“I want to go home with the armadillo, good country music from Amarillo and Abilene. The friendliest people and the prettiest women you’ve ever seen.”
“London Homesick Blues” written by Gary P. Nunn.
If you fall out onto your hand the most common bone that is broken is the radius. Since the bone is distal, or away from the shoulder, this fracture is referred to as a distal radius fracture. There is such a wide variety of fractures and patterns of fracture of the distal radius so that it’s hard to cover everything in one blog post, but since this is such a common injury it seems worthwhile to go over the common treatments and expected outcomes from this very common injury.
These fractures occur in people of all ages, from children to the elderly. These fractures in children are a little different, so I’m going to focus on distal radius fractures in adults. These fractures are very common in younger active adults and in the elderly but can occur in any age group. Young adults can engage in high energy high risk activities (snowboarding is a great example) while older adults have softer bone and are prone to have the distal radius break after falling out onto their arm. Regardless of the age group, these fractures occur in all shapes and sizes. Sometimes there is just a simple crack in the bone, and little more than a brace or a cast is needed. Other times the bone is shattered and requires extensive surgery by an expert to try and get the bone back together where it belongs. What I would like to do is walk you through the thought process I go through when I evaluate a patient with a distal radius fracture and what treatment options I offer to patients.
The first order of business is to determine how “bad” the break is. I look at the overall alignment of the fracture; that is, is it straight or not. I also look at the wrist joint. It’s important to have the joint lined up as close as possible to normal, so if the joint is out of place surgery is often needed to line the joint back up. Third, I look at how many pieces the break is in. Sometimes the bone is lined up okay, but if there are a lot of pieces (the medical term is comminution then the break may not stay in place and may require surgery to keep the bone lined up.
The second important factor is to assess the patient and their needs. An elderly person who doesn’t mind a little bit of a crooked wrist can often function quite well with a distal radius fracture that doesn’t heal perfectly. On the other hand a younger, active person almost always need perfect or near perfect alignment to have a good working wrist. I don’t have any set age limit about when I’ll operate or not operate on patients with this fracture. I have operated on patients over 80 because they needed to be able to take care of themselves or others. I try to make sure I understand what each patient needs before recommending treatment.
So what are the options for treatment? For simple fractures, which for me means the bone is straight, there’s not a lot of pieces, and the joint is lined up, most surgeons use a cast. This can vary from 3 to 6 weeks depending on the surgeon. In these cases I usually go for 2 to 3 weeks in a cast then switch to a removable brace. It probably takes 3 to 4 months to regain strength and dexterity in the wrist.
The second scenario we see is a break that is out of place ( the medical term is displaced). Some of these fractures can be reduced (a common term is be “set”). If the bone goes back into place, the joint is lined up, and there aren’t too many fracture fragments, then the fracture can often be treated without surgery. I like to keep a close eye on these fractures and get an x-ray about once a week for the first three weeks to make sure the bone isn’t slipping out of place. Once again it usually requires about 6 weeks in a cast or brace for the bone to heal and 3 to 4 months, or even longer, for the patient to regain strength and motion in the wrist.
The third scenario involves fractures which usually require surgery. These can be fractures that won’t go back in place, fractures that involve the joint surface, fractures with multiple fragments or any combination of the three factors above. In these cases I usually recommend surgery. Over the last 15 years some new plates have been developed allow us to restore alignment to the radius and keep the bone in place while it’s healing. These plates have a good track record. They usually don’t have to be removed, and most people aren’t bothered by the plates in their day to day activities. Other surgeons use a combination of smaller plates and pins called “fragment specific fixation” and this seems to work very well. In the past surgeons would put pins from the bone and connect them to a frame outside the wrist called an “external fixator”. I think that overall the use of the external fixator is declining and probably most surgeons use them in severe open or compound injuries. Some fractures involve the joint but are a single large piece and these can sometimes be fixed with screws only and not a plate. After the surgery most patients only need a removable brace. The recovery period is probably about the same as the fractures that we can treat without surgery. This surgery has the usual risks of infection and possible bleeding complications, but fortunately these are rare. There have been problems with tendons rupturing after this surgery. This is not common but it’s something you need to be aware of when contemplating surgery.
I’ve found that the newer plates have really improved the outcome of treatment of patients with distal radius fractures. Clearly not every fracture needs surgery, and not every patient needs surgery so it’s important to have a good discussion with your surgeon to make sure the treatment you both decide on is the best for you.