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Wrist FracturesWrist Fractures
Wrist FracturesWrist Fractures
Wrist Defined:Wrist Defined:Carpal Bones Carpal Bones Distal RadiusDistal RadiusDistal UlnaDistal Ulna
Wrist FracturesWrist Fractures
Wrist Joints:Wrist Joints:CMC CMC IntercarpalIntercarpalRadiocarpalRadiocarpalDRUJDRUJ
““drudgedrudge””
Wrist FracturesWrist Fractures
Wrist Fractures:Wrist Fractures:(that we are going to discuss)(that we are going to discuss)
ScaphoidScaphoidDistal RadiusDistal RadiusDistal UlnaDistal Ulna
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Scaphoid FxScaphoid Fx
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Fate of Nonunions:Fate of Nonunions:Mack 1984Mack 1984
20 20 –– 30 Years: Pan Carpal Arthritis30 Years: Pan Carpal ArthritisRuby 1985Ruby 1985
97% DJD If Nonunion > 5 Years97% DJD If Nonunion > 5 YearsDuppe 1994Duppe 1994
ArthritisArthritis SymptomaticSymptomaticUnitedUnited 1/471/47 3/473/47UnunitedUnunited 4/94/9 5/95/9
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
11
2233
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
4455
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Suspect Scaphoid FxSuspect Scaphoid Fx’’s !!!s !!!
Hx : Fall on Outstretched HandHx : Fall on Outstretched Hand
Pain : Pain : ““anatomic snuffboxanatomic snuffbox””
Pain : Pain : ““with scaphoid compressionwith scaphoid compression””
Xray : NormalXray : Normal
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Suspect Scaphoid FxSuspect Scaphoid Fx’’s !!!s !!!
Over treat : Short Arm Thumb SpicaOver treat : Short Arm Thumb Spica
Re Xray : Two Weeks Re Xray : Two Weeks (AP, Lat, Scaphoid Oblique)(AP, Lat, Scaphoid Oblique)
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Suspect Scaphoid FxSuspect Scaphoid Fx’’s !!!s !!!
““I gotta know and money is no objectI gotta know and money is no object””
MR Scan will be positive within hoursMR Scan will be positive within hoursBone Scan will be positive within days Bone Scan will be positive within days
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Scaphoid Fx : Scaphoid Fx : Fx line visible, No displacementFx line visible, No displacement
Rx: long vs short arm thumb spicaRx: long vs short arm thumb spica
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Scaphoid Fx : Scaphoid Fx : Fx line visible & Fx displacedFx line visible & Fx displaced
Rx: Consider ORIFRx: Consider ORIF
Need for fixation is relative to Fx locationNeed for fixation is relative to Fx location
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
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33
11
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
112233
1. Tubercle Fx1. Tubercle FxRx: SplintRx: Splint
2. Waist Fx2. Waist FxRx: >1mm DisplacedRx: >1mm Displaced
ORIFORIF3. Proximal Pole3. Proximal Pole
Rx: You see it Rx: You see it You fix itYou fix it
Wrist Fractures: ScaphoidWrist Fractures: ScaphoidWrist Fractures: Scaphoid
36 weeks36 weeks
Wrist Fractures: ScaphoidWrist Fractures: ScaphoidWrist Fractures: Scaphoid
Another 12Another 12--16 weeks?16 weeks?
Wrist Fractures: ScaphoidWrist Fractures: ScaphoidWrist Fractures: Scaphoid
2 weeks in splint2 weeks in splint10% motion loss, no strength loss10% motion loss, no strength loss
6 wks post6 wks post
Wrist Fractures: ScaphoidWrist Fractures: ScaphoidWrist Fractures: Scaphoid
Non union: A Simple Non union: A Simple Problem Made DifficultProblem Made Difficult
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Bone GraftBone GraftTechnically demandingTechnically demanding
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Bone GraftBone Graft
1 year of wrist protection1 year of wrist protection1 year limited use1 year limited use30% motion loss30% motion loss30% strength loss30% strength loss
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Conclusions: Conclusions: In most casesIn most cases
Non Op Rx is truly radicalNon Op Rx is truly radical& & Op Rx is conservativeOp Rx is conservative
Wrist Fractures: ScaphoidWrist Fractures: Scaphoid
Refer Early !Refer Early !
Wrist Fractures: Distal Radius Wrist Fractures: Distal Radius
““after a period timeafter a period time…….all do well.all do well””
Abraham Colles Abraham Colles
Wrist Fractures: Distal Radius Wrist Fractures: Distal Radius
““after a period timeafter a period time…….all do well.all do well””
Abraham Colles Abraham Colles
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Distal radius fxDistal radius fx’’s differ in:s differ in:
Mechanism of injuryMechanism of injuryEnergy of injuryEnergy of injuryArticular involvementArticular involvementAssociated InjuriesAssociated Injuries
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Simple BendingSimple Bending
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Compression:Compression:Most CommonMost CommonLow & high EnergyLow & high Energy
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Shearing:Shearing:
Inherently UnstableInherently Unstable
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Fx Dislocation:Fx Dislocation:
Deceptively Deceptively SimpleSimple
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Combined Complex:Combined Complex:
High EnergyHigh EnergyComminuted Comminuted OpenOpen
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment GoalsTreatment Goals
““Begin with the end in mind!Begin with the end in mind!””David CoveyDavid Covey
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment GoalsTreatment Goals
Radial inclRadial incl > 5> 5°°Tilt Tilt neutral +neutral +LengthLength neutralneutralGaps Gaps < 2 mm < 2 mm Step off Step off < 2 mm < 2 mm Stable Stable DRUJDRUJ
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment Based On: Treatment Based On: DemandDemand
Low Demand: Minimal TreatmentLow Demand: Minimal TreatmentHigh Demand: CRPP vs ORIFHigh Demand: CRPP vs ORIF
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment Based On: Treatment Based On: Three Xray ParametersThree Xray Parameters
Metaphyseal StabilityMetaphyseal StabilityArticular Step Off / GapsArticular Step Off / GapsDRUJ Stability DRUJ Stability (after radius fixation)(after radius fixation)
Wrist Fractures: Distal RadiusWrist Fractures: Distal RadiusWhat is stable?What is stable?
