Wrist and hand fractures: Orthopaedic management

Distal radius fractures

Distal radius fractures are among the most common orthopedic injuries, accounting for one-sixth of all fractures seen in the emergency department (ED). As in many orthopedic injuries, there is a bimodal distribution pattern of patients presenting with this injury. Younger patients, 18 to 25 years old, often have a higher-energy injury such as motor vehicle accident or fall from height while older patients, typically age 65 or older, represent lower-energy mechanisms such as ground-level falls associated with osteoporosis. The fracture pattern and its treatment can vary substantially, depending on the mechanism of injury.

The initial workup of a distal radius fracture should begin with a detailed history including mechanism of the injury, associated injuries, patient age, and hand dominance. A thorough physical examination must include an examination of the skin to ensure the fracture is not open as well as a neurovascular examination. Examine and document wrist deformity, swelling, and ecchymosis. A quick survey of the distal motor function of the radial, ulnar, and median nerves is obtained by testing the motor function of the extensor pollicis longus (thumbs up), first dorsal interosseus (peace sign or crossing fingers), and abductor pollicis brevis (thumb away from fingers perpendicular to palm). Sensation should be documented by testing the dorsal first web space (radial), the tip of the small finger (ulnar), and the tip of the index finger (median). Careful examination of the median nerve sensory distribution is required as acute carpal tunnel syndrome may develop after displaced distal radius fractures. Imaging should include three-view radiographs of the wrist (anterior-posterior, lateral, and oblique), hand, forearm, and elbow. X-rays of a distal radius fracture can be seen in Figure 1 .

Closed, nondisplaced fractures are amenable to treatment in a splint or cast. Displaced fractures must be reduced and splinted in the ED. Even in fractures that will require surgery, reduction in the ED provides pain control and soft tissue rest while waiting for definitive fixation. The reduction is commonly performed under a “hematoma block” in which local anesthetic is injected into the hematoma of the fracture. Hanging arm traction may be used to assist with reduction once the hematoma block has been performed. Reduction maneuvers include using traction, which provides ligamentotaxis (fracture reduction through ligamentous tightening around the displace bone), as well as fracture manipulation. Once the fracture is reduced, a splint is used to hold the reduction. The splint should be molded in a way to enforce the reduction while avoiding being too tight or placing the wrist in too much flexion. Adequacy of the reduction is based on the angulation of the distal articular surface, radial length, and congruity of the articular surface. When considering operative and nonoperative treatment of a distal radius fracture, the surgeon must take into account qualities of both the fracture as well as the patient. For example, a distal radius fracture in a 20-year-old laborer may be treated differently than a 75-year-old patient who is retired and injured his or her nondominant hand. If after reduction a patient is determined to be treated nonoperatively, it is important that the surgeon has close follow-up with that patient, typically on a weekly basis, to obtain x-rays to be sure the reduction has not been lost for the first 3 to 4 weeks.

Operative treatment is indicated for fractures that are too unstable to be treated with closed reduction. However, fracture stability is difficult to discern with multiple attempts in the literature to find ways of classifying a fracture as stable or nonstable. Lafontaine et al described instability parameters of (1) dorsal angulation greater than 20 degrees, (2) dorsal comminution, (3) intra-articular radiocarpal fracture, (4) associated ulnar fracture, (5) age older than 60. Three or more of the five parameters demonstrate an unstable fracture and therefore would benefit from surgery.

Operative treatment options included percutaneous pinning, external fixation, dorsal plating, fragment-specific plating, and volar plating with the latter being most common. Regardless of the fixation model of choice, the goal of operative treatment is an anatomic reduction that restores length, alignment, and rotation. Volar plating is achieved through a volar approach to the wrist (modified Henry approach). A variety of volar plates are available with options of fixed or variable angle locking screws, pegs, and nonlocking screws. Implant selection is typically based on the fracture pattern and surgeon preference. The key to success is an anatomical reduction and the ability to maintain satisfactory alignment during fracture healing.

Wrist injuries with severe soft tissue trauma or extensive fracture comminution, or in an unstable polytrauma patient, may be stabilized with an external fixator or an internal plate spanning from the forearm to the hand. Although external fixation still has a role, the recent trend has been toward the use of internal spanning plates due to the high rate of pin site infections and soft tissue irritations associated with the external devices. These plates are used to allow bony and soft tissue healing then removed typically 3 to 4 months after implantation. Open distal radius fractures can occur, especially in high-energy mechanisms. Open fractures are classified using Gustilo-Anderson classification based on the size of soft tissue injury. Treatment of open fractures includes antibiotics (typically a first-generation cephalosporin), tetanus prophylaxis, thorough wound debridement, and fracture stabilization. Depending on soft tissue injury and contamination, more than one debridement in the operating room may be necessary prior to definitive fixation. However, most fractures can be washed out and undergo definitive fixation at the same time.

Acute carpal tunnel syndrome (ACTS), though rare, can be seen with distal radius fractures. Symptoms include severe pain in the median nerve distribution that progresses to a dense neuropathy. Providers should have a high index of suspicion for ACTS in the setting of distal radius fracture as this is a surgical emergency. If ACTS is a concern, the first step in treatment is an adequate reduction and splinting to take pressure off the median nerve. The affected extremity should then be elevated and symptoms should be monitored with neurologic checks every 4 hours. If symptoms persist or do not improve, this is an indication for urgent surgical fixation of the fracture and acute carpal tunnel release.

One should also pay close attention to the distal radioulnar joint (DRUJ) stability after distal radius fixation, as DRUJ instability is often underappreciated. If the DRUJ is deemed unstable, appropriate treatment measures must be taken as an unstable DRUJ is a common cause of pain and disability after distal radius fractures.

Though often overlooked, distal radius fractures in the elderly population are often fragility fractures associated with osteoporosis. Other fragility fractures include vertebral fractures and hip fractures. A history of a fragility fracture is a predictor of future fragility fractures. Hospital systems should make an attempt to identify distal radius fractures that are fragility fractures and have an algorithm in place for patients to be given information and treatment to help prevent future fractures.