Wrist Joint Fracture

The wrist joint links hand to forearm. Hand movement like flexion, extension, lateral tilt and rotation are hinged at wrist joint. The three dimensional movements of the hand are anchored around wrist joint. Wrist joint fracture results following a fall over out stretched arm. Wrist joint fracture is one of the common injuries observed in emergency room. Wrist Joint fracture results in disruption of ligaments, tendon and muscles.

Bones of Wrist Joint

Bones of Wrist Joint

Wrist joint is a flexible joint and involves 15 bones. These 15 bones form three segments of the wrist joint. The three segments of the Wrist Joint are as follows-

Bones of Proximal Wrist Joint-

Proximal wrist joint is a pivot joint between radius and ulna. Joint is linked between head of the distal end of ulna and radius bone. Ulna lies against ulnar notch of radius bone. The link between ulna and radius is covered with smooth cartilages. Joint is covered by synovial capsule. Capsule is lax around the joint thus allowing semi-rotation of joint during pronation and supination.

Bones of Intermediate Wrist Joint-

Intermediate wrist joint is formed by two links or inter-joints-

  • First link- First link is between Radius and Ulna with proximal row of carpal bones.
  • Second link- Second link is between proximal and distal row of carpal bones.

Bones of Distal Wrist Joint-

Distal wrist joint is formed by carpal bones of distal row and proximal end of metacarpal bone. Distal row of carpal bones consists of Trapezium, Trapezoid, Capitate, Hamate and Pisiform bones.

Epidemiology of Wrist Joint Fractures-

Several epidemiological studies performed in USA suggest that-

  • Upper extremity injuries are the most common injuries seen in emergency room. Study performed by Ootes D and Lambers KT suggests 3,468,996 patients had visited emergency room in 2009 with upper extremity injuries.1
  • Most common injury of upper extremity is fracture of radius and ulna (44%) and fracture of one of the carpal bones (14%)1. Wrist injuries were observed in 2450 cases.2
  • Carpal bone fracture is often associated with dislocation of wrist joint or fracture of radius or ulna.
  • Most common carpal bone fracture observed is Scaphoid fracture. (70 to 80%).1
  • Next common carpal bone fracture is tirquetrum (14%), trapezial (2.3%) and hamate (1.5%).
  • Fracture of lunate, pisiform and capitate are rare.1

Types of Wrist Joint Fracture

Fracture of Distal End of Radius and Ulna-

Fracture of distal radius bone is known as a Colles' fracture. Colles' fracture is often seen following sport injury or fall.

Fracture of Carpal Bones

Fracture of Carpal Bones

Scaphoid Fractures-

Scaphoid bone fracture is the most common carpal bone fracture observed in patients with history of osteoporosis and following sports injury. Scaphoid bone is shaped like cashew nut and lies between proximal phalanx of thumb and distal end of radius. Scaphoid fracture is mistaken for wrist sprain, since symptom often are mild and examination does not show any swelling or significant tenderness.

Triquetrum Fracture-

Triquetrum lies between styloid process and proximal row of the carpal bone. Fracture of triquetrum is often misdiagnosed as tendonitis or ligamental sprain.

Lunate Fracture or Necrosis-

Also known as Kienbock Disease. Frequent wrist contusion and sprain associated with lunate fracture causes necrosis of lunate.

Lunate fracture is divided in 4 stages according to MRI findings.

  • Stage I: Decreased signals observed on MRI.
  • Stage II: MRI shows fracture.
  • Stage III: MRI shows collapse of lunate bone and forward displacement of capitate bone.
  • Stage IV: MRI shows generalized arthritis of wrist joint with findings of stage III.

Fracture of Metacarpal Bone-

Proximal end of metacarpal bone forms a link with carpal bones of distal row of wrist joint. Metacarpal bone fracture could be isolated or associated with carpal bone fracture.

