II. Epidemiology

  1. Most Common Wrist Injury
  2. Represents one sixth of all Fractures overall
  3. More common at extremes of age (age<18 years and age>65 years)
    1. Young (<18 years): High energy injury (e.g. skateboarding, Inline Skating, Downhill Skiing)
    2. Elderly: Low impact injury (e.g. fall) and underlying Osteoporosis (fragility Fracture)

III. Mechanism

  1. Fall on an outstretched hand

IV. Exam

  1. See Forearm Fracture
  2. See Hand Exam
  3. See Wrist Exam
  4. Injury exam mantra: "joint above, joint below, circulation, motor function and Sensation, skin and compartments"
  5. Evaluate for open Fracture
  6. Evaluate for Ecchymosis, deformity, shortening, rotation
  7. Evaluate Wrist Range of Motion
  8. Evaluate for Carpal Bone injury (e.g. Navicular Fracture)
  9. Complete Hand Neurovascular Exam
    1. Evaluate for Median Nerve injury (finger opposition, Sensation palm and first 3.5 fingers)

V. Types

  1. Colles Fracture
    1. Occurs with Fall on Outstretched Hand with Forearm pronated
    2. Transverse Distal Radius Fracture with dorsal displacement and angulation of distal fragment
    3. "Dinner fork" deformity (distal fragment angulated dorsally)
    4. Often associated with ulnar styloid Fracture
  2. Smith Fracture (Reverse Colles Fracture)
    1. Example Injury: Bicycling Injury with injury when falling over handlebars
    2. Transverse Distal Radius Fracture
    3. Volar displacement and angulation of distal radius fragment
  3. Barton Fracture
    1. High force injury (e.g. direct blow or motorcycle injury)
    2. Distal Radius Fracture with dislocation or subluxation of radiocarpal joint
    3. Colles Fracture or Smith Fracture AND radiocarpal dislocation
    4. Higher risk injury for Compartment Syndrome and open Fracture
  4. Radial Styloid Fracture
    1. Fracture of the lateral aspect of the distal radius
    2. Styloid Fractures may be isolated or a part of a larger Distal Radius Fracture
    3. Styloid Fractures may also be associated with Scaphoid Fractures, carpal dislocations and other Carpal Bone injuries
  5. Hutchinson Fracture (Chauffeur Fracture)
    1. Occurs with posterior directed Fall on Outstretched Hand with hand in ulnar deviation
    2. Intra-articular Radial Styloid Fracture
    3. Associated with carpal injury (Scaphoid Fracture, lunate Fracture)
  6. Die Punch Fracture
    1. Fracture at the Lunate fossa of the distal radius articular surface (50% of radiocarpal joint)
    2. On impact (e.g. Fall on Outstretched Hand), Lunate punches into the distal radius
      1. Analogous to a die punch press in manufacturing
    3. Results in unstable Fracture with intraarticular extension
      1. Typically requires open reduction and internal fixation (with volar locking plate)
      2. Uncomplicated, non-displaced Fractures may be treated with non-surgical management
    4. References
      1. Kiel (2023) Crit Dec Emerg Med 37(10): 16-7

VI. Signs

  1. Distal Radius Fracture
    1. Displacement ("Dinner Fork" Deformity)
    2. Dorsal Angulation with volar prominence
    3. Shortening
    4. Radial Deviation of hand
  2. Ulnar styloid Injury often associated (60%)
  3. Thumb Ulnar Collateral Ligament Injury often associated

VII. Complications

  1. Compartment Syndrome
    1. Significantly increased pain after reduction despite analgesia may suggest Compartment Syndrome
  2. Median Nerve Injury
    1. Most common nerve injury after angulated, displaced Distal Radius Fracture (esp. Colles Fracture)
    2. Presents with thumb and index finger Muscle Weakness (test with opposition) and median sensory deficit
  3. Ligamentous Injury
    1. Thumb Ulnar Collateral Ligament Rupture

