Wrist Distal Radius Fracture – Causes, Symptoms, Treatment

Wrist Distal Radius Fracture

Wrist Distal Radius Fracture/A distal radius fracture, commonly known as a wrist fracture, is defined by the involvement of the metaphysis of the distal radius. The fracture may or may not involve the radiocarpal joint, distal radioulnar joint, and/or the distal ulna. This injury is commonly associated with high-energy mechanisms in younger patients and lower energy mechanisms or falls in older patients. The fracture results in acute wrist pain and swelling, and if left untreated, it can result in significant morbidity. Treatment can involve both non-operative and operative management and ultimately depends on multiple factors.

Causes of Wrist Distal Radius Fracture

High-energy injuries may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

Common mechanisms in younger individuals

  • Falls from height
  • Motor vehicle accident
  • Injuries sustained during athletic participation
  • Simple falls from standing height
  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of a broken distal radius.
  • Sports injuries – Many distal radius fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Wrist Distal Radius Fracture

  • Swelling, pain, and stiffness in the wrist
  • Clicking or clunking in the wrist
  • The weakening of grip strength
  • Tenderness directly over the lunate bone
  • Difficulty or pain when turning the hand upward
  • Wrist pain
  • Tenderness directly over the lunate bone
  • Decreased motion or stiffness of the wrist
  • Swelling

Staging/ Classification of Wrist Distal Radius Fracture

Multiple Classification Systems of Distal Radius Fractures

Frykman Classification 

Based on the pattern of intraarticular involvement

  • Extraarticular distal radius fracture
  • 1 + distal ulna fracture
  • Intraarticular distal radius fracture involving radiocarpal joint
  • 3 + distal ulna fracture
  • Intraarticular distal radius fracture involving distal radioulnar joint
  • 5 + distal ulnar fracture
  • Intraarticular distal radius fracture involving radiocarpal and distal radioulnar joint
  • 7 + distal ulna fracture

Fernandez Classification

Based on the mechanism of injury

  • Metaphyseal bending fracture with the inherent problems of loss of volar tilt and radial shortening relative to the ulna
  • Shearing fracture requiring reduction and often buttressing of the articular segment
  • Compression of the articular surface without the characteristic fragmentation; also the potential for significant interosseous ligament injury
  • Avulsion fracture or radiocarpal fracture-dislocation
  • Combined injury with significant soft tissue involvement owing to high-energy injury

Common Eponyms for Distal Radius Fractures

Colles fracture

  • Low energy, intraarticular and extraarticular distal radius fracture demonstrating dorsal angulation, dorsal displacement, and radial shortening
  • Clinically, described as a “dinner fork” deformity

Smith fracture

  • Low energy, extraarticular distal radius fracture demonstrating volar angulation

Barton fracture

  • Fracture-dislocation or subluxation of the wrist. The dorsal or volar rim of the distal radius gets displaced with the hand and carpus
  • Volar involvement is more common

Chauffeur’s fracture

  • Avulsion fracture of the radial styloid

Die-punch fracture

  • A depressed fracture of the lunate fossa of the articular surface of the distal radius

Diagnosis of Wrist Distal Radius Fracture

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

Associated injuries include

  • Ipsilateral elbow
  • Ipsilateral shoulder
  • Distal radial ulnar joint
  • Radial styloid fracture
  • Triangular fibrocartilage complex
  • Scapholunate ligament
  • Lunotriquetral ligament

Magnetic Resonance Imaging –  Diffuse decrease in lunate bone marrow signal on T1-weighted images is a hallmark of the disease. Signal changes on T2-weighted images or short-TI inversion recovery (STIR, which nullifies signal from fat) images vary with progression and extent of osteonecrosis. MRI also assesses the integrity of the articular cartilage.