Classification of Wrist Joint Fracture

Carpal Bone Fractures Are Classified As Follows-

  • Stable Fracture- Stable fracture is either hairline or non-displaced fracture of radius, ulna, carpal bone or metacarpal bone. Stable fracture is associated with minimum soft tissue injury. Stable fracture is treated with cast or splint.
  • Unstable Fracture- Non- displaced fracture could be unstable in few cases. Unstable non-displaced fracture may change its alignment and become partial or complete displaced fracture. Unstable fracture may need internal or external fixation treatment.
  • Delayed Non Union- Non-displaced or reduced Carpal Bone Fractures may not heal for prolonged period. Prolonged healing may result in prolonged cast placement or surgical fixation of the fracture.
  • Displaced Fracture- Fragments of Carpal bones are unstable and not aligned. Fragments are either partially or completely displaced. Such fracture needs surgical treatment.

Causes of Wrist Joint Fracture

Injuries of Wrist Joint-

  • Sport Injuries3
  • Domestic Fall
  • Auto Accident
  • Work Accident
  • Repetitive Stress

Wrist Joint Osteoporosis4

  • Weak and Brittle Bones.
  • Imbalance of maintaining bone minerals.
  • Minerals such as calcium resorption in bone is higher than daily redposition condition is known as osteopenia.
  • Osteopenia associated with weak and brittle bone is known as osteoporosis.

Paget's Disease Of Wrist Joint-

  • Paget's disease is caused by increased number of osteoclast in skeletal tissue. Osteoclasts are skeletal cells responsible for increased resorption of bone.
  • Disease is divided in 2 phase-
    • Phase 1 of Paget's disease is caused by excessive breakdown and formation of bone.
    • Phase 2 of Paget's diseases results in replacement of resorped bone with inferior quality of bone.
  • Weak regenerated bones have a tendency to break or fracture.
  • Brittle bone occasionally causes wrist joint fracture following abnormal twist and turn of the joint.

Cortisone Medications-

  • Prolonged use of oral and inhalation glucocorticoids (GCs) results in abnormal bone mineral density. Condition is known as glucocorticoid induced osteoporosis.
  • Corticosteroid induced osteoporosis has a tendency to fracture.
  • Osteoporosis caused by glucocorticoids is dose dependent disease. Higher the dosage chances of fracture is also greater.
  • Wrist joint fracture is one of the few fracture resulting from cortisone induced osteoporosis.

Symptoms of Wrist Joint Fracture

Chronic Wrist Joint Pain

  • Severe continuous pain immediately following fracture.
  • Pain is localized over fractured bone.
  • Continuous throbbing pain.

Wrist Joint Tenderness-

  • Severe pain is elicited when skin and subcutaneous tissue is pressed over the joint.
  • Light touch results in severe pain, which may last for several minutes.

Wrist Joint Swelling-

  • Complaints of wrist joint swelling with pain.
  • History suggests slow or rapid increase of swelling.
  • Slow expansion or swelling of soft tissue is secondary to edema caused by inflammation or bleeding resulting in hematoma.
  • Rapid occurrence of swelling is secondary to dislocation of the joint or fragment segment protruding through the soft tissue.

Signs of Wrist Joint Fracture

A wrist joint fracture should be suspected when severe pain and joint deformity follows injuries. Common symptoms of a wrist fracture include:

Joint Swelling

  • Wrist joint swelling following injury feels either soft, firm or hard.
  • Soft wrist joint swelling secondary to edema is caused by soft tissue inflammation.
  • Firm wrist joint swelling is secondary to hematoma caused by bleeding within wrist joint.
  • Hard wrist joint swelling is caused by fragment of fractured segment protruding through soft tissue.

Bruising-

  • Bruise or contusion is a reddish and purple discoloration of skin and subcutaneous tissue.
  • Bruising is caused by subcutaneous hematoma (blood clot), which results from bleeding under the skin and subcutaneous tissue.
  • Substantial bleeding in deeper tissue and joint spreads into subcutaneous tissue and dermis resulting in bruises.

Deformity-

Joint deformity following fracture of wrist joint is observed secondary to protrusion of joint fragments.

