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Arturo Villarreal M.D., Board Certified Orthopaedic Surgeon, Georgetown, Cedar Park, Round Rock, TX / Services / Hand & Wrist / Conditions / Fractures of the Hand and Fingers / Wrist Fracture

What is the distal radius?

The radius is one of the bones of the forearm. It extends from the elbow to the wrist. The distal end refers to the portion of the bone closest to the wrist. The radius is involved with the motions of the elbow, including flexion and extension. It is also involved wrist flexion, extension, radial and ulnar deviation as well as forearm rotation (supination and pronation).

Wrist Fracture

Figure 1. Bone of the upper extremity with the arrow pointing to radius. (Licensed from Adobe stock)

How is the distal radius injured?

The radius is commonly injured during a fall onto an outstretched hand. Other common causes include car accidents or injuries during sporting activities.

Wrist Fracture

Figure 2. Image demonstrating fall on to hand resulting in a distal radius fracture. Other fracture types also demonstrated. (Licensed from Adobe stock)

What are the symptoms of distal radius fractures?

The most common symptoms of distal radius fractures are pain and swelling at the wrist. Pain is typically worsened with wrist motion. There can also be an obvious deformity of the wrist if the fracture is very displaced.

How is a distal radius fracture diagnosed?

During the clinic visit x-rays will be obtained. This is typically sufficient for diagnosis. In some cases advanced imaging such as MRI or CT scan may be needed for determining more subtle injuries, ruling out related injuries or for surgical planning purposes.

Wrist Fracture

Figure 3. X-rays demonstrated a wrist without fracture on the top row and x-rays showing a fracture on the bottom row.

What are the treatment options for distal radius fractures?

Treatment options are always individually tailored. Considerations include age, activity level, type of activity, how recent the injury occurred, partial versus complete tear, prior treatment, and associated injuries.

The x-rays will be used to evaluate several measurements. One of the more important measurements is the dorsal tilt. See figure for an example of measurements. Certain fracture types also tend to be more unstable and have better outcomes with surgical fixation.

For non surgical treatment of distal radius fractures splint and/or cast immobilization is utilized for 4-8 weeks. Immobilization may include either short or long arm splints/casts. The type and duration of immobilization with depend on patient age, activity, level and fracture instability.

Surgical treatment typically involves the placement of a plate and screws on the radius. This will typically hold the fracture stable to allow for early range of motion. After fixation of the wrist, range of motion is typically started within 7-14 days. This allows for earlier return to full range of motion and independence. In cases where other injuries are present or in very unstable fracture patterns a fixation method known as bridge plating may be used. This involves placing a plate across the wrist with screws in the hand (metacarpal) and forearm (radius). Due to the nature of the plating method, early range of motion is not performed. This also requires a second surgery for plate removal to allow for range of motion of the wrist.

How is distal radius fixation performed?

The surgery is performed under a general anesthetic typically with the use of a regional nerve block.

Wrist Fracture

Figure 4. A roughly 6-8 centimeter incision is made over the wrist where the purple line is shown above.

Wrist Fracture

Figure 5. The fracture is then identified, reduced, and the plate is placed in an appropriate position. (credit: Arthrex.com)

Wrist Fracture

Figure 6. Once reduction is achieved, screws are then placed to hold the fracture in place. (credit: Arthrex.com)

Wrist Fracture

Figure 7. Example of an x-ray in the top left showing the screws in place. (credit: Arthrex.com)

Timing of distal radius surgery

Surgery is ideally performed within 2-3 weeks from the time of injury. Although surgery can be performed after this time period it may require additional procedures such as osteotomy (re-breaking the bone) in order to properly reduce the fracture.

Outcomes of distal radius surgery

Outcomes following distal radius surgery are generally good. Grip strength has been found in studies to return to ~70-100% of the uninjured side. Patient reported outcome measures typically show the greatest improvement in the first 3-6 months following surgery with additional, progressive, improvement extending to 1 year and beyond.

Wrist Fracture

Figure 8. Table summarizing outcomes from "Comparison of 24-Month Outcomes After Treatmetn for Distal Radius Fracture The WRIST Randomzed Clinical Trial" JAMA Network Open. 2021;4(6):e2112710. (VLPS- Volar locking plate system)

Return to sport after distal radius surgery

There are currently no generally accepted guidelines on return to sport. In general, return to sport will be determined based on the specific sport, position, and activity level. You should typically have achieved a pain free range of motion with xray evidence of fracture healing prior to return.

What are the possible complications after distal radius surgery?

Complication rates after surgical fixation have been reported around 5-30%.

Infection

Infection is an uncommon complication after this type of surgery. Rates are typically below 3% for any type of infection with rates of deep infection being less than 1%. Smoking can increase infection risk. Prevention at the time of surgery includes the surgical sterilization of the skin and using the use of antibiotics at the time of surgery. Presentation of infections could include fever, chills, increased pain and swelling at the surgical site, redness, warmth and drainage. Management often includes antibiotics and possibly surgical irrigation and debridement.

Nerve Injury

Major nerve injury is uncommon. Carpal tunnel syndrome can be associated with the trauma of the fracture itself. In some cases a carpal tunnel release may be performed at the time of fracture fixation. Peri-incisional numbness can also occur. This can result in an area of decreased sensation and can occur in <10% of cases. This typically resolves with observation.

Vascular Injury

Injury to the radial artery has been reported but is extremely rare. Injury to this artery may require a vascular repair.

Tendon injury

Irritation and rupture of both flexor and extensor tendons at the wrist can occur. Although irritation may occur in up to 5% of patients, rupture is typically seen in <1% of cases. If irritation is persistent this may require removal of hardware that is irritating the tendon. In cases of rupture this may require tendon repair or tendon transfer.

