Wrist Fractures - FisiokinesiterapiaWrist Fractures: Scaphoid Fate of Nonunions: Mack 1984 20 – 30...

Wrist FracturesWrist Fractures

Wrist Defined:Wrist Defined:Carpal Bones Carpal Bones Distal RadiusDistal RadiusDistal UlnaDistal Ulna

Wrist Joints:Wrist Joints:CMC CMC IntercarpalIntercarpalRadiocarpalRadiocarpalDRUJDRUJ

““drudgedrudge””

Wrist Fractures:Wrist Fractures:(that we are going to discuss)(that we are going to discuss)

ScaphoidScaphoidDistal RadiusDistal RadiusDistal UlnaDistal Ulna

Wrist Fractures: ScaphoidWrist Fractures: Scaphoid

Scaphoid FxScaphoid Fx

Fate of Nonunions:Fate of Nonunions:Mack 1984Mack 1984

20 20 –– 30 Years: Pan Carpal Arthritis30 Years: Pan Carpal ArthritisRuby 1985Ruby 1985

97% DJD If Nonunion > 5 Years97% DJD If Nonunion > 5 YearsDuppe 1994Duppe 1994

ArthritisArthritis SymptomaticSymptomaticUnitedUnited 1/471/47 3/473/47UnunitedUnunited 4/94/9 5/95/9

Suspect Scaphoid FxSuspect Scaphoid Fx’’s !!!s !!!

Hx : Fall on Outstretched HandHx : Fall on Outstretched Hand

Pain : Pain : ““anatomic snuffboxanatomic snuffbox””

Pain : Pain : ““with scaphoid compressionwith scaphoid compression””

Xray : NormalXray : Normal

Over treat : Short Arm Thumb SpicaOver treat : Short Arm Thumb Spica

Re Xray : Two Weeks Re Xray : Two Weeks (AP, Lat, Scaphoid Oblique)(AP, Lat, Scaphoid Oblique)

““I gotta know and money is no objectI gotta know and money is no object””

MR Scan will be positive within hoursMR Scan will be positive within hoursBone Scan will be positive within days Bone Scan will be positive within days

Scaphoid Fx : Scaphoid Fx : Fx line visible, No displacementFx line visible, No displacement

Rx: long vs short arm thumb spicaRx: long vs short arm thumb spica

Scaphoid Fx : Scaphoid Fx : Fx line visible & Fx displacedFx line visible & Fx displaced

Rx: Consider ORIFRx: Consider ORIF

Need for fixation is relative to Fx locationNeed for fixation is relative to Fx location

112233

1. Tubercle Fx1. Tubercle FxRx: SplintRx: Splint

2. Waist Fx2. Waist FxRx: >1mm DisplacedRx: >1mm Displaced

ORIFORIF3. Proximal Pole3. Proximal Pole

Rx: You see it Rx: You see it You fix itYou fix it

Wrist Fractures: ScaphoidWrist Fractures: ScaphoidWrist Fractures: Scaphoid

36 weeks36 weeks

Another 12Another 12--16 weeks?16 weeks?

2 weeks in splint2 weeks in splint10% motion loss, no strength loss10% motion loss, no strength loss

6 wks post6 wks post

Non union: A Simple Non union: A Simple Problem Made DifficultProblem Made Difficult

Bone GraftBone GraftTechnically demandingTechnically demanding

Bone GraftBone Graft

1 year of wrist protection1 year of wrist protection1 year limited use1 year limited use30% motion loss30% motion loss30% strength loss30% strength loss

Conclusions: Conclusions: In most casesIn most cases

Non Op Rx is truly radicalNon Op Rx is truly radical& & Op Rx is conservativeOp Rx is conservative

Refer Early !Refer Early !

Wrist Fractures: Distal Radius Wrist Fractures: Distal Radius

““after a period timeafter a period time…….all do well.all do well””

Abraham Colles Abraham Colles

Wrist Fractures: Distal Radius Wrist Fractures: Distal Radius

““after a period timeafter a period time…….all do well.all do well””

Abraham Colles Abraham Colles

Wrist Fractures: Distal RadiusWrist Fractures: Distal Radius

Distal radius fxDistal radius fx’’s differ in:s differ in:

Mechanism of injuryMechanism of injuryEnergy of injuryEnergy of injuryArticular involvementArticular involvementAssociated InjuriesAssociated Injuries

Simple BendingSimple Bending

Compression:Compression:Most CommonMost CommonLow & high EnergyLow & high Energy

Shearing:Shearing:

Inherently UnstableInherently Unstable

Fx Dislocation:Fx Dislocation:

Deceptively Deceptively SimpleSimple

Combined Complex:Combined Complex:

High EnergyHigh EnergyComminuted Comminuted OpenOpen

Treatment GoalsTreatment Goals

““Begin with the end in mind!Begin with the end in mind!””David CoveyDavid Covey

Treatment GoalsTreatment Goals

Radial inclRadial incl > 5> 5°°Tilt Tilt neutral +neutral +LengthLength neutralneutralGaps Gaps < 2 mm < 2 mm Step off Step off < 2 mm < 2 mm Stable Stable DRUJDRUJ

Treatment Based On: Treatment Based On: DemandDemand

Low Demand: Minimal TreatmentLow Demand: Minimal TreatmentHigh Demand: CRPP vs ORIFHigh Demand: CRPP vs ORIF

Treatment Based On: Treatment Based On: Three Xray ParametersThree Xray Parameters

Metaphyseal StabilityMetaphyseal StabilityArticular Step Off / GapsArticular Step Off / GapsDRUJ Stability DRUJ Stability (after radius fixation)(after radius fixation)

Wrist Fractures: Distal RadiusWrist Fractures: Distal RadiusWhat is stable?What is stable?

