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JarkkoJokihaara

Wrist Injuries

Essentials

  • Fracture of the distal radius (wrist fracture) is the most common fracture of the upper limb in adults, and usually associated with falling.
  • In younger patients, the criteria for an acceptable position should be fulfilled. In older patients (above 65 years of age), there is no clear association between the radiological healing position and the recovery from the wrist fracture, and hence surgical treatment is probably not useful, but it can be considered case by case.
  • The majority of typical fractures of the distal radius (Colles' fractures) can be treated conservatively in primary health care. In other types of wrist fracture, consulting a hand surgeon or orthopaedist should usually be considered.
  • Final recovery may take 6-12 months. In most cases, there will be no permanent impairment of daily functionality, but some patients may continue to have wrist symptoms regardless of the method of treatment.
  • The most common fractures of actual carpal bones are fractures of the scaphoid bone.

Typical fracture of the distal radius (Colles' fracture) Closed Reduction Methods for Treating Distal Radial Fractures in Adults, Percutaneous Pinning for Distal Radial Fractures in Adults, Conservative Treatment of Distal Radial Fractures in Adults, Anaesthesia for Treating Distal Radial Fracture in Adults, Surgical Treatment of Distal Radial Fractures in Adults, Late Displacement of Fractures of the Distal Radius, Remanipulating Colles' Fracture, Rehabilitation for Distal Radial Fractures

  • A fracture of the distal radial metaphysis with dorsal displacement of the distal fragment (pictures )
  • A fissure may extend to the joint surface. The fracture area may be comminuted.
  • Most cases can be treated conservatively.
  • Criteria for an acceptable position in patients under 65:
    • dorsal tilt ≤ 15°
    • radial shortening ≤ 3 mm in relation to the ulna
    • articular step-off or gap ≤ 1 mm
    • radioulnar inclination angle ≥ 15°.
  • Perform reduction, i.e. move the fractured fragments into place before applying a plaster cast.
    • Pain relief at the fracture site is essential to enable the patient to relax their upper limb muscles; provide local anaesthesia e.g. by injecting 10 ml of 1% lidocaine dorsally into the fracture line.
    • Apply steady traction to the hand, moving the fracture area to separate the fracture fragments. An assistant applies counter traction by pulling back on the upper arm.
    • Maintaining the traction, perform the actual reduction: first place the fracture in extension and then push the dorsally displaced fragment back into place by pressing it with your thumb and simultaneously moving the fracture into slight flexion.
    • Hold the reduction position until the plaster has dried.
  • Dorsal plaster cast from the upper third of the forearm to the knuckles
    • Place a stockinette on the skin, covered by 1-2 layers of cotton padding.
    • Apply wrist plaster cast in a functional position (0-20° extension). Slight flexion is acceptable but excessive wrist flexion, ulnar deviation and pronation should be avoided.
    • Elbow, metacarpophalangeal and thumb base joints must be able to move freely.
  • Check the position by x-ray (at least PA and lateral views).
  • The recommended time in plaster is 4-5 weeks.
    • X-rays of a fracture in an acceptable position should be repeated after 1 and 2 weeks, and, as necessary, after 5 weeks.
    • Repeat x-rays are not generally necessary if a fracture position not fulfilling the above radiological criteria was justifiably accepted in the first place.
    • Surgical treatment should be considered if the fracture position is unacceptable after reduction or has become worse on follow-up pictures taken at 1-2 weeks. A hand surgeon or orthopaedist should be consulted in such cases. Repeat closed reduction at 1-2 weeks is not recommended.
    • If an acceptable position in follow-up imaging is taken as a criterion for successful treatment, the same radiological criteria apply as at the primary stage.
  • In patients over 65, the radiological findings do not predict the functional outcome, and surgical treatment is probably not useful even if the fracture position is unacceptable or becomes worse during plaster cast treatment, falling below acceptable limits. Surgical treatment can be considered in active elderly people in whom good functionality of the upper limb is important. Careful individual assessment of the need for surgical treatment is warranted in such cases.
  • Further treatment
    • The patient should be given an information handout before being sent home.
    • In the early stage, the limb should be elevated and finger movement exercises done to reduce swelling and adhesions.
    • Active range of motion exercises of the shoulder, elbow, knuckle and finger joints should be done several times a day throughout the plaster cast treatment
    • If the plaster feels tight, it must be corrected or a new plaster cast applied. After replacement of the plaster cast, check the fracture position by repeat x-raying.
    • If an early fracture complication (nerve or tendon injury, inflammation) is suspected, urgent consultation of a hand surgeon or an orthopaedist is indicated.
    • Complex regional pain syndrome (CRPS; Complex Regional Pain Syndrome (CRPS)) may develop as a fracture complication. Symptoms include unexpectedly severe pain, alternation of sensation and motor functions, and autonomic nervous system dysfunction. Treatment can be started in primary health care, with urgent referral to physical therapy or an outpatient pain clinic, as necessary. If CRPS is suspected of being due to nerve injury (CRPS type II), a hand surgeon should be consulted.
    • If recovery is delayed (6-12 months) despite appropriate treatment and the patient has a symptomatic fracture ossified in malposition or if their functional ability is significantly threatened, write a non-urgent referral to specialized care, as necessary.
  • Possible associated injuries
    • Fracture of the ulnar styloid process and/or triangular fibrocartilage complex (TFCC) injuries are common.
    • Distal ulnar fractures (of the caput or neck) are rarer. As such fractures can easily cause instability of the forearm, surgical treatment is often indicated.
    • Injury to or pressure on the median nerve. After fracture or treatment, fingers I-III may show numbness but this should resolve in 24-48 hours. If not, a hand surgeon or orthopaedist should be consulted.
    • The abductor pollicis longus tendon may be severed during or after plaster cast treatment due to friction and inflammation of the fracture area.
    • Rupture of the ligament between the scaphoid and lunate bones (scapholunate ligament, scapholunate dissociation) in association with fractures extending to the radial joint surface
      • The diagnosis of ligamentous wrist injuries is based on clinical examination and magnetic resonance imaging, as necessary.
    • Fracture of the scaphoid bone