VIII. Imaging: Wrist XRay

IX. Management: General

  1. See Forearm Fracture
  2. External Fracture Reduction as indicated (see below)
  3. Fracture Immobilization initially with Splinting and then with Casting (see below)
  4. Orthopedic referral (see indications below)
    1. Within 3-5 day follow-up if further reduction or surgery otherwise needed
  5. Colles Fracture
    1. See Management below
  6. Smith Fracture (Reverse Colles Fracture)
    1. Volar angulation of distal radius fragment
    2. Fracture does not involve articular surface
      1. Traction and Manipulation
      2. Immobilization with Splinting and Casting
    3. Fracture involves articular surface
      1. Often involves volar subluxation of Carpal Bones
      2. Open Reduction and Internal Fixation (ORIF)
  7. Barton Fracture
    1. Distal Radius Fracture with dislocation)
    2. Open reduction and Internal fixation (ORIF) required (joint surface is involved)
    3. Evaluate for Compartment Syndrome, open Fracture

X. Management: Anesthesia

  1. Conscious Sedation
    1. First-line Anesthesia unless skilled with Hematoma Block or Regional Anesthesia
    2. Fracture >4 hours prior (Hematoma Block less likely to be effective)
  2. Regional Anesthesia
    1. See Hand and Wrist Regional Anesthesia
    2. Supraclavicular Brachial Plexus Block
    3. Infraclavicular Brachial Plexus Block
      1. Safer, without risk of phrenic nerve injury
  3. Local Anesthetic (sufficient if recent Fracture within prior 4 hours)
    1. Hematoma Block
      1. Needle inserted dorsally into FractureHematoma
      2. Aspirate to confirm needle within Hematoma
      3. Inject 5-10 ml Local Anesthetic
    2. Inject tip of ulna as well

XI. Management: Manual Reduction (Technique 1)

  1. Assistant Position
    1. Grasps Forearm for countertraction
  2. Surgeon Position
    1. Grasps hand of affected wrist
    2. Thumb of other hand is placed on distal fragment
  3. Break up Impaction
    1. Wrist is hyperextended
  4. Dorsal Displacement and rotation is corrected
    1. Apply traction and countertraction
    2. Continue Thumb pressure on distal fragment
    3. Distal fragment dorsal cortex apposed with proximal
  5. Radial and Dorsal Angulation Corrected
    1. Apply Ulnar and Volar pressure over distal fragment
  6. Assess if Length is Restored
    1. Palpate radial styloid

XII. Management: Finger Trap Reduction (Technique 2)

  1. Anesthesia as above
  2. Break up Impaction by hyperextending wrist
  3. Place Index finger and thumb in finger traps
  4. Apply counterweight to upper arm
  5. Manipulate Fracture as above

XIII. Management: Immobilization with Sugar Tong Splint

  1. Fluoroscopy (C-Arm) confirms alignment during Splinting
  2. Assistant applies steady traction at hand
  3. Wrist in slight pronation
  4. Avoid volar flexion of wrist
    1. Risk of Median Nerve Compression (Carpal Tunnel)
  5. Apply cast padding from MCP heads to above elbow
  6. Apply felt pad to volar surface of proximal fragment
  7. Splint with 10 cm wide, 12 plaster plies around elbow
  8. Dorsal half ends at MCP heads
    1. Mold over the distal fragment
  9. Volar half ends 1-2 cm distal to Fracture
  10. Maintain wrist in ulnar deviation
    1. Wrap a strip of plaster around distal splint
    2. Include distal MCP
    3. Keep strip proximal to distal palmar crease
  11. ACE Wrap Sugar Tong in place