Radiography – Normal early in the disease. Findings, when present, depend on the morphological stage and include diffuse lunate sclerosis, cystic changes, articular surface collapse, carpal collapse, mid-carpal and/or radio-carpal secondary arthrosis. Coronal fractures may occur in lunates with a type I morphology.

Computed Tomography – Is useful for surgical planning. It is also more sensitive than radiography for detecting subtle subchondral fractures, coronal lunate fractures, fragmentation, carpal instability, and the degree of trabecular disruption. Patients are frequently re-staged after CT imaging.

Nuclear Scintigraphy – Findings are non-specific. It previously found use as an adjunct for diagnosing early-stage disease. It has fallen out of favor since introducing MRI.

Differential Diagnosis

Radiographs confirm the diagnosis; however, the following must merit consideration:

  • Associated and contributory injuries should always be in the differential
  • Pathologic fracture
  • Associated injuries to the carpus

Treatment of Wrist Distal Radius Fracture

Nonoperative management

Fractures that are non-displaced and within the distal third of the bone can be managed non-operatively with immobilization in a cast. There is active debate as to whether a long or short arm cast is optimal and whether a thumb spica should be included to immobilize the thumb, but there is no evidence currently to suggest one option is better than the other.

The cast usually needs to remain on for six weeks with repeat radiographs taken at this time to assess for the union. Time to union varies depending on the location of the fracture. The distal-third would be expected to heal within 6-8 weeks, the middle-third within 8-12 weeks and the proximal third within 12-24 weeks.  The relative increase in time to healing while moving from distal to proximal is secondary to the tenuous blood supply and retrograde arterial flow.

Do no HARM for 72 hours after injury

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running and movement – Running and walking may cause further damage, and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgical Fixation

Indications for operative management include:

  • Displacement greater than 1mm
  • An intrascaphoid angle greater than 35 degrees (humpback deformity)
  • A radiolunate angle of more than 15 degrees
  • Transcaphoid perilunate dislocation
  • Proximal pole fractures
  • Comminuted fractures
  • Non displaced waist fractures in individuals that need to return quickly to work/sport
  • Nonunion or avascular necrosis

Surgical fixation involves the insertion of single or multiple screws and can be done percutaneously or via an open procedure. The latter is preferable for non-unions and those fractures that exhibit gross displacement with the former for acute, minimally displaced fractures.

Technique

The positioning of the screw is crucial and should be in the middle third of the central axis of the scaphoid; this provides the most stability, reduces time to union, and improves alignment.

Access to the scaphoid can be via a dorsal or volar approach. The decision is made based on surgeon preference and the location of the fracture. The volar approach uses the interval between flexor carpi radialis and the radial artery and is the optimal approach for waist and distal pole fractures. It has the benefits of allowing exposure of the entire scaphoid and radioscapholunate ligament and is least damaging to the vascular supply. The dorsal approach is preferred for proximal pole fractures but places the vascular supply at greater risk of injury.

Nonunion

Treatment of scaphoid non-union is approachable in a variety of ways. Early on in its course, open reduction and internal fixation with bone grafting can is an option.  Bone graft can be sourced from the distal radius or the iliac crest.

Complications

Median Nerve Neuropathy (Carpal Tunnel Syndrome)

  • Most frequent neurologic complication
  • One percent to 12% of low-energy fractures and up to 30% of high-energy fractures
  • Treat with acute carpal tunnel release in progressive paresthesias, weakness in thumb opposition if symptoms do not respond to closed reduction, and if they last greater than 24 to 48 hours

Extensor Pollicus Longus Tendon Rupture

  • Nondisplaced distal radius fractures have a higher rate of spontaneous rupture of the extensor pollicus longus tendon

Radiocarpal Arthrosis

  • The reported incidence of up to 30%
  • Ninety percent of young adults will develop symptomatic arthrosis if articular step-off is greater than 1 to 2 mm
  • May also be asymptomatic
  • Malunion and nonunion
  • Compartment Syndrome
  • Complex Regional Pain Syndrome

References