There are three parts to the
treatment of a fracture of this sort, firstly to reduce the
fracture, that is to put the two parts of the fracture back to their
original position. Once the fracture is reduced, it needs to be kept
in the correct position until the bones have a chance to heal, this
on average takes about six weeks. The third part of fracture
treatment is to ensure that the soft tissues of the arm are kept
mobile until the arm can get back to its original use.
There are many methods of treatment for fractures
of the wrist and it is true to say that Orthopaedic surgeons are
undecided as which method of treatment is best. The particular
method of treatment will depend both upon the preference and
experience of the surgeon and will also depend upon the nature of
the fracture. Most surgeons will use a variety of methods to treat
fractures of the wrist. It is also worth saying that traditionally
treatment of these fractures has been guided by the statement of
COLLES in his original paper who said that people with these
fractures do well even if the fracture isn’t reduced. This has meant
that these fractures have tended to be under treated in the past
although most Orthopaedic surgeons now realise that treatment of
these fractures is important if later problems are to be avoided.
This is particularly true these days when patients place greater
demands upon their wrists and are less willing to accept limitations
of movement and/or pain. Experimental studies which have looked at
these fractures have demonstrated that approximately 97% of
fractures are of the COLLES’ type i.e. the deformity is away from
the palm and about 3% are towards the palm, that is the SMITH’S type
of fracture.
Reduction of the fracture may be achieved by
manipulation of the fracture, that is pulling on the hand to pull
the bones back into place. This is commonly performed in the
Anaesthetic Department or Emergency Room and whilst general
anaesthesia may be used for this, it is more common to do it by some
means of local anaesthetic block or by injection of local
anaesthetic into the fracture site (what is known as a haematoma
block). Once the fracture has been reduced, it is often maintained
by use of a plaster applied to the arm, a so called COLLES’ plaster.
Instead of a full plaster, a backslab is often used in the early
stages after injury, that is a plaster which as its name suggests
consists of a slab of plaster which does not completely encircle the
limb and so, although it protects the injured area and maintains the
reduction, allows the arm to swell as it is likely to do in the
early stages.
If your Orthopaedic surgeon decides that plaster
treatment alone is suitable for your fracture, it is important
particularly in the early stages to elevate the limb but more
importantly, to get the affected limb mobilized, not just the
fingers and thumb but also the elbow and shoulder as these will
often give problems in the long term.
If however the
treating surgeon feels that plaster treatment will not control the
fracture then he or she may decide that operative treatment is
appropriate. The options which may be considered include:
| 1. |
Fixing the fracture in
position with stainless steel wires ("K" wires). |
| 2. |
Using an external fixator in which pins are
drilled into the bone either side of the fracture and connects
to a stabilising device outside of the body. |
|
3. |
Opening the
fracture and fixing it in place with screws and plates. These
screws and plates may be made of metals such as stainless steel
or titanium or materials which the body is able to absorb (so
called reabsorbable plates). |
|
4. |
Intra-medullary
devices. These are devices which are inserted into the inside
of the bone through a small opening in the radius (the main bone
of the arm) which are then fixed in place with screws to prevent
the fracture from moving. |
Whichever method is chosen,
because the bone tends to splinter at this site (what Orthopaedic
surgeons call comminution), any of the methods mentioned above may
be combined with filling the space that becomes apparent when the
fracture is reduced i.e. moved back into position, traditionally
this was achieved by using bone taken from the pelvis (bone graft)
or by sterilised bone from other materials or other sources of bone
mineral e.g. coral. These days it is more common to use bone
substitutes ,
these consist of the mineral content of bone
which is made into a form which allows it to be injected into the
fracture site.
More recently, if internal fixation is used i.e.
insertion of plates and screws into bone, they are often what is
known as angularly stable i.e. unlike earlier versions of plates,
the screws are fixed into the plate (usually this is achieved by a
thread in the screw which screws into the plate itself). This makes
the plate and screws what is known as “angularly stable”. The
benefit of this is that it prevents the lining of the joint or
articular surface falling back into the space and more importantly,
may often these days mean that bone graft is not required.