1. Easily Reduced1. Easily Reduced2. Transverse Fx Pattern2. Transverse Fx Pattern3. Minimal 3. Minimal

Dorsal ComminutionDorsal Comminution4. No Articular Step Off4. No Articular Step Off5. Maintains Reduction: 5. Maintains Reduction:

> 3 Weeks> 3 Weeks

What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce

Wrist Fractures: Distal RadiusWrist Fractures: Distal RadiusWhat is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction

What is Unstable?What is Unstable?1. Can1. Can’’t Reducet Reduce2. Lose Reduction 2. Lose Reduction 3. Comminution 3. Comminution

> > 1/3 AP Diameter1/3 AP Diameter

> > 1/3 AP Diameter1/3 AP Diameter4. >20 Degrees Dorsal Tilt4. >20 Degrees Dorsal Tilt

(prior to reduction)(prior to reduction)

> > 1/3 AP Diameter1/3 AP Diameter4. >20 Degrees Dorsal Tilt4. >20 Degrees Dorsal Tilt5. Volar Obliquity5. Volar Obliquity

What is Displaced?What is Displaced?> 2mm Measurable > 2mm Measurable

Articular Step OffArticular Step Off

Treatment?Treatment?

All stable fxAll stable fx’’s can be treated in cast / splintss can be treated in cast / splintsAll unstable fxAll unstable fx’’s require interventionss require interventions

Closed reduction Closed reduction ±± Percut Pins Percut Pins ±± Ex Fx Ex Fx

±± Open Reduction Open Reduction ±± Plates Plates ±± Bone GraftBone Graft

Closed Reduction:Closed Reduction:Longitudinal TxnLongitudinal TxnPalmar TranslationPalmar TranslationPronation HandPronation Hand

relative to Forearmrelative to ForearmUlnar TiltUlnar TiltNO Wrist Flexion!!!!NO Wrist Flexion!!!!

modified from John Agee M.D.modified from John Agee M.D.

Longitudinal TxnLongitudinal Txn

Palmar TranslationPalmar TranslationPronation Hand Relative to ForearmPronation Hand Relative to ForearmUlnar TiltUlnar Tilt

Treatment?Treatment?

All stable fxAll stable fx’’s can be treated in cast / splintss can be treated in cast / splintsAll unstable fxAll unstable fx’’s require interventionss require interventions

Closed reduction Closed reduction ±± Percut Pins Percut Pins ±± Ex Fx Ex Fx

±± Open Reduction Open Reduction ±± Plates Plates ±± Bone GraftBone Graft

Treatment ?Treatment ?

TreatmentTreatment

Treatment Treatment

Treatment ?Treatment ?

Treatment Treatment

Wrist Fractures: DRUJWrist Fractures: DRUJ

Treatment of Unstable DRUJ:Treatment of Unstable DRUJ:Address Radius FirstAddress Radius First

Then Assess DRUJThen Assess DRUJFix if Necessary Fix if Necessary

Caveats:Caveats:1. R/O Carpal Tunnel Syndrome1. R/O Carpal Tunnel Syndrome2. Excessive Pain = RSD2. Excessive Pain = RSD3. Most Common Cause of RSD3. Most Common Cause of RSD

Undiagnosed CTS & A Flexed WristUndiagnosed CTS & A Flexed Wrist

Caveats: Post Injury CareCaveats: Post Injury Care1. Keep those fingers moving1. Keep those fingers moving

Full extension to full flexion Full extension to full flexion 2. Keep the hand elevated above heart until2. Keep the hand elevated above heart until

swelling subsidesswelling subsides3. If you immobilize above the elbow do so 3. If you immobilize above the elbow do so

with the forearm in supinationwith the forearm in supination

Caveats: Post Injury CareCaveats: Post Injury Care

If you canIf you can’’t do the above with a cast then t do the above with a cast then your patient is best served with Fx fixation.your patient is best served with Fx fixation.

Caveats: Post Injury ExpectationsCaveats: Post Injury Expectations

Following the above guidelinesFollowing the above guidelinesDRUJ pain DRUJ pain ≈≈ 8 mo8 mo’’ssMaximum Improvement Maximum Improvement ≈≈ 18 mo18 mo’’ss

ROM ROM 80%80%Grip Grip 80%80%

Thank YouThank You

Wrist Fractures - FisiokinesiterapiaWrist Fractures: Scaphoid Fate of Nonunions: Mack 1984 20 – 30...

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