1. Easily Reduced1. Easily Reduced2. Transverse Fx Pattern2. Transverse Fx Pattern3. Minimal 3. Minimal
Dorsal ComminutionDorsal Comminution4. No Articular Step Off4. No Articular Step Off5. Maintains Reduction: 5. Maintains Reduction:
> 3 Weeks> 3 Weeks
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce
Wrist Fractures: Distal RadiusWrist Fractures: Distal RadiusWhat is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction 3. Comminution 3. Comminution
> > 1/3 AP Diameter1/3 AP Diameter
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction 3. Comminution 3. Comminution
> > 1/3 AP Diameter1/3 AP Diameter4. >20 Degrees Dorsal Tilt4. >20 Degrees Dorsal Tilt
(prior to reduction)(prior to reduction)
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction 3. Comminution 3. Comminution
> > 1/3 AP Diameter1/3 AP Diameter4. >20 Degrees Dorsal Tilt4. >20 Degrees Dorsal Tilt5. Volar Obliquity5. Volar Obliquity
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
What is Displaced?What is Displaced?> 2mm Measurable > 2mm Measurable
Articular Step OffArticular Step Off
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment?Treatment?
All stable fxAll stable fx’’s can be treated in cast / splintss can be treated in cast / splintsAll unstable fxAll unstable fx’’s require interventionss require interventions
Closed reduction Closed reduction ±± Percut Pins Percut Pins ±± Ex Fx Ex Fx
±± Open Reduction Open Reduction ±± Plates Plates ±± Bone GraftBone Graft
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Closed Reduction:Closed Reduction:Longitudinal TxnLongitudinal TxnPalmar TranslationPalmar TranslationPronation HandPronation Hand
relative to Forearmrelative to ForearmUlnar TiltUlnar TiltNO Wrist Flexion!!!!NO Wrist Flexion!!!!
modified from John Agee M.D.modified from John Agee M.D.
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Longitudinal TxnLongitudinal Txn
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Palmar TranslationPalmar TranslationPronation Hand Relative to ForearmPronation Hand Relative to ForearmUlnar TiltUlnar Tilt
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment?Treatment?
All stable fxAll stable fx’’s can be treated in cast / splintss can be treated in cast / splintsAll unstable fxAll unstable fx’’s require interventionss require interventions
Closed reduction Closed reduction ±± Percut Pins Percut Pins ±± Ex Fx Ex Fx
±± Open Reduction Open Reduction ±± Plates Plates ±± Bone GraftBone Graft
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment ?Treatment ?
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
TreatmentTreatment
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
TreatmentTreatment
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment Treatment
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment ?Treatment ?
Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius
Treatment Treatment
Wrist Fractures: DRUJWrist Fractures: DRUJ
Wrist Fractures: DRUJWrist Fractures: DRUJ
Treatment of Unstable DRUJ:Treatment of Unstable DRUJ:Address Radius FirstAddress Radius First
Then Assess DRUJThen Assess DRUJFix if Necessary Fix if Necessary
Wrist FracturesWrist Fractures
Caveats:Caveats:1. R/O Carpal Tunnel Syndrome1. R/O Carpal Tunnel Syndrome2. Excessive Pain = RSD2. Excessive Pain = RSD3. Most Common Cause of RSD3. Most Common Cause of RSD
Undiagnosed CTS & A Flexed WristUndiagnosed CTS & A Flexed Wrist
Wrist FracturesWrist Fractures
Caveats: Post Injury CareCaveats: Post Injury Care1. Keep those fingers moving1. Keep those fingers moving
Full extension to full flexion Full extension to full flexion 2. Keep the hand elevated above heart until2. Keep the hand elevated above heart until
swelling subsidesswelling subsides3. If you immobilize above the elbow do so 3. If you immobilize above the elbow do so
with the forearm in supinationwith the forearm in supination
Wrist FracturesWrist Fractures
Caveats: Post Injury CareCaveats: Post Injury Care
If you canIf you can’’t do the above with a cast then t do the above with a cast then your patient is best served with Fx fixation.your patient is best served with Fx fixation.
Wrist FracturesWrist Fractures
Caveats: Post Injury ExpectationsCaveats: Post Injury Expectations
Following the above guidelinesFollowing the above guidelinesDRUJ pain DRUJ pain ≈≈ 8 mo8 mo’’ssMaximum Improvement Maximum Improvement ≈≈ 18 mo18 mo’’ss
ROM ROM 80%80%Grip Grip 80%80%
Wrist FracturesWrist Fractures
Thank YouThank You