Distal radius fractures
The distal radius is one of the most commonly fractured bones in the body - it's the bone that people have usually broken when they say they have a "broken wrist". Most commonly it is fractured from a fall onto an outstretched hand.
The radius is one of the two bones of the forearm (see right); the "distal" radius refers to the end portion of the radius bone. It is most commonly broken from an impact on the hand, such as occurs in a fall - whether that fall is from standing height, a ladder or a motorbike.
Some distal radius fractures are treated with a cast and some are treated with surgery. This depends on a number of factors, including the exact location and type of the break, whether the bone fragments have moved significantly from their normal position, your activity levels and your personal preferences. In most cases the diagnosis and treatment is planned from plain x-rays. If you have a "nasty" fracture a CT scan may be performed prior to surgery to facilitate surgical planning.
Image Credit (right): HandDecide from Orca Health
Types of distal radius fractures
Undisplaced/stable distal radius fracture
The term "displacement" refers to whether the broken portions of the bone have moved in relation to each other. An "undisplaced" fracture is one where the parts of the bone have not significantly moved (they are not "displaced"). This type of fracture can be treated in a plaster or fibreglass cast and does not require surgery. In many cases it is so hard to see the fracture on the x-ray that you won't be able to pick it unless someone with a trained eye points it out.
An undisplaced fracture is treated with a cast or restrictive splint for 6 weeks. During this time x-rays are performed to check that your fracture has not changed in position and that the bone is healing satisfactorily. While the cast or splint is in position you will be encouraged to maintain a full range of movement of the joints that are not included within the splint. Once the cast or splint is removed you will be given exercises and therapy to regain the range of movement of your wrist joint and to regain the strength of your forearm and hand muscles.
Displaced/unstable distal radius fracture
A "displaced" fracture exists when the broken portions of the bone have moved - they can move apart, compress together and angle towards or away from each other. If you have a displaced fracture then often when you visit an emergency department the doctors will give you pain medication and local anaesthetic, then try to pull or push the fracture into a better position before applying a plaster cast. If the bone fragments can be put back into an acceptable position you do not necessarily need surgery and you may be able to be treated with a cast for 6 weeks.
Commonly the bone fragments are not held perfectly in place in a cast, and they can tend to drift back to the "displaced" position. This is because the fracture is "unstable" - that is, forces on the fragments tend to pull them apart from their original position, so while they can be pulled back into position, that position is not stable. If this is the case your surgeon may recommend that you have surgery, so that a plate and screws can be used to hold the bone in the proper position while it heals.
One of the potential benefits of surgery is that you do not have to be in a cast for 6 weeks after surgery. If the surgery is able to hold the bone fragments in position then you will be placed in a lightweight, removable splint and you will be able to start therapy to regain your range of movement immediately after the surgery.
Intra-articular distal radius fracture
An intra-articular distal radius fracture is one where the break goes through the joint surface. It is important that the joint surfaces be as smooth as possible to reduce the chances of developing osteoarthritis, so surgery is more likely to be advised for a break that involves the joint surface.
If the break is not "displaced" then the fracture can be treated with a cast for 6 weeks. During this time x-rays are performed to check that your fracture has not changed in position and that the bone is healing satisfactorily. While the cast or splint is in position you will be encouraged to maintain a full range of movement of the joints that are not included within the splint. Once the cast or splint is removed you will be given exercises and therapy to regain the range of movement of your wrist joint and to regain the strength of your forearm and hand muscles.
If the break is displaced and the joint surfaces have a "step" or a "gap" then surgery is likely to be recommended. In the majority of cases it can be predicted at your first surgical visit whether you will need to have surgery. Occasionally the x-ray position of the fracture may look acceptable at your first review, but look poor at your review a week later.
There is no consensus on whether elderly patients should have surgery for unstable distal radius fractures, as only minor differences exist between functional outcomes and activities of daily living at one year after injury [ref: Schneppendahl J, Windolf J, Kaufmann R, Distal Radius Fractures: Current Concepts, J Hand Surg Am, 2012 Aug; 37(8):1718-25].
Types of distal radius fracture surgery
Closed reduction (also called a "GAMP")
This is usually attempted in a hospital emergency department, or on a child in an operating theatre. During the procedure you are given pain medication and local anaesthetic, then a doctor tries to manipulate your fracture back into place. A plaster is applied and an x-ray taken to check whether the bone position is acceptable.
A closed reduction can also be referred to as "a GAMP". This is an abbreviation that means "General Anaesthetic, Manipulation and Plaster", which describes the sequence of the surgery in an operating theatre.
Closed reduction and k-wire (also called a "GAMP and k-wire")
This is not commonly performed on adults. It is generally performed on children who have a fracture that will not stay in an acceptable position with a "closed reduction" alone. The k-wire is a wire that is passed through the skin and into the bone, holding the fragments in position while the bone heals. Usually more than one wire is placed and the wires are removed at approximately 6 weeks after surgery.
