Distal Radius Fractures of the Wrist: Avoiding Complications with Proper Diagnosis and Treatment
What is a Distal Radius Fracture?
Distal Radial Fractures (also known as wrist fractures) are very common in the U.S. The injury is most common among those who have experienced hard falls and instinctively spread their hands out to land. Distal Radial Fractures are also associated with car accidents, motorcycle accidents, and bike accidents. The radius is the most commonly broken bone in the arm and is located on the same side of your thumb. The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks. The Radius is prone to this kind of fracture due to the fact that when a person falls on their hands, the radius is the bone that absorbs the most impact.
A distal radius fracture almost always occurs about 1 inch from the end of the bone. The break can occur in many different ways, however. Two of the most common distal radius fractures are:
- Colle’s fracture – in which the broken fragment of the radius tilts upward. For example, when you spread your hands forward to catch yourself from absorbing the impact of a fall. The palm of the hand makes first contact with the ground while the Radius lands hard over the wrist. This may lead a broken wrist.
- Smith’s fracture – sustained when the back of the wrist makes first contact on impact, forcing the hand under the wrist causing it to break.
Other ways the distal radius can break include:
- Intra-articular fracture. A fracture that extends into the wrist joint. (Articular means, joint.)
- Extra-articular fracture. A fracture that does not extend into the joint is called an extra-articular fracture.
- Open fracture. When a fractured bone breaks the skin, it is called an open fracture. These types of fractures require immediate medical attention because of the risk for infection.
- Comminuted fracture. When a bone is broken into more than two pieces, it is called a comminuted fracture.
It is important to classify the type of fracture, because some fractures are more difficult to treat than others. Intra-articular fractures, open fractures, comminuted fractures, and displaced fractures (when the broken pieces of bone do not line up straight) are more difficult to treat, for example. Sometimes, the other bone of the forearm (the ulna) is also broken. This is called a distal ulna fracture.
What Causes a Distal Radius Fracture?
The most common cause of a distal radius fracture is a fall onto an outstretched arm. Osteoporosis (a disorder in which bones become very fragile and more likely to break) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position.
A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist.
What are the Symptoms of Distal Radius Fractures?
- Wrist pain
- Deformity of the wrist.
How is a Distal Radius Fracture Diagnosed?
An X-ray scan such as a Computed Tomography Exam (CT) or 3d imaging exam maybe used to accurately determine if there are any abnormalities in the bone tissue that may indicate Distal Radius Fracture.
There are a variety of fracture patterns depending on the type of fall or accident. There is no one size fits all solution for these kinds of fractures and the appropriate action must be decided on a case by case basis. The physician must analyze the injury and treat the fractures individually to determine the best outcome for that patient.
What are the Treatment Options for Distal Radius Fractures?
There are many treatment options for a distal radius fracture. The choice depends on many factors, such as the nature of the fracture, your age and activity level, and the surgeon’s personal preferences.
If the broken bone is in a good position, a plaster cast may be applied until the bone heals.
If the position (alignment) of your bone is out of place and likely to limit the future use of your arm, it may be necessary to re-align the broken bone fragments. Reduction is the technical term for this process in which the surgeon moves the broken pieces into place. When a bone is straightened without having to open the skin (incision), it is called a closed reduction.
After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed 2 or 3 weeks later as the swelling goes down more, causing the cast to loosen.
Depending on the nature of the fracture, your doctor may closely monitor the healing by taking regular x-rays. . If the fracture was reduced or thought to be unstable, x-rays may be taken at weekly intervals for 3 weeks and then at 6 weeks. X-rays may be taken less often if the fracture was not reduced and thought to be stable.
The cast is removed about 6 weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.
Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.
Surgery typically involves making an incision to directly access the broken bones to improve alignment (open reduction).
Depending on the fracture, there are a number of options for holding the bone in the correct position while it heals:
- Internal fixation – metal pins (usually stainless steel or titanium), plates, and screws
- Percutaneous fixation – pins and casting
- External fixator – a stabilizing frame outside the body that holds the bones in the proper position so they can heal
- Any combination of these techniques
Internal Fixation (Plates, Screws, Pins)
Internal fixation involves an incision over the fracture and applying a stainless steel plate screwed directly to the bone to achieve alignment. The plate will prevent further displacement of the bone.
Benefits of Internal Fixation include:
- Increased stability
- Strategic placement of implants
- The lack of a need for an external device
- Less obtrusive casting and potential earlier use of the hand
After the patient has gone through the internal fixation procedure they may improve in wrist movement within 1-2 weeks. During that period a temporary splint is used to support the hand.
Percutaneous Fixation with Pins and Casting
Some fixation involves nothing more than pins and the use of a cast. An incision is not necessary and can be done with regional anesthetics in the operating room. A cast is then applied; once the fracture has healed the pins are removed to allow for therapy, the final treatment.
Benefits of Percutaneous Pin Fixation include:
Adequate stability for closed treatment
No need for permanent hardware implantation
Minimal soft tissue or bony complications
Less painful procedure
Minimal scarring and no surgical incision
The procedure involves the implementation of an external frame that holds the bone in place through the use of pins. Percutaneous pins are used in combination with the external frame in support of the bone fragments. The external frame allows the patient to move the fingers freely for lightweight activities after the procedure is complete. The pins are removed 3 to 6 weeks
Benefits of External Fixation include:
- Minimal soft tissue disruption/minimally invasive
- All hardware is removed (no concerns for airport security or tissue response)
- Skin incisions result in minimal scarring
- Bone graft may be used to support the joint surface
Surgery is required as soon as possible (within 8 hours after injury) in all open fractures. The exposed soft tissue and bone must be thoroughly cleaned (debrided) and antibiotics may be given to prevent infection. Either external or internal fixation methods will be used to hold the bones in place. If the soft tissues around the fracture are badly damaged, your doctor may apply a temporary external fixator. Internal fixation with plates or screws may be utilized at a second procedure several days later.
Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain.
The surgeon may recommend combining ibuprofen and acetaminophen to relieve pain and inflammation. The combination of both medications is much more effective than either one alone. If pain is severe, patients may need to take a prescription-strength medication, often a narcotic, for a few days.
What are Potential Complications?
After surgery or casting, it is important that you achieve full motion of your fingers as soon as possible. If you are not able to fully move your fingers within 24 hours due to pain and/or swelling, contact your surgeon for evaluation.
Your surgeon may loosen your cast or surgical dressing. In some cases, working with a physical or occupational therapist will be required to regain full motion.
Unrelenting pain may be a sign of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy), which must be treated aggressively with medication or nerve blocks.
Rehabilitation and Long-Term Outcomes
Most people do return to all their former activities after a distal radius fracture. The nature of the injury, the kind of treatment received, and the body’s response to the treatment all have an impact, so the answer is different for each individual.
Almost all patients will have some stiffness in the wrist. This will generally lessen in the month or two after the cast is taken off or after surgery, and continue to improve for at least 2 years. If your surgeon thinks it is needed, you will start physical therapy within a few days to weeks after surgery, or right after the last cast is taken off. Recovery should be expected to take at least a year.
Some pain with vigorous activities may be expected for the first year. Some residual stiffness or ache is to be expected for 2 years or possibly permanently, especially for high-energy injuries (such as motorcycle crashes), in patients older than 50 years of age, or in patients who have some osteoarthritis. However, the stiffness is usually minor and may not affect the overall function of the arm.