Wrist Fractures

Doug Hanel M.D.

Department Of Orthopaedics
Harborview Medical Center
Childrens Hospital and Regional Medical Cent
University Of Washington

Wrist Fractures
Wrist Defined:
Carpal Bones
Distal Radius
Distal Ulna

Wrist Fractures
Wrist Joints:
CMC
Intercarpal
Radiocarpal
DRUJ
drudge

Wrist Fractures
Wrist Fractures:
(that we are going to discuss)

Scaphoid
Distal Radius
Distal Ulna

Wrist Fractures:
Scaphoid
Scaphoid Fx

Wrist Fractures:
Scaphoid
Fate of Nonunions:
Mack 1984
20 30 Years: Pan Carpal Arthritis
Ruby 1985
97% DJD If Nonunion > 5 Years
Duppe 1994
Arthritis
Symptomatic
United
1/47
3/47
Ununited
4/9
5/9

Wrist Fractures: Scaphoid

1
3

Wrist Fractures:
Scaphoid

Wrist Fractures:
Scaphoid
Suspect Scaphoid Fxs !!!
Hx : Fall on Outstretched Hand
Pain : anatomic snuffbox
Pain : with scaphoid compression
Xray : Normal

Wrist Fractures:
Scaphoid
Suspect Scaphoid Fxs !!!
Over treat : Short Arm Thumb Spica
Re Xray : Two Weeks
(AP, Lat, Scaphoid Oblique)

Wrist Fractures:
Scaphoid
Suspect Scaphoid Fxs !!!
I gotta know and money is no object
MR Scan will be positive within hours
Bone Scan will be positive within days

Wrist Fractures:
Scaphoid
Scaphoid Fx :
Fx line visible, No displacement
Rx: long vs short arm thumb spica

Wrist Fractures:
Scaphoid
Scaphoid Fx :
Fx line visible & Fx displaced
Rx: Consider ORIF
Need for fixation is relative to Fx location

Wrist Fractures:
Scaphoid

Wrist Fractures:
Scaphoid
1
2

1
3

Wrist Fractures:
Scaphoid
1. Tubercle Fx
Rx: Splint

2. Waist Fx
Rx: >1mm Displaced
ORIF

1
3

3. Proximal Pole
Rx: You see it
You fix it

Wrist Fractures:
Scaphoid
36 weeks

Wrist Fractures:
Scaphoid

Another 12-16 weeks?

Wrist Fractures:
Scaphoid
2 weeks in splint
10% motion loss, no strength loss

6 wks post

Wrist Fractures:
Scaphoid
Non union: A Simple
Problem Made Difficult

Wrist Fractures:
Scaphoid
Bone Graft
Technically demanding

Wrist Fractures:
Scaphoid
Bone Graft
1 year of wrist protection
1 year limited use
30% motion loss
30% strength loss

Wrist Fractures:
Scaphoid
Conclusions:
In most cases
Non Op Rx is truly radical
&
Op Rx is conservative

Wrist Fractures:
Scaphoid
Refer Early !

Wrist Fractures: Distal

Radius
after a period time
.all do well
Abraham Colles

Wrist Fractures: Distal

Radius
after a period time
.all do well
Abraham Colles

Wrist Fractures: Distal

Radius
Distal radius fxs differ in:
Mechanism of injury
Energy of injury
Articular involvement
Associated Injuries

Wrist Fractures: Distal

Radius
Simple Bending

Wrist Fractures: Distal

Radius
Compression:
Most Common
Low & high Energy

Wrist Fractures: Distal

Radius
Shearing:
Inherently Unstable

Wrist Fractures: Distal

Radius
Fx Dislocation:
Deceptively
Simple

Wrist Fractures: Distal

Radius
Combined Complex:
High Energy
Comminuted
Open

Wrist Fractures: Distal

Radius
Treatment Goals
Begin with the end in mind!
David Covey

Wrist Fractures: Distal

Radius
Treatment Goals
Radial incl
Tilt
Length
Gaps
Step off
Stable

> 5
neutral +
neutral
< 2 mm
< 2 mm
DRUJ

Wrist Fractures: Distal

Radius
Treatment Based On: Demand
Low Demand: Minimal Treatment
High Demand: CRPP vs ORIF