Fracture of the distal radius with volar angulation (Smith's fracture) Closed Reduction Methods for Treating Distal Radial Fractures in Adults

  • A fracture of the distal metaphysis with volar angulation of the distal fragment (picture )
  • This type of fracture is often unstable and carries a significant risk of functionally poor outcome.
  • Operative treatment is usually necessary, and a hand surgeon or orthopaedist should be consulted to assess the need for such treatment.
  • If conservative treatment is chosen, immobilisation should be done with an angle cast applied from the proximal upper arm down to the knuckles. The plaster cast should be applied with the wrist slightly extended, the forearm in 45-60° supination and the elbow at an angle of 90°.

Shearing fracture of the edge of the distal radial joint surface (Barton's fracture)

  • A dorsal or volar shearing fracture of the distal radial joint surface (dorsal or volar Barton's fracture; picture ).
  • This type of fracture is unstable and carries a high risk of losing the position and a functionally poor outcome.
  • Wrist ligaments are often injured on the contralateral side to the fracture.
  • Operative treatment is usually necessary, and a hand surgeon or orthopaedist should be consulted to assess the need for such treatment.

Fracture splitting the distal radial styloid process (Chauffeur's fracture)

  • A fracture of the joint surface of the radial styloid process facing the scaphoid bone (picture )
  • The fracture is often associated with rupture of the scapholunate ligament, which can be suspected if plain PA x-ray shows widening of the scapholunate gap.
  • An undisplaced fracture may be treated by immobilisation in a dorsal plaster cast, displaced fractures are often treated surgically.

Fracture of the joint surface of the distal radial bone facing the lunate bone (die punch fracture)

  • A fracture of the joint surface of the distal radial bone facing the lunate bone, where the radial joint surface is proximally depressed
  • This type of fracture carries a high risk of poor functional outcome.
  • Surgery should be considered if there is a ≥ 1 mm step-off on the joint surface.

Fracture of the scaphoid bone

  • There is typically a history of falling on the extended wrist.
  • Tenderness on palpation in the anatomical snuff box (fossa tabatière)
  • The wrist may be swollen.
  • Radiography: PA, lateral and oblique views of the wrist and always also ”scaphoid views”
  • If there is a strong suspicion of fracture but no fracture can be seen in plain x-ray, plain x-raying should be repeated in 1-2 weeks or a hand surgeon or orthopaedist consulted, as necessary. In some cases, a CT scan or MRI may be justified to identify a suspected fracture.
  • The method of treatment depends on the type of fracture.
    • An undisplaced mid-waist fracture can be treated by placing a plaster cast until the fracture has become ossified. An undisplaced mid-waist fracture usually becomes ossified in 6-8 weeks.
      • Circular cast from upper forearm to the knuckles. Traditionally a circular cast has been used, but nowadays also a dorsal plaster cast may be used.
      • Place the wrist in its functional position (slight extension), leaving the thumb IP joint free; the thumb MP joint should probably also be left free. Pinch grip by the thumb and index finger should be possible with the plaster cast in place.
    • Where displacement of the mid-waist fracture exceeds 1 mm or the fracture is angulated, as well as if the fracture is proximal, it should usually be treated by surgery.
    • For fractures of the distal tuberculum, a plaster cast should be placed for 3-6 weeks.
      • Dorsal plaster cast from the proximal forearm to the knuckles
      • Wrist in slight extension
  • Ossification is worse if the delay from fracture to beginning of treatment is more than 4 weeks.
  • A hand surgeon or orthopaedist should usually be consulted on the treatment of scaphoid fracture. Assessment of the type of fracture and displacement often requires CT scanning.
  • There are several procedures for following up on fractures treated with plaster cast, and this is another reason for consulting a hand surgeon or orthopaedist to ensure that the further treatment plan conforms to local practice.
    • Plain x-ray films (PA, lateral and scaphoid projections) without plaster cast are often taken for follow-up at 4 as well as 6-8 weeks. The ossification process cannot reliably be assessed by plain x-ray through the plaster cast.
    • CT scanning can also be used for follow-up and provides a more accurate assessment of ossification.
    • If ossification is not proceeding at repeat imaging, surgery should be considered at 6 weeks, for instance.
  • About 5-10% of scaphoid fractures fail to unite. At a late stage, non-union can be observed by plain x-ray or CT scanning showing a fracture gap. A symptomatic non-united fracture should be treated surgically.

Other fractures of the carpal bones

  • Fracture of the triquetral bone is the second most common carpal bone fracture.
    • There is usually a small dorsal fracture fragment seen in a lateral or oblique view of the wrist.
    • Treatment consists of 4-6 weeks of immobilisation in a dorsal plaster cast.
    • Local pain may continue for several months but usually the fracture finally becomes asymptomatic even in the case of non-union.
  • Other carpal bone fractures are rare. They may be associated with significant injuries; further imaging is therefore often indicated and consulting a hand surgeon useful.

Pictures