There are advantages and disadvantages to each of
the methods mentioned above, but it is increasingly recognised that
it is this splintering of the bone which occurs on the top of the
wrist (dorsal comminution) which is the key to preventing the
fracture re-displacing (that is returning to its fractured/broken
position) whilst the bone heals. The advantages and disadvantages of
each method are indicated in the table below:
Advantages and Disadvantages
| Method |
Plaster/brace |
| Advantages |
Easy to apply Operation not required |
| Disadvantages |
Movement of the hand may result in
loss of position of the fracture especially as swelling goes down
Plaster needs to be kept on for six weeks and so wrist and hand stiffness
may result
Plaster cannot control dorsal comminution |
| |
| Method |
"K" wires |
| Advantages |
Technically simple operation |
| Disadvantages |
Because "K" wires are smooth
they are not good at preventing loss of fracture position
A
plaster is still required and stiffness of the wrist may result
As the pins are often left out of the skin infection is a common
complication
Insertion of wires may result
in damage to the tendons around the wrist joint |
| |
| Method |
External fixation |
| Advantages |
Fracture is
reduced by pulling onto the wrist ligaments (what is knows as
ligamentotaxis) without opening up the fracture
Certain
types of fixator include hinges which allow the wrist to move
(and hence help to prevent stiffness) with the fixator on whilst
keeping the fracture in place |
| Disadvantages |
Fixators are often bulky and unsightly
The nature of the wrist ligaments means that
to keep the fracture in place wires, screws or bone graft may
also be needed in addition to the fixator
If the fixator is applied with too much pull
(traction) the wrist or hand may become stiff
The pins
which attach the fixator to bone may become infected (pin site
infection) |
| |
| Method |
Bone Grafting |
| Advantages |
Use of bone
which includes the strong outer layer of the bone (the cortex)
means that this method is strong enough to hold the fracture in
place and prevent loss of position due to dorsal comminution
(see above)
Combining
this with the softer inner bone (cancellous bone) stimulates the
fracture to heal very quickly |
| Disadvantages |
Other methods
such as K wires or screws or even plates may be needed to hold
the graft in place
Bone from
the cortex can usually only be obtained from the pelvis, this is
the main problem as the site from which the bone is taken may be
very painful and result in difficulty in walking for several
weeks |
| |
| Method |
Internal fixation (use of plates and screws) |
| Advantages |
The
greatest advantages of metal plates and screws is that they are
strong enough to fix the fracture in position and this allows
the wrist to be mobilized quickly and often a plaster is not
required
Since the advent of angularly stable implants
which hold the articular surface or lining of the joint in its
correct position, there is less chance of the fracture sinking
back into the space behind the joint and the need to add other
parts to the operation such as using bone graft or bone
substitutes (as described above) is less likely unless the
fracture is extremely unstable
There are
now several different ways in which the wrist may be plated and
these are described below including bioabsorbable plates. |
| Disadvantages |
Plating
of the wrist is a technically difficult operation and inevitably
there is a scar on the wrist
The tendons (leaders) around the wrist joint
are close to the site of the fracture and when metal plates are
used these tendons may become irritated by the plates (what is
known as synovitis) or they may even rupture
The
presence of plates around the wrist may result in discomfort for
the patient in the long term and therefore another operation may
be required to remove the plate itself. |
| |
|
Method |
Intra-medullary
devices |
|
Advantages |
The scars are
smaller than with traditional open reduction and internal
fixation |
|
Disadvantages |
Intra-medullary
devices are most suitable to extra-articular fractures i.e.
those where the joint surfaces are not involved and this
represents a relatively small proportion of distal radial
fractures
These
devices have not been used long enough to demonstrate that they
offer advantages over the current methods |
