Wrist Fractures
Wrist Fractures Wrist Defined: Carpal Bones Distal Radius Distal Ulna
Wrist Fractures Wrist Joints: CMC Intercarpal Radiocarpal DRUJ drudge
Wrist Fractures Wrist Fractures: (that we are going to discuss) Scaphoid Distal Radius Distal Ulna
Wrist Fractures: Scaphoid Scaphoid Fx
Wrist Fractures: Scaphoid Fate of Nonunions: Mack 1984 20 30 Years: Pan Carpal Arthritis Ruby 1985 97% DJD If Nonunion > 5 Years Duppe 1994 Arthritis Symptomatic United 1/47 3/47 Ununited 4/9 5/9
Wrist Fractures: Scaphoid 1 3 2
Wrist Fractures: Scaphoid 4 5
Wrist Fractures: Scaphoid Suspect Scaphoid Fx s s!!! Hx : Fall on Outstretched Hand Pain : anatomic snuffbox Pain : with scaphoid compression Xray : Normal
Wrist Fractures: Scaphoid Suspect Scaphoid Fx s s!!! Over treat : Short Arm Thumb Spica Re Xray : Two Weeks (AP, Lat, Scaphoid Oblique)
Wrist Fractures: Scaphoid Suspect Scaphoid Fx s s!!! I I gotta know and money is no object MR Scan will be positive within hours Bone Scan will be positive within days
Wrist Fractures: Scaphoid Scaphoid Fx : Fx line visible, No displacement Rx: long vs short arm thumb spica
Wrist Fractures: Scaphoid Scaphoid Fx : Fx line visible & Fx displaced Rx: Consider ORIF Need for fixation is relative to Fx location
Wrist Fractures: Scaphoid
Wrist Fractures: Scaphoid 1 1 2 3 2 3
Wrist Fractures: Scaphoid 1. Tubercle Fx Rx: Splint 2. Waist Fx 1 Rx: >1mm Displaced ORIF 3 2 3. Proximal Pole Rx: You see it You fix it
Wrist Fractures: Scaphoid 36 weeks
Wrist Fractures: Scaphoid Another 12-16 16 weeks?
Wrist Fractures: Scaphoid 2 weeks in splint 10% motion loss, no strength loss 6 wks post
Wrist Fractures: Scaphoid Non union: A Simple Problem Made Difficult
Wrist Fractures: Scaphoid Bone Graft Technically demanding
Wrist Fractures: Scaphoid Bone Graft 1 year of wrist protection 1 year limited use 30% motion loss 30% strength loss
Wrist Fractures: Scaphoid Conclusions: In most cases Non Op Rx is truly radical & Op Rx is conservative
Wrist Fractures: Scaphoid Refer Early!
Wrist Fractures: Distal Radius after a period time.all do well Abraham Colles
Wrist Fractures: Distal Radius after a period time.all do well Abraham Colles
Wrist Fractures: Distal Radius Distal radius fx s s differ in: Mechanism of injury Energy of injury Articular involvement Associated Injuries
Wrist Fractures: Distal Radius Simple Bending
Wrist Fractures: Distal Radius Compression: Most Common Low & high Energy
Wrist Fractures: Distal Radius Shearing: Inherently Unstable
Wrist Fractures: Distal Radius Fx Dislocation: Deceptively Simple
Wrist Fractures: Distal Radius Combined Complex: High Energy Comminuted Open
Wrist Fractures: Distal Radius Treatment Goals Begin with the end in mind! David Covey
Wrist Fractures: Distal Radius Treatment Goals Radial incl > 5 5 Tilt neutral + Length neutral Gaps < 2 mm Step off < 2 mm Stable DRUJ
Wrist Fractures: Distal Radius Treatment Based On: Demand Low Demand: Minimal Treatment High Demand: CRPP vs ORIF
Wrist Fractures: Distal Radius Treatment Based On: Three Xray Parameters Metaphyseal Stability Articular Step Off / Gaps DRUJ Stability (after radius fixation)
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: > 3 Weeks
Wrist Fractures: Distal Radius What is Unstable? 1. Can t t Reduce
Wrist Fractures: Distal Radius What is Unstable? 1. Can t t Reduce 2. Lose Reduction
Wrist Fractures: Distal Radius What is Unstable? 1. Can t t Reduce 2. Lose Reduction 3. Comminution > 1/3 AP Diameter
Wrist Fractures: Distal Radius What is Unstable? 1. Can t t Reduce 2. Lose Reduction 3. Comminution > 1/3 AP Diameter 4. >20 Degrees Dorsal Tilt (prior to reduction)
Wrist Fractures: Distal Radius What is Unstable? 1. Can t t Reduce 2. Lose Reduction 3. Comminution > 1/3 AP Diameter 4. >20 Degrees Dorsal Tilt 5. Volar Obliquity
Wrist Fractures: Distal Radius What is Displaced? > 2mm Measurable Articular Step Off
Wrist Fractures: Distal Radius Treatment? All stable fx s s can be treated in cast / splints All unstable fx s s require interventions Closed reduction ± Percut Pins ± Ex Fx ± Open Reduction ± Plates ± Bone Graft
Wrist Fractures: Distal Radius Closed Reduction: Longitudinal Txn Palmar Translation Pronation Hand relative to Forearm Ulnar Tilt NO Wrist Flexion!!!! modified from John Agee M.D.
Wrist Fractures: Distal Radius Longitudinal Txn
Wrist Fractures: Distal Radius Palmar Translation Pronation Hand Relative to Forearm Ulnar Tilt
Wrist Fractures: Distal Radius Treatment? All stable fx s s can be treated in cast / splints All unstable fx s s require interventions Closed reduction ± Percut Pins ± Ex Fx ± Open Reduction ± Plates ± Bone Graft
Wrist Fractures: Distal Radius Treatment?
Wrist Fractures: Distal Radius Treatment
Wrist Fractures: Distal Radius Treatment
Wrist Fractures: Distal Radius Treatment
Wrist Fractures: Distal Radius Treatment?
Wrist Fractures: Distal Radius Treatment
Wrist Fractures: DRUJ
Wrist Fractures: DRUJ Treatment of Unstable DRUJ: Address Radius First Then Assess DRUJ Fix if Necessary
Wrist Fractures Caveats: 1. R/O Carpal Tunnel Syndrome 2. Excessive Pain = RSD 3. Most Common Cause of RSD Undiagnosed CTS & A Flexed Wrist
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
Wrist Fractures Caveats: Post Injury Care If you can t t do the above with a cast then your patient is best served with Fx fixation.
Wrist Fractures Caveats: Post Injury Expectations Following the above guidelines DRUJ pain 8 mo s Maximum Improvement 18 mo s ROM 80% Grip 80%
Wrist Fractures Thank You