Muscle Cramps

Movement of the wrist joint in patient following fracture of wrist joint causes severe pain. Movement of the wrist joint is prevented by continuous forearm and hand muscle contraction. Prolonged muscle contraction results in fatigued muscles and severe cramps. Severe cramps result in severe pain of wrist joint.

Investigations of Wrist Joint Fracture

X-Ray Findings-

Investigations of Wrist Joint Fracture

X-Ray Positive Findings

  • Displaced fracture is seen on plain x-ray.
  • Non-displaced fracture of radius and ulna is seen on plain x-ray.
  • Displaced carpal bone fracture is seen.
  • Osteoporosis of wrist joint bones.

X-Ray May Not Show

  • Hairline fracture of radius and ulna.
  • Hairline fracture of carpal bone.
  • Displaced fracture of carpal bone.

MRI Findings-

MRI Will Show Following Abnormalities-

  • Hairline fracture of radius, ulna, carpal bone and metacarpal bone.
  • Non-displaced fracture of radius, ulna, carpal bone and metacarpal bone.
  • Hematoma (blood clot) in subcutaneous tissue and wrist joint.
  • Wrist joint dislocation associated with fracture of wrist joint.
  • Osteoporosis of wrist joint bone.
  • Necrotic fractured bone.

CAT Scan

CAT Scan Will Show Following Abnormalities Of The Wrist Joint-

  • Radius and Ulna Fracture.
  • Carpal Bone Displace Fracture.
  • Fracture Associated With Wrist Joint Dislocation.
  • Hematoma (blood clot.)

Ultrasound

Ultrasound Will Show Following Abnormalities-

  • Wrist Joint Dislocation.
  • Fracture of Radius and Ulna.
  • Hematoma within Wrist Joint.
  • Subcutaneous Hematoma.

Wrist Joint Arthroscopy

Arthroscopy is performed in later stages. Arthroscopy is performed to diagnose fracture and dislocation of wrist joint. Arthroscopy also assists to rule out tendon rupture or ligamental tear. Arthroscopy often follows arthroscopic surgery.

Blood Examinations

Blood examination is done to rule out joint infections. Following abnormal blood examinations are observed in septic wrist joint.

  • White Blood Cell Count- Increased.
  • Erythrocyte Sedimentation Rate- Increased.

Treatment of Wrist Joint Fracture

  1. Conservative Treatment
  2. Medications
  3. Physical Therapy (PT)
  4. Interventional Pain Therapy
  5. Close Reduction Of Dislocation And Fracture
  6. Surgical Treatment

1. Conservative Treatment for Wrist Joint Fracture

a. Restriction of Wrist Joint Activities

  • Reduces Pain
  • Reduces Joint Swelling.

b. Heat and Infra-Red Therapy

  • Reduces Pain
  • Stiffness of the Joint.

c. Daily Exercise Prevents

  • Muscle Stiffness
  • Muscle Weakness
  • Muscle Atrophy
  • Joint Stiffness

d. Splint or Cast Treatment for

  • Hairline Fracture
  • Non-Displaced Fracture

e. Elevate Wrist Joint Prevents

  • Swelling of the Soft Tissue.
  • Stiffness of the Wrist Joint.

f. Applying Ice on the Wrist Joint Reduces

  • Hematoma
  • Swelling of the Joint

2. Medications for Wrist Joint Pain Caused By Fracture

  1. NSAIDs
  2. Opioids
  3. Anti-Depressant Analgesics
  4. Anti-Epileptic Analgesics
  5. Muscle Relaxants

A. NSAIDS (Non-Steroidal Anti-inflammatory Medications).

NSAIDs are prescribed for Inflammation and Pain.

Motrin-

  • Tablets are available as 200 mg, 600 mg and 800 mg.
  • Daily dosage is 1600 to 2400 mg per day.

Naproxen-

  • Tablets are available as 275 mg, 350 mg and 500 mg.
  • Daily dosage- 750 to 1500 mg per day.

