What treatments should I consider?
The goals of treatment of distal radius fractures are:
- To relieve the pain of the injury
- To facilitate healing by immobilizing the fracture fragments
- To ensure that the fracture heals in a position which does not compromise wrist function
- To protect the region during the healing process
- To allow return to normal function as soon as possible
There are a wide variety of treatment options available to treat distal radius fractures. Non-operative treatment is the mainstay of treatment, particularly in the elderly. Long experience has shown that although these fractures may not heal in perfect alignment, this does not usually cause a significant loss of function in the elderly population. The risks associated with surgery and anesthesia made the choice of non-operative treatment attractive.
However, some fractures do need to be treated by surgery. During the last few years, a number of new surgical techniques and implants have been developed. These new tools and techniques are more successful at holding the bone fragments in good position while the fracture heals. These improvements have prompted a re-evaluation of surgery as a treatment for many wrist fractures. Today, improvements in anesthetic technique and surgical implants have made surgery a good option for all unstable wrist fractures.
If the fracture is stable and nondisplaced then its position does not need to be improved by manipulation. These fractures can be treated in a cast. This accomplishes three of the goals of treatment; it improves the pain by splinting the fracture very securely; it protects the fracture; and by preventing movement of the wrist it makes it more likely that the fracture fragments will stay in position.
A cast must be tight enough to hold the forearm and wrist securely but not so tight that it compresses the damaged and swollen tissues of the forearm. This can be a difficult issue because the region is usually very swollen at the time the cast is put on. You can often expect more swelling in the next few days so the cast may get too tight; then as the swelling goes down it may get loose. If you stay in the hospital after a cast has been put on the staff will be asking you about the circulation and sensation in your fingers; they are making sure the cast is not too tight.
Quite often the cast is "split" right after it has hardened. A small strip of plaster is removed down one side of the cast and the padding is cut to allow the cast to spread apart if the arm swells. Then when the swelling has gone down the cast can be closed up to tighten it around the arm.
Another popular option is to splint the wrist with a "slab" of plaster for the first few days and apply a cast once the swelling has gone down.
Follow-up of a fracture in a cast may require frequent visits to the cast clinic. The doctor needs to know that the cast is fitting comfortably and that the fracture has not shifted too far out of position. This usually involves repeat x-rays at intervals during the healing period. It is sometimes necessary to replace the cast. If the cast becomes loose, gets wet, or breaks it should be replaced immediately. This can normally be done in the office without the need for anesthesia.
Some patients wonder how the cast can be cut without cutting them. The cast cutter is a special type of saw. Although a cast cutter looks like a saw, it works by vibration. The blade only rotates a few millimeters then reverses. Anything hard, like the cast, resists this small movement and is cut; anything soft and giving, like your skin, will vibrate with the cutter and all you will feel is a buzz. If the skin is so tense that it doesn't move when a cast cutter blade touches it, you can get a small cut; if the cutter hurts, say so at once.
Your cast will be removed when there is evidence of healing on x-ray. At six weeks there is usually enough new bone formation (callus) to allow for removal of the cast. This new bone is still quite weak, though and you should protect the fracture for a few weeks more. Sometimes this means a removable splint. You can take off the splint to exercise the wrist until you can recover the same movements as the other side. You should not use the wrist for heavy activity until the doctor is satisfied the fracture is adequately healed.
Closed Reduction & Cast
Frequently the position of the fracture is not acceptable. The angulation or the impaction is so severe that the function of the wrist would be impaired if allowed to heal in this position. In these cases, the surgeon may opt to improve the position of the fracture by manipulating it. This is called a fracture reduction. Manipulating a fracture is painful and requires an anesthetic, either general, regional or local.
Regional anesthesia is accomplished by injecting a local anesthetic into the armpit next to the nerves that run to the hand. This makes the entire arm numb for about two hours. This is called an axillary nerve block. Another valuable regional anesthesia technique is an intravenous block. The circulation to the arm is stopped by a tourniquet and local anesthetic is injected into the venous system. This makes the arm numb from the tourniquet down to the hand. A third option is to inject local anesthetic directly into the fracture site. This is called a hematoma block.
