Monthly Archives: September 2012
Fractures of the wrist are some of the more common injuries seen in orthopedic clinical practice. They typically occur as a result of falls and thus occur in all age groups. The mechanism of injury can be high energy, such as a fall off of a motorcycle or a sports related injury. Low energy injuries are also common, occurring frequently in elderly individuals after relatively minor slip and fall accidents.
The wrist joint is the junction of the forearm, and its two bones, the radius and the ulna, and the hand. The hand bones (8) are called the carpal bones the radius is the largest bone comprising the wrist and the most frequently injured in falls.
Most distal radius fractures (at the wrist) are minor and can be treated with a cast or splint for 4-6 weeks. Others, however, may result in displacement (separation of pieces), angulations (twisting of pieces) or comminution (fragmentation- multiple pieces). These injuries require more aggressive treatment especially in younger, active individuals. A concern with older individuals, who sustain low energy fractures, is the presence of underlying osteoporosis. A fracture of the wrist is many times one of the first signs of developing osteoporosis , and can increase the risk of subsequent fractures (hip, pelvis eg ) up to 5-10 times.
Numerous treatment options are available. The most simple being a manipulation (setting) of the fracture followed by application of a cast. This may be performed under local or general anesthesia. Other fractures are termed unstable, or unlikely to be maintained in position by a cast. These require stabilization usually with operative fixation, using pins, wires, screws and/or plates. Another indication for surgical treatment is the disruption of the joint surface of the radius (the end of the bone at the wrist joint). Separation or step off of the joint surface greater than 2 millimeters may result in the development of arthritis once the fracture has healed.
One of the most commonly used surgical techniques of fracture reduction and fixation utilizes a small plate, secured to the undersurface of the bone with multiple screws. These are called “locking plates” as the screws lock to the plate and can provide fixation even in very thin, brittle bone. The plates are low profile and placed below the muscles of the wrist on the bone surface. The fracture can be manipulated visually and also with x-ray intraoperatively to gain the desired positioning. The surgery usually takes less than an hour. The skin closure is performed with a subcuticular running stitch (beneath the skin) which requires no suture removal and is quite cosmetic. Post operatively a splint is placed for immobilization and comfort and many times early range of motion can be initiated. Physical therapy is commonly performed. Full recovery averages 3-4 months.
While many older techniques have been equally successful obtaining the desired result of healing, pain relief and return to normal functional activities, volar plating seems to promote a quicker, less painful recovery for distal radius fractures. Rarely do the plates need to be removed.
Follow-up in older individuals involves testing and possibly treatment for underlying osteoporosis.
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