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Distal Radius Fracture
Aka: Distal Radius Fracture, Colles Fracture, Colles' Fracture- Epidemiology
- Most Common Wrist Injury
- Represents one sixth of all Fractures overall
- More common at extremes of age
- Young: High energy injury (e.g. skateboarding, Inline Skating, Downhill Skiing)
- Old: Low impact injury (e.g. fall)
- Mechanism
- Fall on an outstretched hand
- Signs
- Distal Radius Fracture
- Displacement ("Dinner Fork" Deformity)
- Dorsal Angulation with volar prominence
- Shortening
- Radial Deviation of hand
- Ulnar styloid Injury often associated (60%)
- Thumb Ulnar Collateral Ligament Injury often associated
- Distal Radius Fracture
- Complications
- Compartment Syndrome
- Significantly increased pain after reduction despite analgesia may suggest Compartment Syndrome
- Median Nerve Injury
- Most common nerve injury after angulated, displaced Distal Radius Fracture
- Presents with thumb and index finger Muscle Weakness and sensory deficit
- Compartment Syndrome
- Imaging: Wrist XRay
- See Wrist XRay
- Management: Anesthesia
- Conscious Sedation
- First-line Anesthesia unless skilled with hematioma block
- Fracture >4 hours prior (Hematoma Block less likely to be effective)
- Local Anesthetic (sufficient if recent Fracture within prior 4 hours)
- Hematoma Block
- Needle inserted dorsally into Fracture hematoma
- Aspirate to confirm needle within hematoma
- Inject 5-10 ml local Anesthetic
- Inject tip of ulna as well
- Hematoma Block
- Conscious Sedation
- Management: Manual Reduction (Technique 1)
- Assistant Position
- Grasps Forearm for countertraction
- Surgeon Position
- Grasps hand of affected wrist
- Thumb of other hand is placed on distal fragment
- Break up Impaction
- Wrist is hyperextended
- Dorsal Displacement and rotation is corrected
- Apply traction and countertraction
- Continue Thumb pressure on distal fragment
- Distal fragment dorsal cortex apposed with proximal
- Radial and Dorsal Angulation Corrected
- Apply Ulnar and Volar pressure over distal fragment
- Assess if Length is Restored
- Palpate radial styloid
- Assistant Position
- Management: Finger Trap Reduction (Technique 2)
- Anesthesia as above
- Break up Impaction by hyperextending wrist
- Place Index finger and thumb in finger traps
- Apply counterweight to upper arm
- Manipulate Fracture as above
- Management: Immobilization with Sugar Tong Splint
- Fluoroscopy (C-Arm) confirms alignment during Splinting
- Assistant applies steady traction at hand
- Wrist in slight pronation
- Avoid volar flexion of wrist
- Risk of Median Nerve Compression (Carpal Tunnel)
- Apply cast padding from MCP heads to above elbow
- Apply felt pad to volar surface of proximal fragment
- Splint with 10 cm wide, 12 plaster plies around elbow
- Dorsal half ends at MCP heads
- Mold over the distal fragment
- Volar half ends 1-2 cm distal to Fracture
- Maintain wrist in ulnar deviation
- Wrap a strip of plaster around distal splint
- Include distal MCP
- Keep strip proximal to distal palmar crease
- ACE Wrap Sugar Tong in place
- Management: Isolated Distal Radius Fracture
- Non-displaced Distal Radius Fracture (torus Fracture, buckle Fracture)
- Immobilize in a Short Arm Cast for 3 weeks
- Removable splints have been used with similar outcomes to Casting
- Displaced and overlapping Distal Radius Fracture
- Ulna Fracture also
- See Colles Fracture management above
- Ulna greenstick Fracture
- Complete ulna Fracture for adequate reduction
- Manage as Colles Fracture
- Ulna intact or greenstick Fracture
- Do not re-Fracture
- Reduction may be quite difficult
- Maximally supinate wrist
- Digital pressure to replace the distal radius
- Alignment is paramount
- Re-align as best as possible
- Apposition is secondary to alignment
- Bayonet apposition is acceptable
- Ulna Fracture also
- Non-displaced Distal Radius Fracture (torus Fracture, buckle Fracture)
- Management: Discharge Instructions
- Management: Orthopedic referral indications
- Distal radius dorsal angulation >5 to 10 degrees
- Radial Inclination change >5-10 degrees
- Radial Height shortening >2 mm
- Young athletes, or those with occupation or hobby requiring highly functional hand and wrist
- Rotational deformity tolerated (criteria contingent on 50% apposition or greater)
- Age >8 years: Refer for >10 degrees rotational deformity
- Age <8 years: Refer for 15-20 degrees rotational deformity
- Management: Follow-Up
- Days 1-2
- Phone: Is Splint too tight?
- Days 5-7
- Repeat Wrist XRay
- Strongly consider weekly XRay for first 3 weeks
- Apply Short Arm Cast
- Do not limit motion of the elbow or the metarcarpophalangeal joints
- Anticipate mal-union after swelling decreases
- Elderly
- Mal-union may be acceptable
- Re-manipulation may result in greater morbidity
- Young
- Malunion unacceptable
- Radial head shortening results in dysfunction
- Correction of mal-union
- Re-manipulation and closed reduction
- Open reduction and internal fixation (ORIF)
- External fixator
- Malunion unacceptable
- Elderly
- Repeat Wrist XRay
- Weeks 4-6
- Cast may be removed
- Weeks 7-9
- Wrist support or cast until pain subsides
- Days 1-2
- References