Wrist Fractures Flashcards
Colles’ fracture
complete fracture of the distal radius with dorsal displacement of the distal fragment and radius shortening (from hyperextension of the wrist)
Smith’s fracture
complete fracture of the distal radius with volar displacement of the distal fragment (from hyperflexion of the wrist))
Barton’s fracture
fracture-dislocation of rim of radius along the carpus caused by shearing forces from the proximal carpus translating across the radius
Chauffeur’s fracture
fracture of distal radial styloid
Salter-Harris fracture
fracture of the growth (epiphyseal) plate of children and teens
Galeazzi’s fracture
unstable fracture of radial shaft and DRUJ disruption (usually the result of a FOOSH and most common in males)
Monteggia’s fracture
unstable fracture of ulnar shaft and radial head dislocation (usually the result of a FOOSH or blunt trauma)
Greenstick fracture
incomplete fracture common in children
concave side of bone may be intact or buckled with convex side fractured
Torus (buckle) fracture
incomplete fracture common in children
concave side of bone compresses (buckles) with convex side intact
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
Secondary healing
process of bone tissue repair and reorganization
consists of the inflammatory phase, repair phase, remodeling phase
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
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
Peripheral portions of TFCC
ligamentus and capable of bearing tensile loads generated during gripping or weight bearing on the wrist
% of load traveling through the carpal bones and transferred to the radius by TFCC
80%
% of load traveling through the carpal bones and transferred to the ulna by TFCC
20%
FOOSH
fall on out-stretched hand
44% of UE fractures
15% of all adult fractures in US
Most common distal forearm fracture
Colles’ fracture
2nd most common distal forearm fracture
Smith’s fracture
Categories of forearm fractures (3)
- extra-articular fracture
- intra-articular fracture
- comminuted
Extra-articular fracture
fracture did not cross into the joint space
Intra-articular fracture
fracture did cross into the joint space
Comminuted fracture
bone breaking into multiple segments
Types of fixation for distal radius fracture (4)
- cast
- external fixation
- dorsal plating
- volar fixed angle plating
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)
- digital flexion
- wrist extension
- ulnar deviation
- 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)
- monitor shoulder movement, strength, and function
- some casting positions are with moderate wrist flexion - monitor for CTS
- encourage finger movement
- edema control
- watch for extensor and intrinsic tightness
- educate on signs of infection
- modalities as appropriate
Complications following distal forearm fractures(8)
- Complex Regional Pain Syndrome (CRPS)
- Negative Ulnar Variance
- Positive Ulnar Variance
- Ulnocarpal abutment syndrome (ulnar impaction syndrome)
- malunion
- non-union
- teninopathy and tendon rupture
- 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
- AROM - all joints
- don’t let digital extensors initiate wrist extention
- opposition exercises to protect the EPL
- monitor pain
- normal vs. functional ROM
- edema control
- scar management
- dynamic/static progressive orthoses
- stretching
- 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)
- non-union
- malunion
- AVN (Keinbock’s disease)
- OA
- carpal instability
- nerve compression
- late tendon ruptures
- SNAC wrist (scaphoid non-union advanced collapse)