Wrist Fractures: Distal

Radius
Treatment Based On:
Three Xray Parameters
Metaphyseal Stability
Articular Step Off / Gaps
DRUJ Stability (after radius fixation)

Wrist Fractures: Distal

Radius
What is stable?
1. Easily Reduced
2. Transverse Fx Pattern
3. Minimal
Dorsal Comminution
4. No Articular Step Off
5. Maintains Reduction:
> 3 Weeks

Wrist Fractures: Distal

Radius
What is Unstable?
1. Cant Reduce

Wrist Fractures: Distal

Radius
What is Unstable?
1. Cant Reduce
2. Lose Reduction

Wrist Fractures: Distal

Radius
What is Unstable?
1. Cant Reduce
2. Lose Reduction
3. Comminution
> 1/3 AP Diameter

Wrist Fractures: Distal

Radius
What is Unstable?
1. Cant Reduce
2. Lose Reduction
3. Comminution
> 1/3 AP Diameter
4. >20 Degrees Dorsal Tilt
(prior to reduction)

Wrist Fractures: Distal

Radius
What is Unstable?
1. Cant Reduce
2. Lose Reduction
3. Comminution
> 1/3 AP Diameter
4. >20 Degrees Dorsal Tilt
5. Volar Obliquity

Wrist Fractures: Distal

Radius
What is Displaced?
> 2mm Measurable
Articular Step Off

Wrist Fractures: Distal

Radius
Treatment?
All stable fxs can be treated in cast / splints
All unstable fxs require interventions
Closed reduction
Percut Pins Ex Fx
Open Reduction Plates
Bone Graft

Wrist Fractures: Distal

Radius
Closed Reduction:
Longitudinal Txn
Palmar Translation
Pronation Hand
relative to Forearm
Ulnar Tilt
NO Wrist Flexion!!!!

modified from John Agee M.D.

Wrist Fractures: Distal

Radius
Longitudinal Txn

Wrist Fractures: Distal

Radius
Palmar Translation
Pronation Hand Relative to Forearm
Ulnar Tilt

Wrist Fractures: Distal

Radius
Treatment?
All stable fxs can be treated in cast / splints
All unstable fxs require interventions
Closed reduction
Percut Pins Ex Fx
Open Reduction Plates
Bone Graft

Wrist Fractures: Distal

Radius
Treatment ?

Wrist Fractures: Distal

Radius
Treatment

Wrist Fractures: Distal

Radius
Treatment

Wrist Fractures: Distal

Radius
Treatment

Wrist Fractures: Distal

Radius
Treatment ?

Wrist Fractures: Distal

Radius
Treatment

Wrist Fractures: DRUJ

Wrist Fractures: DRUJ

Treatment of Unstable DRUJ:
Address Radius First
Then Assess DRUJ
Fix if Necessary

Wrist Fractures
Caveats:
1. R/O Carpal Tunnel Syndrome
2. Excessive Pain = RSD
3. Most Common Cause of RSD
Undiagnosed CTS & A Flexed Wrist

Wrist Fractures
Caveats: Post Injury Care
1. Keep those fingers moving
Full extension to full flexion
2. Keep the hand elevated above heart until
swelling subsides
3. If you immobilize above the elbow do so
with the forearm in supination

Wrist Fractures
Caveats: Post Injury Care
If you cant do the above with a cast then
your patient is best served with Fx fixation.

Wrist Fractures
Caveats: Post Injury Expectations
Following the above guidelines
DRUJ pain 8 mos
Maximum Improvement 18 mos
ROM
80%
Grip
80%

Wrist Fractures
Thank You