Distal radius fracture (Broken wrist)
What is distal radius fracture?
The Radius is the largest bone of the forearm, which is subjected to fracture more commonly than any other bone of the arm. The end of the radius bone that forms the part of wrist joint is known as distal radius. Distal radius fracture is the break or discontinuation of the radius bone towards its distal end or the wrist. It is also known as broken wrist. and in young patients (18-25 years) it is caused by high energy falls, motor vehicle accidents, cyclists, skiing, skaters or in contact sports like rugby, football etc.
In elderly patients with weak osteoporotic bone, fall onto an outstretched hand can cause Distal radius (Colle’s) fracture.
Distal radius fracture is one of the most common fracture in orthopaedic practice. It accounts for 20 % of all fractures treated in emergency ward, and 8-15 % of all injuries of bone in adults. 50 % of the cases of broken wrist is intra-articular and is associated with injuries to triangular fibrocartilage complex (TFCC, 40%), scapholunate ligament (30%) and lunotriquetral ligament (15%).
What are the symptoms of distal radius fracture?
Pain, tenderness, swelling, deformity (dinner fork) and bruising are the common symptoms of broken wrist. Pain is felt especially on moving your wrist. You may feel difficulty in movement of the hand or wrist. Visible deformity is also present in some cases i.e. wrist hangs or bends away which look like bent or crooked. You may feel numbness in the hand in rare cases, which calls for emergency treatment.
How is it diagnosed?
Your orthopaedic surgeon will assess your complete medical history, history of trauma or injury and careful physical examination. He will ask for X- ray to confirm the diagnosis and CT scan in selected cases to find out status of joint, associated fractures, ligament injuries, gaps or step in the joint surface. . MRI scan is valuable in selected cases of possible ligament injuries.
What happens if nothing is done?
Untreated distal radius fracture may result in non-union or malunion of the broken fragments. It may lead to constant wrist pain, stiffness and weakness in the affected wrist and progress to arthritis. It also could cause rupture in extensor pollicis longus (EPL) tendon and poor hand function
How is it treated?
Majority of the broken wrist can be treated conservatively, and it includes rest, ice packs, closed reduction, immobilisation by a cast, pain killers, and hand therapy.
Surgery is indicated in
- Open fractures
- Comminuted fractures
- Unstable wrist
- Displaced intra- articular fractures (>2 mm)
- Dorsal angulation of distal end of radius (>5 degrees)
- Shortening of radius bone (>5 mm)
- Associated TFCC injuries
- Displaced extra- articular fractures
- Associated ligament injuries, carpal fractures, nerve injury, artery injury etc
What are the non-operative treatments?
The non-operative treatments involve –
- Closed reduction- your surgeon will realign your bones by pulling down your wrist and immobilizing in a cast. This process is also called reduction maneuver or closed reduction. This mechanical pulling is performed gently and slowly but still, it is painful. You might need anaesthesia and painkillers like codeine or paracetamol before this procedure so that you don’t feel pain.
- Immobilization- after closed reduction, your wrist is immobilized in aa cast for 4- 6 weeks to allow proper healing and prevent new injury to the affected area.
- Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first two days of the injury as it can relieve pain and swelling.
- Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate pain and swelling in the wrist for few days, as long-term consumption of these medicines can delay fracture healing and may cause damage to your kidneys and stomach.
- You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of its joints.
- Hand therapy- early motion exercises are started after 1 to 2 weeks of immobilization to prevent stiffness and maintain the good mobility in your elbow. Your elbow is prone for getting stiff and extra bone formation. Early physiotherapy under the supervision of your surgeon and physiotherapist is paramount for optimal outcome.
- The fracture union is confirmed by x-rays at regular intervals – 2,4,6 and12 weeks, however in selected patients’ weekly x-rays are needed to assess displacement in the first 3 weeks
- Physical therapy – physical exercises are stated after removal of the cast or splint. They are started with gentle exercises and are slowly progressed to strenuous and strengthening exercises to improve the range of motion and prevent stiffness. They are important to strengthen the muscles and the wrist.
What does the operation involve?
The main purpose of the operation is to facilitate the realignment and stabilization of the fractured ends of the radius bone during the process of healing. It can be done by arthroscopy or open surgery.
- You are admitted to the hospital and the operation is usually performed as a day case.
- The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation, but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
- A tourniquet is tied around your upper arm to reduce blood loss during surgery.
- Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation. In open fractures, the soft tissues and bone that are exposed, so they are cleaned thoroughly. A cut or incision is made in the affected site and the subcutaneous fat and muscles are moved aside in a gentle manner to look into the bone. The bone fragments are repositioned to their normal position. This procedure is called open reduction. Then, the bone fragments are fixed with the help of plates, pins or screws so that they remain in the proper position while healing process. This process is called internal fixation. In some cases, the fracture is reduced and held with pins or pins connected to a rod (external fixator). In cases of multiple fractures, bone substitutes are used to have faster healing and to fill the gap. The muscles and subcutaneous fat are then closed. The skin is closed with the help of absorbable sutures.
- The operation takes 1-2 hours to end. Most patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Your wrist is rested in a half cast for 2 weeks to protect it from injury and allow proper healing.
- You should keep your arm elevated (above the level of your heart) most of the times as it prevents swelling. Besides keep moving your fingers, elbow and shoulder.
- Before discharge, your physiotherapist will teach you gentle exercises of the hand, wrist, elbow and shoulder that you can start soon after the operation from the first day.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
- Following ORIF with plates and screw, usually the plaster is changed to splint and hand therapy commenced
- If the fracture is fixed with pins, that has to stay for 6 weeks and removed in the clinic after check x-rays
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You will be guided by your surgeon and hand therapists based on radiographic (X-ray) and clinical union of the fracture. In majority of the cases, you could start a gentle range of movement (ROM) exercises at 2 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around six weeks. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
Are there any risks?
- Carpal tunnel syndrome (median nerve neuropathy, 1-30%)
- EPL rupture
- Stiffness in the wrist
- Superficial or deep infections (1-2% which may raise to >5 % in diabetics)
- Post-traumatic radiocarpal arthritis
- Hardware complications- screw penetration into the joint
- Radiocarpal arthrosis
- Injury to ulnar nerve and radial sensory nerve
- Complex regional pain syndrome
What are the results of the operation?
The results of the operation are excellent with minimal complications. Most patients regain their normal range of motion and function of the wrist. The outcome is more predictable under the author’s experiences.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury. You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
- 57 year old plumber fell off from a ladder (20 feet) and sustained a complex fracture to his distal radius and ulna
- The fractures were fixed with plates and screws and he recovered full function back in his hand and wrist in three months
&0 year old lad had a fall on an outstretched hand and broke her wrist. This was fixed with plates and screws. She returned to her pre-injury level of activities three months after surgery.