-operative management of carpal bone fractures

non-displaced and good blood flow cast for 6-8 weeks when fully healed - PROM, static and dynamic orthosis

Operative management of carpal bone fractures

``` displaced fractures or blood supply issues pins or ORIF partial fusion proximal row carpectomy pisiform excision ```

Rehabilitation guidelines for wrist fractures

1. AROM - all joints 2. don't let digital extensors initiate wrist extention 3. opposition exercises to protect the EPL 4. monitor pain 5. normal vs. functional ROM 6. edema control 7. scar management 8. dynamic/static progressive orthoses 9. stretching 10. strengthening

Edema control for wrist fractures

- cold packs during first 48 hrs - avoid slings if possible - compressive dressings or wraps - active muscle pumping

When is UE elevation not appropriate?

if there is arterial compromise

Scaphoid fractures

70-90% of carpal fractures

Complications following wrist fractures (8)

1. non-union 2. malunion 3. AVN (Keinbock's disease) 4. OA 5. carpal instability 6. nerve compression 7. late tendon ruptures 8. SNAC wrist (scaphoid non-union advanced collapse)