Wrist fracture

Synonyms

Radius fracture, (distal) radius fracture, radius base fracture, Colles fracture, Smith fracture

Definition wrist fracture

The wrist fracture is the most common fracture that occurs in humans. This is due to the fact that many people try to absorb falls with their hands, usually as a reflex, which causes the joint to suffer. Wrist fracture is colloquially referred to as the fracture of the end of the radius (one of the forearm bones) that is far from the body and thus close to the wrist.

With about 20 to 25% of all fractures, the wrist fracture leads the list of common fracture injuries in humans. In principle, it can occur at any age, but it is more common in young people between 14 and 18 (here mainly due to high-risk behavior with fall consequences) and older people over 60 (here especially as a result of osteoporosis). Normally, the cause of a radius fracture (wrist fracture) is due to a fall.

When you fall, you try to support yourself and thus exert a massive force on the wrist, which it is often unable to withstand – thus causing the fracture. Usually this happens when the wrist is extended, the radius fracture is called Colles fracture in this case. The rarer case of a flexed wrist in an accident is called a Smith fracture.

The reasons for the fall can be very diverse. In younger people, it is often sports injuries, for example in soccer, handball, skateboarding or snowboarding, that lead to unfortunate falls. In older people, on the other hand, falls are often caused by insecure gait and stumbling, and the bones, which are usually already pre-damaged by osteoporosis, have an increased risk of suffering considerable damage even from minor injuries.

Typically, a wrist fracture is directly associated with pain, which increases with pressure and movement. Also, swelling of the joint usually develops quite quickly after the accident. In addition, a malposition of the wrist is often found.

This is caused by the fact that the fracture shifts towards the back of the hand and the spoke, resulting in the classic picture of the bayonet position. Since the mobility is limited due to the pain and swelling, the patient usually carries the hand in a typical relieving position to relieve the joint. If the hand is moved after all, so-called “crepitations”, a crackling noise, can occur due to bone parts rubbing against each other.

If this occurs together with a malposition, a wrist fracture can be considered safe. In some cases, there is also a tingling or similar sensation in the area of the fingers, which suggests that nerves have also been irritated or damaged by the fracture. and bruise on the wristThe diagnosis of a wrist fracture can usually be made solely on the basis of the patient’s medical history (i.e. the interview with the patient) and the clinical picture including a physical examination.

If a patient comes to us after a fall with a swollen, painful wrist, which also shows crepitations and the typical malposition, the diagnosis of a wrist fracture is virtually certain. During the physical examination, the patient’s mobility, blood circulation and feeling in the wrist can also be checked. In order to confirm the suspected diagnosis or to obtain more precise information (for example, where exactly in the bone the fracture is located or whether parts of the bone have come loose and/or shifted), the physician can also request an X-ray.

This is usually taken in two planes, i.e. once from the front and once from the side, in order to have a good view of all bones of the wrist. This is especially helpful in order to be able to decide on an appropriate therapy afterwards. More rarely, computed tomography (CT) is used to diagnose a wrist fracture, for example if the information provided by the X-ray is not accurate enough.

There are several options available for the treatment of a wrist fracture, which are preferred depending on the case. In principle, a decision is made between conservative (i.e. non-operative) and operative therapies. Both forms of therapy aim to completely restore the original shape of the joint, which means that the axes and lengths of the bones should be normal again, so that the functionality of the wrist is completely restored.In the case of a simple wrist fracture that is not displaced, the treatment simply consists of putting on a plaster cast, which must usually be worn for 6 weeks.

By immobilising the arm, the bone pieces can grow together again correctly. However, it is important to have regular x-ray checks made to see whether any bone displacement has occurred subsequently, so that these can be detected at an early stage and then treated appropriately. If, on the other hand, the wrist fracture is displaced (dislocated), it must be set up (repositioned) before the plaster cast is applied.

For this purpose, the fracture site is first numbed by injecting a local anesthetic into the fracture gap. Then the bones are brought back into the correct position by simultaneous traction of the upper arm and fingers. This procedure should always be performed under X-ray control.

If the dislocation is more serious but the fracture is still stable, a closed reduction can be performed. This is the insertion of wires to stabilize the fracture during the healing process. This procedure can be performed on an outpatient basis, but a plaster cast must still be worn for 6 weeks afterwards.

