Wrist fractures are well the most common orthopedic injuries every year in the United States and globally. The most common mechanism is a fall on the outstretched hand but there are many other ways in which a wrist fracture can be produced. The fracture will usually involves the radius, but may also involve the end of the ulna or one of the small carpal bones. See figure 1. During the fracture there may be tension forces on the bone that pull pieces apart or compressive forces that compress or compact the bone together. In the elderly osteoporosis may lead to a significant compression of the bone or produce multiple fragments (comminution). In wrist fractures, the fracture may not involve the actual wrist joint (extra-articular) or the wrist joint may be disrupted by the fracture (intra-articular). Although there are common fracture patterns,each fracture is unique and has its own” personality”. there is also often injury to the surrounding soft tissues(bone covering or periosteum, tendons, ligaments or nerves) when the fracture occurs. These soft tissue injuries must be recognized and treated in order to prevent "soft tissue disease" which may result in scarring and stiffness afterwards. Finally the patient which has the fracture is just as important as the fracture that the patient has. Factors such as age, general health, osteoporosis, smoking and malnutrition can affect fracture healing.
Careful assessment of the full extent of the fracture and the affected joints or soft tissues are critical to prepare a complete fracture treatment plan. This may involve taking multiple x-rays or a CT scan to completely evaluate the fracture pattern. It must be determined whether the fracture is stable or unstable due to the fracture pattern and muscular forces across the wrist. Osteoporosis and the degree of comminution(number of fracture pieces) also play a part in determining the stability of the fracture. it must also be determined whether the fracture is undisplaced and well aligned or displaced with angular or rotational deformity that will affect healing and function. Involvement of the adjacent joints by the fracture(intra-articular or extra-articular) must also be determined. The age and health of the patient as well as their functional needs (musician versus heavy laborer) must also be taken into account in preparing the fracture treatment plan.
In general broad terms, stable, undisplaced, extra-articular fractures of the wrist are usually treated conservatively with a protective splint or cast. In such cases where osteoporosis is known or suspected, frequent repeat x-rays and evaluation and maybe necessary to avoid later compression and collapse of the fracture even in a cast or splint. An external fixator or percutaneous pins may be applied to help try and prevent such collapse. An external fixator consists of pins that are placed through the skin into the bone hooked together with clamps and a bar that help hold the bone in the correct configuration. It looks much like a erector set applied to the wrist. percutaneous pins are stainless steel pins that are driven through the skin and across the fracture to help hold it in place. A plaster splint may also be used together with these techniques to help hold the fracture. usually occupational therapy will be started right away to reduce swelling(edema control) and start finger motion.
For severely displaced fractures with angular or rotational deformity and for displaced fractures that involve the joint, open reduction and internal fixation(ORIF) may be necessary. In this surgery an incision is made over the fracture and pins, screws or plates are used to reduce the fracture (correct its alignment). The soft tissues and skin are closed and an additional splint is usually used. In some cases the internal fixation may allow early controlled range of motion of the wrist. Our preference is for rigid internal fixation in order to allow early range of motion when possible and to avoid "soft tissue disease" and resultant stiffness. once the fracture is healed, the splint or cast may be removed in more aggressive range of motion and strengthening exercises are used.
Despite our best efforts and external or internal fixation, delayed healing or further settling of the fracture can occur. Arthritis of the affected joints may develop as well a stiffness of the wrist and fingers. This is sometimes an unfortunate nature of the fracture and affected bone. other risks are anesthesia related problems, wound healing problems or infection. Sometimes a second surgery may be required to remove the orthopedic hardware or correct some of the residual problems from the fracture.