Daypro-

  • Tablet available as 600 mg.
  • Daily Dosage- 600 to 1200 mg per day.

Celebrex-

  • Tablet available as 100 mg and 200 mg.
  • Daily dosage- 200 to 400 mg per day.

B. Opioids

Opioids are prescribed for acute and chronic pain.

Opioids are divided in two groups as

  • Short Acting Opioids.
  • Long Acting Opioids.

Short Acting Opioid Medications For Treating Wrist Joint Pain-

Hydrocodone: Vicodin, Lortab and Norco.

  • Vicodin- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 650 mg of Tylenol.
  • Daily Dosage- 15 to 60 mg of hydrocodone.
  1. Lortab- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 500 mg of Tylenol.
  2. Daily Dosage- 15 to 60 mg of hydrocodone.
  1. Norco- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 350 mg of Tylenol.
  2. Daily Dosage- 15 to 60 mg of hydrocodone
  3. Norco is preferred if higher dosage like 30 to 60 mg of hydrocodone is prescribed for pain treatment so tylenol dosage is kept below 2 gram.

Oxycodone- Oxy IR and Percocet.

  • Oxy-IR- Strength of pills- 5 mg, 7.5 mg and 10 mg
  • Daily dosage- 15 to 60 mg.
  1. Percocet- Pills contain Oxycodone and Tylenol.
  2. Strength of Oxycodone- 5 mg, 7.5 mg and 10 mg.
  3. Strength of Tylenol- 325 mg, 500 mg and 650 mg.
  4. Maximum allowed dosage of Tylenol is 4 gm.

Morphine-

  • MS IR (Morphine Sulphate Immediate Release)
  • Available as liquid and pills.
  • Liquid Strength- 20 mg/mL
  • Pill Strength- 15 and 30 mg
  • Daily dosage 60 mg to 120 mg.

Long Acting Medications-

Oxycodone- Oxycontin

  • Pills available as 10 mg, 20 mg, 40 mg and 80 mg.
  • Suggested safe dosage per day- 40 mg to 160 mg.

Morphine- MS Contin

  • Pills available as 15 mg, 30 mg, 60 mg, 100 mg and 200 mg.
  • Suggested safe dosage per day- 90 mg to 200 mg.

Methadone

  • Pills available as 10 mg.
  • Suggested safe dosage per day- 40 to 80 mg.

C. Muscle Relaxants-

Muscle relaxants are prescribed for muscle spasm and joint stiffness of the wrist.

Baclofen

  • Pills available as 5 mg, 10 mg, 15 mg and 20 mg.
  • Suggested safe dosage per day- 30 to 60 mg.

Flexeril

  • Pills available as 5 mg and 10 mg.
  • Suggested safe dosage per day- 20 to 30 mg.

Skelaxin

  • Pills available as 800 mg.
  • Suggested safe dosage per day- 2400 to 3200 mg.

Robaxin

  • Pills available as 500 mg and 750 mg.
  • Suggested safe dosage per day- 1500 to 2150 mg.

3. Physical Therapy (PT) For Wrist Joint Fracture

Goal of Physical Therapy (PT) to Treat Wrist Joint Fracture-

  • Improve Joint Movements.
  • Enhance Muscle Strengthening.
  • Maintain Normal Muscle Tone.
  • Augment Coordination.

Physical Therapy Techniques-

  • Exercise
  • Stretching
  • Ultrasound Therapy
  • Infrared or Heat Therapy
  • Cold Therapy
  • Massage Therapy

4. Interventional Pain Therapy for Wrist Joint Fracture

Interventional pain therapy is an invasive treatment. Choice of Interventional Pain Therapy is as follows

  1. Needle Therapy
  2. Nerve Ablation Treatment
  3. Placement of Spinal Cord Stimulator
  4. Placement of Intrathecal Catheter and Programmable Pump.

