Distal Radius Fractures
What is a distal radius fracture?
A fracture of the distal radius is the most common injury of the wrist. A fracture is a broken bone. A fracture can result from mild impact such as a fall onto the out-stretched hand through to high energy injuries such as mountain bike & motor vehicle accidents. The severity of the fracture will depend on the force of the impact and the strength of the bone. More force is required to break /fracture a healthy young bone than an older osteoporotic bone.
Phone
02 6185 2705
Fax
02 6185 2705
Location
Suite 4A, Level 2
Peter Yorke Building
173 Strickland Cres
Deakin ACT 2600
OSTEOPOROSIS
In older patients, a fracture of the wrist may be a sign of osteoporosis and a bone mineral density (BMD) scan should always be performed. Diagnosis and treatment of osteoporosis can reduce the risk future fractures and permanent disability.
Australian Osteoporosis Guidelines.
What are the types of distal radius fractures?
Extra-articular – does not involve the joint.
Intra-articular – involves the joint.
Fractures that involve the joint (intra-articular) are more likely to result in post-traumatic arthritis if the joint lining (articular cartilage) is uneven. A "step" in the joint lining of 2mm or more is an indication for surgery.
Non-displaced – the bone is broken but not out of position.
Displaced – the fracture has moved out of position.
Displacement may require surgery, depending on severity.
Angulated – bent at an angle. (Image 2)
Angulation may require treatment, depending on the severity.
Comminuted – in many pieces. (Image 3)
These tend to be less stable and more likely to require surgery.
Distal radius fractures in children - growth plate fractures
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Distal radius fractures in children usually occur at the growth plate (physis) as it is made of cartilage and therefore weaker than bone.
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The most common is the Salter-Harris II fracture (below).
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Salter-Harris I-IV fractures rarely cause growth issues if the fracture is reduced (put back in normal position).
Salter-Harris V is a very severe injury which may cause growth arrest (the radius stops growing). However, growth arrest can also be treated and usually does not cause more than 2cm of shortening.
What are the treatment options for distal radius fractures?
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Cast only
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Manipulation/closed reduction
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Open reduction & internal fixation
Cast only
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Fractures that are not displaced (out of position) may only require cast treatment.
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Initially, a backslab or splint that prevents the fracture moving while the swelling decreases is applied.
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A cast should not be applied for 10-14 days after the fracture due to swelling. A tight cast can cut off circulation to the hand.
Closed reduction/manipulation under anaesthetic (MUA)
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This involves some form of anaesthetic - local, regional or general.
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The fracture is pushed back into position, a backslab applied to hold the fracture in position.
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X-ray is performed to confirm that it is in a good position.
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Suitable for many children's fractures as these involve sliding along the cartilage growth plate to put the fracture back into place. Once pushed back in place, growth plate injuries are usually stable.
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Rarely suitable for adults as the bone is usually crushed (like honeycomb). So, even if the fracture is reduced, it is unlikely to stay there because there is a space created by crushing of the bone and the fracture tends to settle back into its original position. (See image below)
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May be used as a temporary measure before definitive surgery if a fracture is very deformed and there is a risk of nerve compression or impairment of circulation.
Open reduction & internal fixation
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Adult fractures that are displaced, angulated and/or have intra-articular steps in the joint lining >2mm will usually require surgical treatment.
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Surgery is recommended to prevent arthritis and allow a return to near normal movement.
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If fractures heal in displaced or angulated positions movement, including rotation of the forearm can be reduced & arthritis can develop.
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This involves a general anaesthetic and a 60–90-minute operation.
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An ~10cm incision is made on the forearm and a plate and screws are inserted once the fracture has been “reduced” (put back in its normal position).
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X-rays are taken in the operating theatre to check the fracture and plate position.
Recovery
First 2 days:
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Elevation on pillows or sling and pain relief.
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Shower with plastic bag to keep dry.
2 weeks:
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Postoperative review.
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Physiotherapist will make a splint and commence exercises.
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May drive short distances if adequate grip and strength.
2 months
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Most people will no longer require a splint.
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There will still be some stiffness & swelling. Physiotherapy continues.
3-4 months
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Most people will have returned to all normal activities including contact sports, heavy manual work and weight lifting.
6-12 months Maximum recovery.
Risks of surgery
Distal radius fracture surgery is very safe and allows people to return to moving their wrist at 2 weeks compared to 6 weeks for cast treatment. The main risks are:
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Infection (<1%) - a single dose of intravenous antibiotics at the time of surgery
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Discomfort requiring removal the plate (~20%)
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Nerve injury (<1%) leaving some numbness in the palm/fingers
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Tendon rupture (~1-2%) from abrasion of tendons by the plate or screws.
WARNING SIGNS OF IMPENDING TENDON RUPTURE
If you develop pain or swelling months after recovering from distal radius plating surgery, it is likely that a tendon is being irritated by the plate or screws. You should see your surgeon immediately and the plate should be removed as a matter of urgency to avoid tendon rupture.
Complications of distal radius fractures
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Carpal tunnel syndrome is the most common complication of carpal tunnel syndrome. Swelling and deformity of the wrist can put pressure on the median nerve that passes through a tunnel in the wrist.
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Wrist deformity Some deformity may be acceptable to elderly patients who wish to avoid an anaesthetic, but significant deformity can result in loss of the ability to rotate the forearm.
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Wrist stiffness - more severe injuries may result in some loss of wrist movement. Usually this will only interfere with activities such as pushups where near full movement is required.
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Ulnocarpal Abutment Syndrome - when the radius is shortened/impacted relative to the ulna pain can result from the ulna bone “hitting” against the small (carpal) bones of the wrist.
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Post-traumatic arthritis - pain and stiffness due to damage to the articular cartilage (joint lining) of the wrist.