In the case of an unstable wrist fracture (a fracture is considered unstable if it has at least three of the following criteria: comminuted fracture, involvement of the joint surface, dislocations, involvement of the wrist, patient older than 60), open surgery is preferred. In this case, stabilization is achieved with the help of plates that are normally used on the flexion side, as they lead to fewer complications here. These plates can remain in the body for the rest of life.

Although this type of surgery is more invasive and cannot be performed on an outpatient basis, it has the advantage that patients do not have to wear a cast and can put full weight on their wrist practically immediately. However, surgical treatment of a fractured wrist is always decided by the treating physician. In the same way, surgical therapy can be preferred to conservative treatment if longer immobilization is limited (e.g.

in older, multimorbid patients) or if high loads are to be possible again as quickly as possible (e.g. in competitive athletes). The aim of operative fracture treatment is to bring the individual fragments into an optimal position so that they can grow together again without any consequences. It is important that the original length and angle of the wrist bones are restored.

Depending on the type of spoke fracture, there are different procedures for the surgical treatment of the fracture. Common to all of them is that the procedure is performed under general anesthesia or local anesthesia (regional anesthesia/plexus anesthesia; only the affected arm is anesthetized) and the surgeon first repositions the fractured bone pieces back into the correct position (manual reduction) before fixing them in this position afterwards. How the spoke fracture is ultimately fixed depends largely on the type of wrist book.

If the fracture is unstable (radius)
Do not allow the fracture ends to be brought into the correct position by reduction
Are shifted too much against each other
A joint involvement has occurred or
Even an open fracture or comminuted fracture is present.
One possibility is the wire fixation of the spoke fracture, which is used for rather slightly displaced wrist fractures without joint involvement. In this procedure, small wires (so-called “Spick wires” or Kirschner wires) are drilled into the spoke through small skin incisions made beforehand and anchored in such a way that the fracture gap is fixed. The forearm is then immobilized for 3-4 weeks and the wires are removed under local anesthesia after about 6 weeks.
This technique is preferred for young patients, but less so for adults. One disadvantage is that the collapse of the bones in the fracture zone cannot be completely prevented and in isolated cases secondary displacement may occur.
If, in addition to the spoke fracture, the stylus process of the spoke is also broken off in the context of a wrist fracture, screws are usually used for fixation to reattach the bone fragments to each other and stabilize the fracture (so-called screw osteosynthesis).An additional wire may also be inserted to provide even more strength in the fracture. Here too, a cast is then applied, but this can be removed after about 1 week, so that a mobilizing physiotherapy can be started immediately.
The screws and wires in this fracture treatment are removed after about 4 weeks under local anesthesia.
If the wrist fracture is particularly unstable, a joint surface is involved or the fracture has shifted again after previous surgical therapy, often only the implantation of a metal plate can provide sufficient fixation (so-called plate osteosynthesis). This plate is usually placed on the flexor side and close to the wrist on the radius in order to straighten the joint surface, which is usually compressed. The metal plate lies directly on the fracture gap and is fixed to the left and right of it with screws in the spoke.
Thanks to the plating, the wrist fracture is usually immediately stable for exercise, so that no plaster has to be put on and mobilizing physiotherapy can be started immediately. The plate and screw material can also remain in the body so that no further surgery is necessary. The disadvantage here is that the insertion of the plate requires a much larger skin incision than with wire fixation or screw osteosynthesis.

Therefore, there is also a greater risk of nerve, vascular and soft tissue injury.
If a wrist fracture has more than two fragments or is even a comminuted fracture, an external fixator may also be the means of choice. In this case, the physician inserts two metal pins into the radius above the wrist and two into the second metacarpal bone during surgery, which are braced from the outside with rods. In this way, all fragments are held in the correct position from the outside.
The disadvantage of this method compared to the other methods is the greater risk of infection, since bacteria can easily enter the body from the outside via the metal pins and careful wound care is therefore necessary. The external fixator is usually removed after about 6 weeks and then immediately treated with physiotherapy.

Regardless of whether the wrist fracture had to be treated surgically or was treated conservatively from the start – with or without reduction of the fracture – a plaster cast is usually applied to the forearm for 4-6 weeks (except in the case of surgical plate osteosynthesis) (after surgical treatment, the duration of immobilization may also be shorter). A proper aftercare is part of the treatment: In the same way, the intactness of the skin and the smooth healing of wounds (e.g. surgical wounds) must be checked during all plaster changes.

