Wrist Fractures

1
Wrist Fractures
Doug Hanel M.D. Department Of Orthopaedics
Harborview Medical Center Childrens Hospital
and Regional Medical CenterUniversity Of
Washington

2
Wrist Fractures

• Wrist DefinedCarpal Bones Distal RadiusDistal
  Ulna

3
Wrist Fractures

• Wrist JointsCMC IntercarpalRadiocarpalDRUJ
  drudge

4
Wrist Fractures

• Wrist Fractures(that we are going to
  discuss)ScaphoidDistal RadiusDistal Ulna

5
Wrist Fractures Scaphoid
Scaphoid Fx

6
Wrist Fractures Scaphoid
Fate of NonunionsMack 1984 20 30 Years Pan
Carpal Arthritis Ruby 1985 97 DJD If Nonunion gt
5 Years Duppe 1994 Arthritis Symptomatic Uni
ted 1/47 3/47 Ununited 4/9 5/9

7
Wrist Fractures Scaphoid
1

3
2
8
Wrist Fractures Scaphoid

4
5
9
Wrist Fractures Scaphoid
Suspect Scaphoid Fxs !!! Hx Fall on
Outstretched Hand Pain anatomic snuffbox Pain
with scaphoid compression Xray Normal

10
Wrist Fractures Scaphoid
Suspect Scaphoid Fxs !!! Over treat Short Arm
Thumb Spica Re Xray Two Weeks (AP, Lat,
Scaphoid Oblique)

11
Wrist Fractures Scaphoid
Suspect Scaphoid Fxs !!! I gotta know and money
is no object MR Scan will be positive within
hoursBone Scan will be positive within days

12
Wrist Fractures Scaphoid
Scaphoid Fx Fx line visible, No
displacement Rx long vs short arm thumb spica

13
Wrist Fractures Scaphoid
Scaphoid Fx Fx line visible Fx
displaced Rx Consider ORIF Need for fixation
is relative to Fx location

14
Wrist Fractures Scaphoid

15
Wrist Fractures Scaphoid
1

2
1
2
3
3
16
Wrist Fractures Scaphoid
1. Tubercle Fx Rx Splint 2. Waist Fx Rx gt1mm
Displaced ORIF 3. Proximal Pole Rx You see it
You fix it

1
2
3
17
Wrist Fractures Scaphoid
36 weeks

18
Wrist Fractures Scaphoid

Another 12-16 weeks?
19
Wrist Fractures Scaphoid
2 weeks in splint10 motion loss, no strength
loss

6 wks post
20
Wrist Fractures Scaphoid
Non union A Simple Problem Made Difficult

21
Wrist Fractures Scaphoid
Bone GraftTechnically demanding

22
Wrist Fractures Scaphoid
Bone Graft1 year of wrist protection1 year
limited use30 motion loss30 strength loss

23
Wrist Fractures Scaphoid
Conclusions In most cases Non Op Rx is truly
radical Op Rx is conservative

24
Wrist Fractures Scaphoid

Refer Early !

25
Wrist Fractures Distal Radius
after a period time .all do well Abraham
Colles

26
Wrist Fractures Distal Radius
after a period time .all do well Abraham
Colles

27
Wrist Fractures Distal Radius
Distal radius fxs differ in Mechanism of
injury Energy of injury Articular
involvement Associated Injuries

28
Wrist Fractures Distal Radius
Simple Bending

29
Wrist Fractures Distal Radius
Compression Most Common Low high Energy

30
Wrist Fractures Distal Radius
Shearing Inherently Unstable

31
Wrist Fractures Distal Radius
Fx Dislocation Deceptively Simple

32
Wrist Fractures Distal Radius
Combined Complex High Energy Comminuted Open

33
Wrist Fractures Distal Radius
Treatment Goals Begin with the end in
mind! David Covey

34
Wrist Fractures Distal Radius
Treatment GoalsRadial incl gt 5 Tilt
neutral Length neutral Gaps lt 2 mm Step
off lt 2 mm Stable DRUJ

35
Wrist Fractures Distal Radius
Treatment Based On Demand Low Demand Minimal
Treatment High Demand CRPP vs ORIF

36
Wrist Fractures Distal Radius
Treatment Based On Three Xray
Parameters Metaphyseal Stability Articular
Step Off / Gaps DRUJ Stability (after radius
fixation)

37
Wrist Fractures Distal Radius
What is stable? 1. Easily Reduced 2. Transverse
Fx Pattern 3. Minimal Dorsal Comminution 4. No
Articular Step Off 5. Maintains Reduction gt 3
Weeks

38
Wrist Fractures Distal Radius
What is Unstable? 1. Cant Reduce

39
Wrist Fractures Distal Radius
What is Unstable? 1. Cant Reduce 2. Lose
Reduction

40
Wrist Fractures Distal Radius
What is Unstable? 1. Cant Reduce 2. Lose
Reduction 3. Comminution gt 1/3 AP Diameter

41
Wrist Fractures Distal Radius
What is Unstable? 1. Cant Reduce 2. Lose
Reduction 3. Comminution gt 1/3 AP Diameter 4.
gt20 Degrees Dorsal Tilt (prior to reduction)

42
Wrist Fractures Distal Radius
What is Unstable? 1. Cant Reduce 2. Lose
Reduction 3. Comminution gt 1/3 AP Diameter 4.
gt20 Degrees Dorsal Tilt 5. Volar Obliquity

43
Wrist Fractures Distal Radius
What is Displaced? gt 2mm Measurable Articular
Step Off

44
Wrist Fractures Distal Radius
Treatment? All stable fxs can be treated in
cast / splints All unstable fxs require
interventions Closed reduction Percut Pins
Ex Fx Open Reduction Plates
Bone Graft

45
Wrist Fractures Distal Radius
Closed ReductionLongitudinal Txn Palmar
Translation Pronation Hand relative to
Forearm Ulnar Tilt NO Wrist Flexion!!!!

modified from John Agee M.D.
46
Wrist Fractures Distal Radius
Longitudinal Txn

47
Wrist Fractures Distal Radius
Palmar Translation Pronation Hand Relative to
Forearm Ulnar Tilt

48
Wrist Fractures Distal Radius
Treatment? All stable fxs can be treated in
cast / splints All unstable fxs require
interventions Closed reduction Percut Pins
Ex Fx Open Reduction Plates
Bone Graft

49
Wrist Fractures Distal Radius
Treatment ?

50
Wrist Fractures Distal Radius
Treatment

51
Wrist Fractures Distal Radius
Treatment

52
Wrist Fractures Distal Radius
Treatment

53
Wrist Fractures Distal Radius
Treatment ?

54
Wrist Fractures Distal Radius
Treatment

55
Wrist Fractures DRUJ

56
Wrist Fractures DRUJ
Treatment of Unstable DRUJ Address Radius
First Then Assess DRUJ Fix if Necessary

57
Wrist Fractures
Caveats 1. R/O Carpal Tunnel Syndrome 2.
Excessive Pain RSD3. Most Common Cause of
RSD Undiagnosed CTS A Flexed Wrist

58
Wrist Fractures
Caveats Post Injury Care 1. Keep those fingers
moving Full extension to full flexion 2. Keep
the hand elevated above heart until swelling
subsides 3. If you immobilize above the elbow do
so with the forearm in supination

59
Wrist Fractures
Caveats Post Injury Care If you cant do the
above with a cast then your patient is best
served with Fx fixation.

60
Wrist Fractures
Caveats Post Injury Expectations Following the
above guidelines DRUJ pain 8 mos Maximum
Improvement 18 mos ROM 80 Grip 80

61
Wrist Fractures
Thank You