Distal Radial Fracture

There are 2 bones in the forearm; the radius and the ulna. The radius is the one on the thumb side. The wrist end of the bone is called the distal end and is one of the most common sites for a fracture. It typically occurs after a fall onto an out stretched hand. It can also happen in a road traffic accident, skiing or other sports. It is often referred to as a Colles fracture after an Irish surgeon and anatomist, Abraham Colles, in 1814 who first described the injury. There are two age groups who suffer a distal radial fracture; those that occur in elderly patients with thin, osteoporotic bone who fall from a standing height and those that occur in young patients after a high energy injury.

A broken wrist will be immediately painful with bruising, swelling and deformity. Diagnosis is made on x-rays taken in the accident and emergency. You will then be asked to go to fracture clinic where the fracture will be assessed. There are several important aspects to a distal radial fracture which must be identified as they will determine treatment.

Does it extend into the joint; an intra-articular fracture.
Has it broken the skin, called an open fracture?
How many pieces of bone has the fracture made, multiple fragments are called a comminuted fracture.
Have the pieces moved from where they should be and does the new position threaten the function of the wrist. Displaced fracture.
What is the quality of the bone is there evidence of osteoporosis.

The answer to these questions will guide the surgeon on the best treatment plan. There are several common fracture types; there treatment has been outlined below.

Children with greenstick fracture.

Children's bone has the ability to bend before it breaks. It therefore doesn't crack like a dry twig but rather buckles like a green stick. These are stable fractures and heal quickly in a plaster cast. If the fracture is right at the wrist end of the bone a simple below elbow cast is sufficient. If the fracture is more than 3 cm from the wrist a plaster which extends above the elbow is preferred.

The time in plaster is 3 weeks for any child over 6 yrs old, 2 weeks if aged 3-4 and 1 week if under 2 years old. Clinical examination is required to asses for fracture healing. If the fracture site is still painful after the plaster is removed, an x-ray is taken. If there is suspicion that the fracture has not fully healed the arm is put back in plaster for a further 2 weeks.

Bone always grows straight. Therefore children have the ability to 'remodel' their bone as they grow. In children under 8, the ability to do this is amazing and significant deformity can be accepted. Sometimes the bone is too bent and needs to be straightened; this can be done with a short anaesthetic and is called a manipulation under anaesthetic (MUA). The plaster put on after the MUA should be banana shaped as the curve helps to maintain the elastic bone in the correct position.

Children with complete fractures of the forearm.

These are high energy injuries and usually are as a result of accidents such as falling off a swing, trampoline, ice skating or out of a tree. Complete fractures mean the bones are often no longer aligned and usually need to be put back into the correct position (reduce the fracture). The bones then have to be held in this position for 6 weeks while healing takes place. The bone can be held in several different ways depending on the nature of the fracture.

Manipulation and Plaster cast. (MUA) After the child is fast asleep the bone is put back into the right position. Treatment then follows that described above, under the heading green stick fracture. There is a higher chance that the bone will move out of position in the plaster, so check x-rays are necessary to check the alignment of the bone at 1 and 2 weeks after the manipulation. The bone heals well with normal function at 6 weeks, when children can return to sport

Surgery may be necessary when

The bones cannot be manipulated back into acceptable position,
The fracture is too unstable to be held in a plaster,
If check x-rays show the bones have moved out of position in the plaster.

K Wires. These can be used in fractures which are near to the wrist. The bones are pushed back into the correct position and held by passing a wire through the skin then the bone fragment through to solid bone the other side. The wires are left proud of the skin so they can be removed in the clinic after 4-6 weeks. The wires come out easily and are not painful, however most children under 6 find it too upsetting and require a short anaesthetic to have them removed.

Intra medullary rods. These are flexible rods which pass through the centre of the bone. These are excellent at holding the bone straight and promote quick healing. They can be inserted through small incisions so there is less scarring. Depending on the nature of the fracture the arm is rested in a plaster for 2-6 weeks. The rods should stay in for at least 3 months before being removed at a second operation.

Plate and screws. These are used if the fracture is towards one end of the bone. They hold the bone rigid and can control small fragments. They allow early movement but can take longer to fully heal. The arm is usually kept in plaster for only 2 -4 weeks. They require an 8 to 10cm incision. The plates stay in the bone and are not removed. They rarely cause trouble and removing them is associated with complications, such as nerve injury and re-fracture of the bone.