Any suture material should be removed after 10-14 days. Following immobilization, outpatient physiotherapeutic treatment is usually indicated in order to restore full function and load capacity in the affected wrist as quickly as possible.

On the one hand, regular plaster changes and X-ray checks
As well as early movement exercises for the thumb and the remaining long fingers, which are not included in the cast.
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The elbow and shoulder joint should also be actively mobilized during the immobilization period by means of specific movement exercises.
In addition, care should always be taken to ensure proper blood circulation and sensitivity as well as an undisturbed movement function in all five fingers.

With the right therapy, the wrist fracture has a very good prognosis. The dreaded permanent malposition of the wrist as a result of a fracture can actually be prevented almost always if surgery is performed in high-risk cases and if any treatment is accompanied by regular X-ray checks. Otherwise, a radius fracture is accompanied by few complications.

As with any fracture, the risk of developing osteoarthritis in the affected joint is increased. In rare cases, it can also lead to a pain syndrome such as Sudeck’s disease. A complete fracture of a bone – also known as a bone fracture – usually results in the complete severing of the bone structure into two or more fragments.

If the bone is only incompletely interrupted, this is called a bone fissure. A wrist fracture – like any fracture of any bone – can heal in two different ways. A distinction is made between direct (primary) and indirect (secondary) fracture healing.During immobilization by means of a splint or plaster, bone healing proceeds in several phases.

After the fracture phase, in which blood leaks from the beech ends into the fracture gap, an inflammatory reaction begins. This leads to the activation of inflammatory cells that migrate into the coagulated blood in the fracture gap and activate the cells there to form new bone. In the subsequent granulation phase, the coagulated blood is then converted into connective tissue (granulation tissue, soft callus), into which new blood vessels gradually grow.

Bone resorbing cells remove broken and poorly supplied with blood at the fracture ends, bone building cells replace them with new bone substance. At least 4-6 weeks have passed until this happens, but the broken bone or wrist fracture is now considered to be resilient again. In the following phase of callus hardening, over time, minerals are incorporated into the newly formed bone so that it regains its original strength.

However, the fracture is only completely mineralized after 3-4 months. Over time, however, the newly formed bone substance of the hardened callus is further remodeled (remodeling) until, after 6-24 months, it is finally fully aligned in the direction of the main stress in the bone again and corresponds to the original bone.

Direct fracture healing always takes place when the periosteum has remained intact (especially in the case of infantile flexural or greenwood fractures) or when the two ends of the broken bone are in contact, cannot move relative to each other and are well supplied with blood (e.g. after surgical treatment with screws and plates).
Starting from the closely adjacent bone ends, newly formed bone cells are deposited in the fracture gap and gradually interlock the fragments. After only 3 weeks, the broken bone is largely functional again and the wrist can gradually be loaded again.
Indirect fracture healing always occurs when the two fracture ends are no longer in direct contact with each other and are slightly offset from each other.

The duration of complete healing of a wrist fracture depends on the severity of the fracture and the healing process, but also on the age of the patient and the type of fracture treatment. As a rule, surgically treated wrist fractures can be reloaded earlier than those treated conservatively.

This is due to the fact that the fracture ends are brought back into direct contact with each other through the surgical insertion of screws and plates, thus allowing direct bone healing and the wrist to be subjected to stress again after only 3-4 weeks. In contrast, wrist fractures treated purely conservatively – with a plaster cast – usually require a healing period of 4-6 weeks before the first mobilization exercises and light loads are applied. A complete healing of the fracture with unrestricted resilience is ultimately said to be achieved after a period of 8-12 weeks.

Prevention of a wrist fracture is only possible to a limited extent. High-risk sports should be avoided if possible. In some areas you can learn to fall “properly” without injuring yourself additionally when falling. However, since catching the fall with the hand is often a reflex action, this happens completely unconsciously and cannot be prevented. All in all, it can be said that although the fracture of the wrist is a very common consequence of an accident, which leads acutely to massive functional impairment and pain, it is usually very easy to treat due to modern therapy techniques and does not cause any permanent complaints.