A. Needle Therapy for Wrist Joint Injection

Cortisone Injection

Cortisone injection is performed to reduced inflammation. Severe pain if not responding to NSAIDs and opioids, then the chronic pain is treated with frequent cortisone injections. Injections are repeated between 3 to 6 months. Cortisone injection is not recommended for chronic pain caused by Gout and Septic Wrist Joint Arthritis.

Local Anesthetic Injection

Therapeutic value of just local anesthetic injection is very limited. The procedure is performed only as a diagnostic procedure. Procedure is also performed prior to physical therapy so as to relieve the pain to achieve aggressive physical therapy.

Indications for Wrist Joint Local Anesthesia Injection-

  • Diagnostic Injection to evaluate cause of pain.
  • Injection is performed prior to physical therapy.
  • Injection is performed prior to nerve conduction or radiological study.
  • Post surgical pain.

Contraindication for Wrist Joint Corticosteroid and Local Anesthesia Injection

  • Septic Arthritis
  • Skin Infection
  • Septicemia
  • Allergies to local anesthetics

B. Nerve Ablation (Destruction) Treatment for Wrist Joint Fracture

Procedure is selectively performed to destruct (ablate) irritated or pinched nerve caused by wrist joint fracture or scarring of nerve following surgery. Treatment is very rarely needed for wrist joint pain.

Nerve Ablation Techniques-

  • Chemical Nerve Ablation.
    1. Phenol injection near nerve
    2. Alcohol injection close to pinch nerve.
  • Cryoablation using probe
  • Radiofrequency nerve ablation using radiofrequency heat.

i. Chemical Nerve Ablation For Wrist Joint Pain Caused By Wrist Joint Fracture-

a. Phenol Injection-

Phenol is selectively injected near or over the nerve with guidance of X-ray image and ultrasound. Procedure is painful and pain lasts for short period. Phenol destructs peripheral nerve by neurolysis. Procedure is very rarely performed.

b. Alcohol Injection for Wrist Joint Pain

Alcohol is very rarely used. Alcohol injection is very painful and pain lasts for prolonged time. Nerve when regenerate causes severe neuropathic pain. Procedure is performed under guidance of X-Ray and Ultrasound.

Complication Following Phenol or Alcohol Injection-

  • Destruction of surrounding soft tissue, since liquid phenol and alcohol spreads rapidly in soft tissue.
  • Severe scar tissues are formed because of surrounding soft tissue damage. Chemical inflammation of soft tissue is induced by phenol and alcohol.
  • Nerve regeneration follows severe neuropathic pain.
  • Cryo or radiofrequency nerve ablation is preferred over phenol or alcohol injection. Alcohol or phenol spreads over surrounding soft tissue causing severe destruction and scarring.

iii. Radiofrequency Nerve Ablation

Radiofrequency needle is much smaller in diameter than cryo probe. Radiofrequency needle is placed over pinched or irritated nerve. Radiofrequency waves are generated at the tip of the needle, which results in increased temperature. Temperature is maintained at 75 to 900 C for 75 to 90 seconds to nerve ablation.

iv. Cryo Nerve Ablation

Procedure involves placing of cryo probe over irritated or pinched nerve. Cryo probe is much wider in diameter than radiofrequency needle. Procedure involves tiny skin incision to insert a cryo probe. Probe is placed over nerve following nerve stimulation test. Probe temperature is maintained at -70 to -90 degree C for 3 minutes.

C. Spinal Cord Stimulator: Treatment for Chronic Pain Caused By Wrist Joint Fracture

Spinal Cord Stimulator is rarely indicated for wrist joint pain caused by wrist joint fracture. Spinal Cord Stimulator includes stimulator and generator.

Indications for Placement of Spinal Cord Stimulator-

  • Chronic pain caused by wrist joint fracture not responding to medication, physical therapy, interventional treatment and surgery.
  • Alternative to opioid therapy if opioid therapy is contraindicated. Oral opioids are contraindicated if patient is suffering with serious opioid side effects.