XIV. Management: Isolated Distal Radius Fracture

  1. Non-displaced Distal Radius Fracture
    1. See Forearm Fracture in Children (torus Fracture, buckle Fracture, greenstick Fracture)
    2. Immobilize in a Short Arm Cast for 3 weeks
    3. Removable splints have been used with similar outcomes to Castingin buckle Fracture (not greenstick Fracture)
      1. Williams (2013) Pediatr Emerg Care 29(5):555-9 +PMID:23603644 [PubMed]
  2. Displaced and overlapping Distal Radius Fracture
    1. Ulna Fracture also
      1. See Colles Fracture management above
    2. Ulna greenstick Fracture
      1. Complete Ulna Fracture for adequate reduction
      2. Manage as Colles Fracture
    3. Ulna intact or greenstick Fracture
      1. Do not re-Fracture
      2. Reduction may be quite difficult
        1. Maximally supinate wrist
        2. Digital pressure to replace the distal radius
      3. Alignment is paramount
        1. Re-align as best as possible
      4. Apposition is secondary to alignment
        1. Bayonet apposition is acceptable

XV. Management: Discharge Instructions

  1. Ice for 72 hours
  2. Elevation
  3. Maintain active Range of Motion of fingers and Shoulder
  4. Shoulder Sling
    1. Do not use longer than 2-3 days
    2. Risk of Shoulder stiffness

XVI. Management: Orthopedic Referral Indications

  1. Images
    1. radialFractureXRayMeasureLat.png
    2. radialFractureXRayMeasureAP.png
  2. Distal radius dorsal angulation >5 to 10 degrees
  3. Distal Radius Measurements
    1. Line 1 (proximal transverse)
      1. Draw a horizontal, transverse line across the wrist at the distal aspect of the medial radius (ulna articulation)
    2. Line 2 (distal transverse)
      1. Draw a horizontal, transverse line across the wrist at the most distal aspect of the lateral radius (radial styloid)
      2. Radial length (Radial Height) represents the distance between line 1 and line 2
    3. Line 3 (Radial Inclination)
      1. Draw an oblique line between the medial distal radius and the lateral distal radius
      2. Radial Inclination represents the angle between Line 1 (proximal transverse) and this oblique Line 3
  4. Radial Inclination (normal measurements are for adults)
    1. Normal Radial Inclination: 23.6 +/- 2.5 degrees
    2. Acceptable inclination: 139-30 degrees
  5. Radial Height (radial length) shortening (normal measurements are for adults)
    1. Normal Radial Height: 11-12 mm
    2. Acceptable Radial Height: 8-18 mm
    3. Refer for >2 mm of radial shortening
  6. Young athletes, or those with occupation or hobby requiring highly functional hand and wrist
  7. Rotational deformity tolerated (criteria contingent on 50% apposition or greater)
    1. Age >8 years: Refer for >10 degrees rotational deformity
    2. Age <8 years: Refer for 15-20 degrees rotational deformity
  8. Other indications
    1. Fracture-dislocation
    2. Carpal Fracture
    3. Ulnar styloid Fracture
    4. Unstable Fracture or significantly comminuted
    5. Radiocarpal or radioulnar ligament injury or instability
    6. Scaphoid Fracture
    7. Fracture nonunion
    8. Epiphyseal Fracture suspected (children)
    9. Die punch Fracture

XVII. Management: Follow-Up

  1. Days 1-2
    1. Phone: Is Splint too tight?
  2. Days 5-7
    1. Repeat Wrist XRay
      1. Strongly consider weekly XRay for first 3 weeks in displaced Fracture
    2. Apply Short Arm Cast
      1. Do not limit motion of the elbow or the metarcarpophalangeal joints
    3. Anticipate mal-union after swelling decreases
      1. Elderly
        1. Mal-union may be acceptable
        2. Re-manipulation may result in greater morbidity
      2. Young
        1. Malunion unacceptable
          1. Radial head shortening results in dysfunction
        2. Correction of mal-union
          1. Re-manipulation and closed reduction
          2. Open reduction and internal fixation (ORIF)
          3. External fixator
  3. Week 3
    1. Non-displaced Fracture follow-up and consider cast removal
  4. Weeks 4-6
    1. Cast may be removed
  5. Weeks 7-9
    1. Wrist support or cast until pain subsides

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