A "closed reduction and k-wire" procedure can also be referred to as "a GAMP and k-wire". The "GAMP" abbreviation stands for "General Anaesthetic, Manipulation and Plaster".
Open reduction and internal fixation ("ORIF")
This is the most common type of surgery performed for a distal radius fracture. The most common type of "ORIF" for a distal radius fracture puts a plate on the inner aspect of the bone and uses screws to hold the fracture fragments together. This surgery is performed under anaesthetic in an operating theatre. An incision approximately 6cm long is placed on the inner surface of the wrist, over the top of the most prominent tendon that flexes the wrist.
Other types of ORIF surgery may use screws alone, or screws with little plates for each individual fracture (termed "fragment specific fixation"). These types of surgery are used for specific patterns of distal radius fractures. The surgery is performed under anaesthetic in an operating theatre. There may be a single incision or more than one incision may be required. Your surgeon will make these decisions based on the pattern of your fracture.
For example, the fracture on the left is a Chauffeur's fracture (also termed a "Hutchinson" fracture), and is repaired with a single incision along the "thumb side" of the wrist, either using screws or plates and wires according to your surgeon's preference. If your wrist is exceptionally badly broken it may not be possible to hold the fragments together and sometimes a "bridging plate" or an "external fixateur" is applied; this is very uncommon.
After distal radius fracture surgery
After the surgery you will be seen by a hand therapist and will start early movement of your hand and wrist. When you go home you will have medication to take regularly for pain. You will see your surgeon regularly during the follow-up period and have x-rays to check the position and healing of the break. You will not be able to drive until you can grip a steering wheel strongly, which may take 6 weeks or more. You may be able to return to office duties after one week, but in a restricted capacity, especially if your injured wrist is your dominant hand. You will not be able to perform heavy duties or lift items of any significant weight until 6 weeks after surgery, because the surgery does not speed the healing of the bone, it merely puts it in the correct position and stabilises it while it is healing.
The plates and screws that are used in ORIF surgery are not routinely removed.
There is a low rate of complications from surgery for distal radius fracture, but complications can arise from any surgery.
Complications that can arise because you have a distal radius fracture include: pain, swelling, bruising, altered sensation in the fingers, reduced ability to move the hand and wrist, tendon rupture, failure of the bone to heal (termed a "non-union"), failure of the bone to heal in the correct position (termed a "malunion"), wrist instability, compartment syndrome and wrist arthritis. It is relatively common to develop carpal tunnel syndrome after a distal radius fracture, which may require surgery.
Complications that can arise because of surgery for a distal radius fracture include pain, swelling, bruising, altered sensation in the fingers, reduced ability to move the hand and wrist, tendon rupture, failure of the bone to heal (termed a "non-union"), failure of the bone to heal in the correct position (termed a "malunion"), wrist instability, compartment syndrome, wrist arthritis, tendon irritation from the plates or screws, nerve irritation ("neuroma"), infection, bad scarring, injury to nerves, allergic reactions and general complications of surgery (such as clots in the veins in the legs and complications of an anaesthetic). You will notice that many of these complications are the same as the complications of having a distal radius fracture.
Complications of surgery are not common but can happen. To reduce infection we administer antibiotics at the time of surgery, and the risk of infection is very low. We recommend early movement and start hand therapy as soon as practicable after surgery, as we find this maximises your ability to regain movement after a fracture. We keep all patients in hospital overnight after surgery so that we can keep your pain well controlled and your hand elevated to reduce swelling. During surgery I aim to put the joint surfaces back in proper alignment so that you have a reduced risk of arthritis in the joint compared to if you did not have surgery. I take great care of your tissues to prevent inadvertent injury to nerves or other structures. I only recommend surgery if I believe it is in your interests to have the surgery.
To reduce the likelihood of complications, please
- follow all instructions from your surgeon and hand therapist
- let your surgeon and hand therapist know if you are having unexpected problems
- eat a healthy diet
- take Vitamin C daily in a dose of 500mg for 2 months, as this is thought to reduce the likelihood of pain problems
- stop smoking if you are a smoker, as this will reduce the chances of infection and of poor bone healing
Preventing further fractures
Some distal radius fractures happen because of osteoporosis, which is a condition where the bone density is reduced, making the bones prone to fractures with minimal trauma. Over 1 million Australians have osteoporosis [ref: Osteoporosis Australia].
People who have osteoporosis can reduce the likelihood of future fractures with changes in diet, exercise and medications. Speak to your general practitioner about osteoporosis if you think that you may be at risk. A bone density test can diagnose the condition.
For more information about osteoporosis please visit the Osteoporosis Australia website.
X-ray Credits: Radiopaedia.org