Spinal Cord Stimulator Procedure -

  • Spinal cord stimulator is placed over the pinched or irritated nerve at wrist joint or epidural space.
  • Procedure involves two stages-
    1. First stage is a trial phase. Stimulator is placed either over irritated nerve or within epidural space. Nerve or spinal cord is stimulated using external generator for 2 to 3 weeks to evaluate quality of pain relief.
    2. Second stage involves insertion of spinal cord stimulator and generator. Patient is considered for permanent placement of spinal cord stimulator if pain relief is over 50%. Permanent stimulator is placed over nerve at wrist or within epidural space and generator is inserted under skin over abdomen or gluteal area. Spinal cord stimulator connected to generator. The entire device is enclosed within the skin so nothing is seen externally.

Advantages of Spinal Cord Stimulator to Treat Wrist Joint Pain Due to Fracture -

  • Long term pain relief of over 50% of pain
  • Need for pain medication is reduced by at least 50% if not more.
  • Generator needs to be changed every 3 to 7 years.

Disadvantages of Spinal Cord Stimulator to Treat Wrist Joint Pain Due to Fracture -

  • Equipment is inserted in body tissue and thus needs surgical procedure.
  • Infection of the stimulator pocket or generator pocket demands removal of stimulator and generator.
  • Device is expensive.

D. Placement of Intrathecal Catheter and Programmable Pump to Treat Chronic Pain

Indications for Placement of Intrathecal Pump-

  • It is an alternative method of treating chronic pain with opioids. Intrathecal (opioid delivered within CSF) dosage of opioids to relieve chronic pain is 1/100th of oral dosage.
  • Intrathecal opioids are most effective pain medications. Medications injected in CSF are close to spinal cord and least concentration of opioid is necessary to block opioid receptors.
  • Oral opioid dosage may change rapidly in few patients because of resistance and tolerance to opioids. Rapid acceleration of therapeutic dosage of opioids may cause fatal outcome.
  • Fatality rate caused by oral opioids has increase in last 10 to 15 years.
  • Chronic pain not responding to oral opioids, physical therapy, interventional pain therapy, spinal cord stimulator or surgery is often treated by intrathecal pain medications.

Intrathecal Catheter and Pump Procedure Notes-

Intrathecal catheter and pump is placed under sedation or general anesthesia.

  • Intrathecal Catheter Placement- Intrathecal catheter is inserted within CSF (cerebrospinal fluid) under X-Ray guidance. Catheter in inserted between L2 and L5 spine. Catheter is carefully threaded to level of neck under X-ray guidance. Catheter tip is placed between C4 and C7 cervical spine.
  • Programmable Pump Placement- Programmable pump is placed under the skin of abdomen or gluteal area. Catheter is connected to pump. Catheter from back is passed to pump under the skin. Pump and catheter is covered by skin.

Advantages of Intrathecal Catheter and Pump Treatment-

  • Opioid dosage requirement is 1/100th of oral dose.
  • Quality of pain relief is much better than oral opioids.
  • Patients do not control opioid dosage.

Disadvantages of Intrathecal Catheter and Pump Treatment-

  • Infection of pump or catheter pockets.
  • Bleeding on pump or catheter pocket.
  • CSF leak causing CSF fluid accumulation in pump or catheter pockets.
  • Opioids side effects like nausea, vomiting and constipation.
  • Infection from pump and catheter pocket may spread in CSF and cause serious infection like Meningitis and Encephalitis.

5. Close Reduction of Wrist Joint Fracture

Indications for Close Reduction to Treat Wrist Joint Fracture-

  • Isolated wrist joint fracture of radius or ulna.
  • Fracture associated with wrist joint dislocation.
  • Fracture of carpal bone.

How Is Close Reduction To Treat Wrist Joint Fracture Done?

  • Close reduction is performed under deep sedations or general anesthesia.
  • Close reduction is performed by pulling wrist in opposite directions under x-ray guidance.
  • Wrist joint movement is restricted with cast for 6 to 8 weeks. Orthopedic Surgeon mostly performs close reduction.