The time taken for bone to heal from a complete fracture is 6 weeks for any child over 6 yrs old, 4 weeks if aged 3-4 and 2 weeks if under 2 years old. Clinical examination is required to asses for fracture healing. X-rays are not routinely taken because new bone does not always show up. If the fracture site is still painful a check x-ray is taken. If there is suspicion that the fracture has not fully healed the arm is put back in plaster for a further 2 weeks.

Is there anything that can go wrong?

Operations to fix children's radius fractures are very successful and most people who have them are delighted with the operation and are glad they had it done. Like any operation a very small number of patients can have a problem. The main problems are; nerves can be bruised, the hand can become stiff, non union and failure of the plate and screws is very rare. In some patients the plate can be felt under the skin and cause irritation when resting on a table, the plate can be removed at 1 year but is not recommended. The risks of these problems only add up to less than 3 % of all operations. You should discuss the possibility of problems with your surgeon before your operation.

Adult with displaced fracture distal radius.

Patients will notice severe pain and deformity of the wrist. A distal radial fracture often is very easy to identify. Clinical examination in A&E will test for the sensation in the hand, to make sure no nerves were injured; the blood supply to the hand is checked to ensure no vessels have been injured. All the fingers should be able to straighten and bend, to check that no tendons have been injured. A back slab is then applied; this is a half plaster which stops the fracture from moving which reduces the pain. The half plaster will allow for swelling of the wrist.

Investigations

Plain x-rays will diagnose most distal radial fractures. They will identify the nature of the fracture and dictate the necessary treatment. Occasionally, fractures are investigated with CT scans, and these are particularly common with intra-articular fractures, to assess any step in the articular surface, which may pre-dispose to osteoarthritis.

Treatment options

Plaster cast. Only un-displaced simple fractures of the distal radius are treated non-operatively for six weeks. There is a significant trend towards early operative fixation of distal radial fractures, with increasing evidence that better results are possible.

K wires. These are wires which pass through the skin and hold the small fracture fragments together. They have the advantage of only a small stab incision in the skin. However they are only suitable to be used in strong bone which has not been crushed. In poor quality bone, the wires tend to cut out, leaving patients with a recurrent deformity and problems. The k wires are left proud of the skin so they can be removed in clinic at 4 to 6 weeks. Although there is understandably some concern over the removal; it is pain free and easily done. Afterward the wounds should be cleaned and kept dry for a further 2 weeks.

Volar locking plates. This is particularly useful when treating unstable fractures, occurring in patients with osteoporotic bone. Special surgical plates have been developed, which allow the fracture to be fixed solid, even in the presence of thin, poor quality bone. This allows the patients to remove the plaster at 2 weeks and start to move the wrist joint. This reduces stiffness and aids in the return to normal activities.

Return to activities of daily living

A plaster will protect the fracture for the first six weeks, so activities which can be performed while wearing the plaster are allowed if they are not painful. Pain occurs when the fracture fragments move and therefore must not be allowed. Once the plaster is removed there is a period of stiffness which can last for the next 3-6 weeks. Early operative intervention allows for rapid return to activities of daily living, including driving and return to work. Nearly all patients return to all their former activities. The nature of the fracture, the kind of treatment received, and the body's response to the treatment all have an impact, so recovery is different for each scenario.

Most patients should start physiotherapy within a few days to weeks after surgery, or as soon as the last plaster cast has been removed.
Most patients will be able to resume light activities, such as swimming or exercising the lower body in the gym, once the cast is taken off if it is not painful.
Contact sports such as skiing or rugby between three and six months after the injury.
All patients will have some stiffness in the wrist, which will be improved with physiotherapy. Improvement can continue slowly for two years.
Ultimate recovery can be slow. Some pain with vigorous activities may be expected with some residual stiffness or ache for two years or rarely permanently. High-energy injuries (such as motorcycle crashes, etc), intra articular fractures, patients older than 50 years of age, or in patients who have some osteoarthritis are more at risk. However, the stiffness is usually insignificant and will not affect the overall function of the arm.

It has been suggested that people who suffer a wrist fracture may need to be screened for osteoporosis, especially if they have other risk factors. Ask your doctor if you need to be screened or treated for osteoporosis.