Malunion and nonunion

Malunion is when the bone heals in the incorrect position. Nonunion is when the bone does not heal at all. Both appear to occur at rates < 4%. Treatment of malunions may not always be required beyond normal recovery as some patients remain asymptomatic. If symptoms persist, treatment may include revision surgery to correct bony alignment. In the case of nonunion, treatment may include treatment of underlying causes for the nonunion, including smoking cessation, correction of vitamin D levels, use of a bone stimulator or possible revision surgery.

Other reported complications

Other reported complications include wrist stiffness, radius fracture, complex regional pain syndrome and compartment syndrome.

This is not an exhaustive list of all complications. Other complications, although uncommon, can still occur.

Wrist Fracture

Figure 9. Table summarizing outcomes from "Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A review of 417 Patients From a Level 1 Trauma Center" Hand 2020, Vol.15(5) 686-691.

Pain management after surgery

Medications including narcotic pain medications and anti inflammatories may be prescribed after surgery to help reduce pain. Nerve blocks at the time of surgery have been shown to be affective at reducing pain with low risk of long term deficits.

Do I need to use a brace after my distal radius fracture surgery?

Most patients will be placed in a short arm splint immediately following surgery. Patients will then be transitioned to a removable wrist brace between 1-2 weeks after surgery. This can then be removed as tolerated to begin range of motion. Less commonly a long arm splint may be utilized after surgery. In these cases, transition to a brace will be dependent on the stability of the fracture.

When can I return to work after surgery?

Return to work will largely depend on your specific occupational requirements. Many patients are no longer requiring the use of pain medications during the day by the third to fifth day after surgery. If your work is sedentary, you may be able to return as soon as this time. Work that involves heavy lifting may require longer periods away from work if light duty is not available.

When can I drive after surgery?

There is no definitive test we can do to determine when a patient is safe to return to driving. You should not be taking narcotic or sedating medications prior to driving. You should also not need the use of a sling. Studies looking at return to driving after distal radius surgery typically report a timeline from 1-6 weeks, largely dependent on pain control. In general, a patient should possess the strength and range of motion to utilize the vehicles steering wheel in all situations prior to driving.

Post operative Instructions

  • Following your stay in the recovery room and when your vital signs are stable you will be discharged to your escort.
  • Remember, it is normal to feel a little dizzy or drowsy for several hours after surgery. This is due to the action the medicine used during surgery.
  • If you do not have a post operative appointment scheduled, please call the office as soon as possible to schedule this appointment.
  • Take your pain medicine as directed. Begin the pain medicine before you start getting uncomfortable, as the nerve block will wear off. If you wait to take your pain medication until the pain is severe, you will have more difficulty in controlling the pain.
  • If you are taking narcotic pain medication you may need a stool softener to prevent constipation. Over-the-counter medication such as Docusate or Milk of Magnesia is recommended.
  • Notify the office of any fever, chills, or temperature > 100.5.
  • Notify the office of any wound drainage.

Post-Surgery Diet

Resume your diet as tolerated and include vegetables, fruits, and proteins (such as meats, fish, chicken, nuts, and eggs) to promote healing. Also, remember to have adequate fluid intake. It is common after surgery to lack an appetite. This may be the result of anesthesia and the medications. Proper nutrition is needed for healing. During the healing process, the body needs increased amounts of calories and protein. Eat a variety of foods to get all the calories, proteins, vitamins, and minerals you need. If you have been told to follow a specific diet, please follow it.

How should I manage my surgical site and bandages?

You will be in a splint after surgery. You should keep this clean and dry until your follow up. Cast covers can be purchased online to aid in keeping the splint dry during showers.

What is my activity level after surgery?

You will use a sling for comfort. It is okay to remove the sling as tolerated and move the elbow. You should not be lifting with the elbow. You are also encouraged to move your fingers as tolerated. Elevation of the hand will aid with swelling.

Can I smoke following surgery?

You should not smoke after surgery as it interferes with healing.

Questions or Concerns

If at anytime you have questions or concerns you can either contact your surgeon’s medical assistant via email or you can call the main office numbers at: 855-624-3306. You can also use the electronic medical record’s online portal to send questions.

Example rehabilitation protocol:

Post-OP Week 0-2: Begin:
Goals: 1. Minimize swelling and pain
2. Begin forearm supination and pronation
3. Full elbow and shoulder range of motion
Exercises: 1. AROM Elbow as above 5-6 times per day
2. AROM Shoulder
3. AROM fingers
Weeks 2-6: Begin:
Goals: 1. Improve wrist range of motion to 50% of contralateral side by 6 weeks
Exercises: 1. Week 2: ACTIVE Wrist flexion extension, full hand ROM, active supination/pronation
2. Week 2: begin Putty for grip strength, pulley ROM exercises
3. Week 2: ACTIVE Elbow extension to full, begin supine scapular stabilizations (no weight), door ABCs or Circles with ball
4. Week 2: Initiate submaximal progressive strengthening, such as towel and putty squeezing and light-load gripping exercises
5. Week 2: Clinicians may perform a combination of edema control techniques, including MLD and other manual edema mobilization, exercises, elevation, compression gloves, low-stretch bandaging, and/or iHEP instruction, to induce short-term (2-6 weeks) benefits on hand swelling, AROM, function, and pain following nonoperative and operative DRF management.
6. Week 2: Clinicians should integrate GMI as part of a multimodal management strategy to improve short-term outcomes in pain, AROM, and patient-reported function during the early rehabilitation stage (6-8 weeks) for individuals following nonoperative and operative treatment for DRF.
Weeks 7+: Begin:
Goals: 1. Normalize wrist strength and range of motion
Exercises: 1. Continue strengthening exercises to wrist, forearm, and possibly shoulder, depending on sport and/or work requirements

References:

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