Advantages of Close Reduction Treatment to Treat Wrist Joint Fracture-

  • Procedure is performed under sedation.
  • Open reduction and surgery is avoided.
  • Recovery is faster.
  • Infection avoided.

Disadvantages of Close Reduction Treatment to Treat Wrist Joint Fracture -

  • Procedure may fail
  • Casting may not prevent recurrence of dislocation or fracture.
  • Prolonged placement of cast is irritating and at times difficult to tolerate. Healing may take prolonged time and cast has to be kept until healing of fracture site is acceptable.

6. Surgery for Wrist Joint Fracture

Wrist Joint Fracture Reduction-

  • Percutaneous Fracture Reduction
  • Open Fracture Wrist Joint

Percutaneous Fixation with External Fixator, Pins and Casting

Indication for External Fixation to Treat Wrist Joint Fracture-

  • Unstable fracture of wrist joint following close reduction
  • Isolated wrist joint fracture of radius or ulna
  • Fracture of carpal bone.

How is External Fixation to Treat Wrist Joint Fracture Performed?

  • Procedure is performed under sedation like close reduction.
  • Steel or metal pins is inserted in dislocated or fractured fragments through the intact skin.
  • Second pin is inserted in proximal bone either radius or ulna.
  • External Fixator is used to pull two fracture segments. End of fracture segment are placed in normal anatomical aligned position.
  • Cast is applied over hand, wrist and forearm to prevent wrist joint movements.

Advantages of Percutaneous Fixation with External Fixator

  • Open surgery avoided.
  • Better joint stability after reduction of dislocated or fractured wrist joint than close reduction.
  • Permanent placement of hardware is avoided.
  • Minimum soft tissue injury.
  • Less painful procedure than open fixation.
  • Scarring and surgical trauma is avoided.
  • Cast is applied for 2 to 3 week in most cases.

Disadvantages of Percutaneous Fixation with External Fixator-

  • Bulky instruments and frame around wrist joint and forearm.
  • Unable to use injured hand and arm.

Complications of Percutaneous Fixation-

  • It can fail to reduce or maintain dislocated or fractured wrist joint
  • Infection caused by internal pins.
  • Nerve injury while placing pins.
  • Bleeding and hematoma resulting from laceration of blood vessels while placing pins in fractured segments.
  • Laceration or tear of ligaments and tendon by pin.

Internal Fixation (Plates, Screws, Pins) For Wrist Joint Fracture

Indications for Internal Fixation to Treat Wrist Joint Fracture-

  • Displaced fracture.
  • Unstable fracture after close reduction and external fixation.
  • Compound fracture.
  • Fracture associated with symptoms like tingling, numbness and weakness suggesting possible pinch nerve. Fracture needs to be reduced under direct vision to prevent permanent nerve injury.
  • Dislocation associated with fracture.

Advantages of Internal Fixation to Treat Wrist Joint Fracture--

  • Internal fixation prevents vascular and nerve injury.
  • Cast can be removed in 2 to 3 weeks.
  • Early physical therapy prevents long-term muscle atrophy and joint stiffness.
  • Increased joint stability.

Disadvantages of Internal Fixation to Treat Wrist Joint Fracture-

  • Procedure is performed under anesthetics.
  • Recovery involves wound healing and can be prolonged if followed by infection.
  • Infection may need long-term antibiotic treatment.

Complications of Internal Fixation Surgery For Wrist Joint Fracture-

  • Internal instrumentation may be unable to maintain normal alignment of the fracture or dislocated wrist joint.
  • Plate and screws may be misplaced.
  • Joint infection may force to remove hardware.
  • Surgical soft tissue injury may cause nerve damage, vascular tear or tendon rupture.

How is Internal Fixation Surgery Performed For Wrist Joint Fracture?

