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Wrist Fractures

Fractures of radius bone at the wrist are one of the very common fractures presenting to hospital. Middle age female patients with early osteoporosis are proned to get this fracture but it is not uncommon in all age groups. The injury is caused by a fall on the hand. There is immediate pain, swelling and bruising. A deformity described as dinner fork deformity develops when fracture is displaced but this is not so in all wrist fractures.

Hand is examined to check for circulation and nerve functions and x-rays are performed which confirms the fracture of the distal radius. An initial temporary cast is applied to help the pain.

Treatment

If the fracture is Undisplaced or in an acceptable position then treatment is continued initially in the temporary cast which is completed to a full cast a few days later. You will be regularly seen in clinic with x-rays to assess satisfactory progress. Plaster casts are often removed after 4 - 6 weeks and exercise commenced.

Displaced Fractures

If fractures are displaced or in unacceptable position then the treatment involves getting the fracture in good position (reduction) and then holding the fracture in the improved position (maintain reduction). This is achieved either by manipulation of fracture and then application of plaster cast OR by an operation.

Manipulation and Plaster

Wrist FracturesSome simple fractures can be treated by this method. The manipulation is done sometimes under local nerve block to numb the pain or general anaesthetic (GA). Once the fracture is reduced under x-ray and it is stable then a plaster is applied. You will be discharged on the day and the plaster will need to be checked again in a week with x-rays to make sure that the position has maintained. If you get symptoms such as pins and needles or excessive pain then you should report immediately. The plaster may be too tight and will need to be changed.

After 4-6 weeks plaster is removed and exercise is encouraged. It takes a few months before full recovery is achieved. Often recovery is less than full and some loss of movement is common.

If fracture is unstable or multifragmented then other treatment methods will be used. These include manipulation of fracture and wires to hold position. This is not commonly used any more except in children. Use of an external fixator is another option but the method which is most commonly favoured currently is open reduction and fixation of fracture.

Open Reduction and Fixation of Fracture

Very often fractures of distal radius are unstable and even though after manipulation a good position is achieved but after a week it displaces again. Even wiring the fracture does not maintain the position adequately. In this form of treatment the fracture is opened through an incision on the skin usually on the front of the forearm and wrist. The fracture is reduced under direct vision and fixed using a plate and screws. This gives the best chance for the fracture to heal in an appropriate position.

Because it is an open operation there is a small chance of getting infection (1%) and also small risk of tendon and nerve injury. Overall results are better.

It is usually not necessary to be in plaster and early gentle exercise is allowed straight away.

Complications

General complications of wrist fractures include stiffness and some loss of wrist movements and rotation of the forearm are permanent. With therapy and exercise improvement can be achieved up to a limit. It is important not to forget to exercise the shoulder and elbow every now and then.

One curious complication of wrist fracture is Complex Regional Pain Syndrome (CRPS). In this condition the mechanisms which normally control the circulation, sensations, temperature, sweating etc in the limb go out of control and as a result of this, there is excessive pain, swelling, sweating and dryness, sometimes with bluish discoloration of skin. When this happens, the progress is very slow. The treatment is reassurance that the condition will improve and controlling the pain. Gradual movements and physiotherapy will improve the wrist but aggressive exercise is often counterproductive.

Nasser Hyder
Consultant Hand Surgeon
FRCS (Trauma & Orth)

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