These techniques eliminate all painful sensation from the fracture and allow the doctor to manipulate the fracture fragments into an improved position. Once that has been done the wrist is splinted to allow the swelling to go down, and later a cast is applied, or a cast applied right away. An immediate x-ray is taken to make sure that the fracture position is now acceptable. Some surgeons prefer to include the elbow in the cast after closed reduction. This eliminates rotation of the forearm and may reduce the likelihood that the fracture position will move, or displace.
Although the position of the fracture fragments is improved by this technique, there is no certainty that the position will be maintained all the way through the healing period. The muscles that move the wrist and fingers all cross the fracture site. As they contract they put a compressive force on the fracture. In unstable fractures, some settling of the fracture may occur. This may result in recurrence of deformity at the fracture site and may require more aggressive treatment.
Closed Reduction & Pinning
When more control of the fracture fragments is necessary, some type of surgical intervention is usually necessary. One minimally invasive option is to perform a closed reduction and pinning of the fracture. This procedure is suggested when the fracture is considered unstable, but the fragments can be manipulated into an acceptable position. The fragments are stabilized by driving smooth sterile stainless steel pins through the skin and across the fracture. The ends of the pins are cut outside the skin and bent to prevent them migrating any deeper.
This procedure is performed in the operating room using a special x-ray machine called a fluoroscope. This machine projects an x-ray image on a TV screen and allows the surgeon to see the fracture fragments as the pins are being inserted. The procedure requires some type of anesthesia, either a general anesthetic or a regional block.
The wrist is dressed and a cast applied. Once the fracture has healed and is stable the pins are removed. Because they are smooth they come out easily and an anesthetic is not required for this procedure. Smooth pins may hold the fracture fragments in the correct relationship but they may not prevent the fracture from impacting further if the bone is crushed or very fragile.
Closed Reduction & External Fixation
Another method of stabilizing the unstable fracture is the external fixator. After the fracture is manipulated into a better position, special threaded pins are drilled into the bone above and below the fracture. These pins are connected by a system of rods. This procedure also requires a fluoroscope and some type of anesthesia, either a general anesthetic or a regional block.
The apparatus allows the surgeon to distract the fracture, keeping tension on it so that it is less likely to shorten and collapse. It also holds the fracture immobile so a cast is not needed. The apparatus is maintained until fracture healing has advanced and the fracture is stable. The frame and the pins are then removed. Usually there is minimal discomfort and this can be done without anesthesia.
This apparatus may not be successful in maintaining the reduction of the fracture due to the action of the muscles alluded to above. The apparatus itself may be uncomfortable for the patient and the pins may cause problems with the tendons if they transfix them. Pin track infections can also be a problem.
Open Reduction & Internal Fixation
This technique has gained popularity and is the preferred method of treatment of unstable distal radius fractures for many surgeons. The bone is exposed by an incision on the front or back of the wrist depending on the exact anatomy of the injury. The fracture fragments are reduced into anatomical position and held there with a metal plate.
Sometimes additional bone (bone graft) is also inserted into the fracture to make it stronger and speed up healing. The advantage of this technique is that the bone fragments can be put back in position more easily under direct visual control and the fixation is stronger. It is not always necessary to remove the fixation (implant) after healing.
Casting is not needed after the surgery although the wrist may be splinted for comfort. It is usually possible to move the wrist early on and this is encouraged to help prevent stiffness. This option has been suggested for patients with a light job who need to return to work as early as possible.
The main disadvantages of ORIF are the greater exposure of the fracture, leading to concerns about infection and loss of blood supply and the longer more elaborate surgery which may stress the patient more. Many of the other methods of treatment also require anesthesia. With modern techniques of anesthesia it may be that the difference between regional anesthesia for closed reduction and anesthesia for open reduction, are not important.
Surgeons are reluctant to operate on elderly patients with multiple medical problems and this is probably the main reason for the continued popularity of nonsurgical methods of treatment. Many surgeons are not certain that there is convincing evidence that open reduction and internal fixation makes a major difference to the long term function of elderly patients who have low demand. Despite the commoness of the problem it is difficult to study these issues and settle them once for all.