  • Skin Incision- Skin incision is made following general anesthesia or regional anesthesia.
  • Reduction of Fracture or Dislocation- Fracture fragments exposed using special equipment. Fracture is reduced either manually or using special equipment.
  • Internal fixation is performed using one of the following surgical technique-
    1. "K" Wire Placement.
    2. Screw and Plate.
  • "K" Wires- "K" wire is a stainless steel wire, which holds the fragments of fracture together. Surgery is indicated for carpal or metacarpal fracture.
  • Plate and Screws- Fracture or dislocation is fixed with plate, which is anchored to bone by screws. Plate and screws are made of stainless steel or titanium. Plates are shaped to maintain anatomical curves of wrist joint.

Recovery and Prognosis of Wrist Joint Fracture

Wrist joint is formed by radius, ulna and metacarpal bone. Metacarpal bones that often fracture are scaphoid, lunate and triquetral. The recovery time of healing of the wrist fracture bone depends on type of fracture. Hairline and stable non-displaced wrist fracture heals within 4 to 6 weeks. Displaced and comminuted wrist fracture takes 6 to 10 weeks for complete healing. Overlapping fracture may not heal and diagnosis may be delayed by few weeks. Overlapping wrist fracture is treated with surgery. Fracture of most of the wrist bones are stable and non-displaced fracture. Few displaced fracture can be reduced to normal anatomical position under anesthesia with or without surgery. Overall wrist fracture heals with non-surgical or surgical treatment within 6 to 10 weeks. During the healing period, wrist is immobilized with braces, splint or cast. The immobilizing of the wrist causes weakness and atrophy of the wrist muscles. Following healing of the fracture, patient is referred to physical therapy for 4 to 8 weeks. Considering healing time and time for physical therapy, patient may need 10 to 16 weeks to achieve normal function. Prognosis of wrist joint fracture depends on residual pain. Patient often suffers with mild to moderate pain. Pain eventually subsides or disappears with continuous use of wrist joint.

References:

  1. Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures.

    Komura S, Yokoi T, Nonomura H, Tanahashi H, Satake T, Watanabe N.

    J Hand Surg Am. 2012 Mar;37(3):469-76. doi: 10.1016/j.jhsa.2011.11.011. Epub 2012 Feb 7. Department of Orthopaedic Surgery, Gifu Prefectural General Medical

    Center, Gifu, Japan.

  2. The epidemiology of upper extremity injuries presenting to the emergency department in the United States.

    Ootes D, Lambers KT, Ring DC.

    Hand (N Y). 2012 Mar;7(1):18-22. doi: 10.1007/s11552-011-9383-z. Epub 2011 Dec 14.

    Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Suite 2100, 55 Fruit street, Boston, MA 02114 USA.

  3. Epidemiology of United States high school sports-related fractures, 2008-09 to 2010-11.

    Swenson DM, Henke NM, Collins CL, Fields SK, Comstock RD.

    Am J Sports Med. 2012 Sep;40(9):2078-84. doi: 10.1177/0363546512453304.

    Ohio State University, College of Medicine, Columbus, Ohio, USA.

  4. The effects of osteoporosis on functional outcome in patients with distal radius fracture treated with plate osteosynthesis.

    Büyükkurt CD, Bülbül M, Ayanoğlu S, Esenyel CZ, Oztürk K, Gürbüz H.

    Acta Orthop Traumatol Turc. 2012;46(2):89-95. doi: 10.3944/AOTT.2012.2440.Department of Orthopedics and Traumatology, Karapınar State Hospital, Konya, Turkey.

  5. Paget's disease in the hand: correlation of magnetic resonance imaging with histology.

    Trumble TE, Wu RK, Ruwe PA.

    J Hand Surg Am. 1990 May;15(3):504-7.

    Department of Orthopaedics, University of Washington School of Medicine, Seattle 98195.

  6. Oral glucocorticoid use is associated with an increased risk of fracture.

    Steinbuch M, Youket TE, Cohen S.

    Osteoporos Int. 2004 Apr;15(4):323-8.

    Procter and Gamble Health Care Research Center, 8700 Mason-Montgomery Road, Mason, OH 45040-9462, USA.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: December 26, 2015

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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