Fractures of the Wrist by Mr G J Packer, Orthopaedic Surgeon in Essex, UK.

 
Treatments for Fractures of the Wrist

It is usually obvious to the patient following a fall once a fracture of the wrist has occurred, the wrist joint is usually very painful and swollen and it may of course be deformed.  Immediate treatment consists of resting the painful part (for example in a sling).  The use of something cold will help control swelling, ice or frozen peas are suitable but they should always be wrapped in something (e.g. a towel) and NEVER applied directly to the skin.  This is because direct contact with ice may cause skin damage to occur.

Medical advice should be sought immediately and it is important to remember that the patient may require an anaesthetic for treatment of these fractures and it is therefore important to avoid food and drink until a Doctor or other Medical Practitioner has seen the injury so as to avoid a delay in treatment.

Almost always an X-ray (radiograph) of the wrist is required to make an accurate diagnosis of wrist fractures and to decide upon the correct treatment. Figure four shows the typical appearance of a wrist fracture (in this case a COLLES’ fracture). This X-ray shows that the radius has both bent and moved away from the palm.  It is this movement (what Orthopaedic surgeons call angulation and displacement) which causes the dinner fork deformity.

Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.
Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.

Leaving the fracture in this position (figure five) will almost certainly result in the problems mentioned above, particularly if the radius remains short compared to the ulna. For this reason, this fracture will almost certainly require further treatment.

Figure five: X-ray of Colle’s fracture seen from the front to show that the radius becomes shortened. Click here to view a larger version.
Figure five: X-ray of Colle’s fracture seen from the front to show that the radius becomes shortened. Click here to view a larger version.

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  

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This page was last updated on 30/Nov/2009