Colles’ fracture definition
- extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal displacement ± ulnar styloid fracture
- most common fracture in those >40 yr, especially in women and those with osteoporotic bone
Colles’ fracture mechanism
FOOSH
Colles’ fracture clinical features
- “dinner fork” deformity
* swelling, ecchymosis, tenderness
Colles’ fracture investigations
• X-ray: AP and lateral wrist
Colles’ fracture treatment
• goal is to restore radial height (13 mm), radial inclination (22°), volar tilt (11°), as well as DRUJ stability and useful forearm rotation
• non-operative
■ closed reduction (think opposite of the deformity)
◆ hematoma block (sterile prep and drape, local anesthetic injection directly into fracture site) or conscious sedation
◆ closed reduction:
1) traction with extension (exaggerate injury),
2) traction with ulnar deviation, pronation, flexion (of distal fragment – not at wrist)
◆ dorsal slab/below elbow cast for 5-6 wk
◆ x-ray at 1 wk, 3 wk, and at cessation of immobilization to ensure reduction is maintained
■ obtain post-reduction films immediately; repeat reduction if necessary
• operative
■ indicatio : failed closed reduction, or loss of reduction
Displaced intra-articular fracture
Comminuted
Severre osteoporosis
Dorsal angulation >5o or volar tilt >20o
>5 mm radial shortening
■ percutaneous pinning, external fixation, or ORIF
Smith’s Fracture definition
volar displacement of the distal radius (i.e. reverse Colles’ fracture)
Smith’s Fracture mechanism
fall onto the back of the flexed hand
Smith’s Fracture investigations
X-ray: AP and lateral wrist
Smith’s Fracture treatment
• usually unstable and needs ORIF
• if patient is poor operative candidate, may attempt non-operative treatment
■ closed reduction with hematoma block (reduction opposite of Colles’)
■ long-arm cast in supination x 6 wk
Complications of wrist fractures
- most common complications are poor grip strength, stiffness, and radial shortening
- distal radius fractures in individuals <40 yr of age are usually highly comminuted and are likely to require ORIF
- 80% have normal function in 6-12 mo
Early Difficult reduction ± loss of reduction Compartment syndrome Extensor pollicis longus tendon rupture Acute carpal tunnel syndrome Finger swelling with venous block Complications of a tight cast/splint
Late
Malunion, radial shortening
Painful wrist secondary to ulnar prominence
Frozen shoulder “shoulder-hand syndrome”)
Post-traumatic arthritis
Carpal tunnel syndrome
CRPS/RSD
Scaphoid fracture epidemiology
- common in young men; not common in children or in patients beyond middle age
- most common carpal bone injured
- may be associated with other carpal or wrist injuries (e.g. Colles’ fracture)
Scaphoid fracture mechanism
FOOSH: impaction of scaphoid on distal radius, most commonly resulting in a transverse fracture through the waist (65%), dstal (10%), or proximal (25%) scaphoid
Scaphoid fracture clinical features
- pain with resisted pronation
- tenderness in the anatomical “snuff box”, over scaphoid tubercle, and pain with long axis compression into scaphoid
Tender snuff box: 100% sensitivity, but 29% specific, as it is also positive with many other injuries of radial aspect of wrist with FOOSH
• usually nondisplaced
Scaphoid fracture investigations
- X-ray: AP, lateral, scaphoid views with wrist extension and ulnar deviation
- ± CT or MRI
• bone scan rarely used
■ note: a fracture may not be radiologically evident up to 2 wk after acute injury, so if a patient complains of wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat as if positive for a scaphoid fracture and repeat x-ray 2 wk later to rule out a fracture; if x-ray still negative, order CT or MRI
Scaphoid fracture treatment
• early treatment critical for improving outcomes
• non-operative
■ non-displaced (<1 mm displacement/<15° angulation): long arm thumb spica cast x 4 wk, then short arm cast until radiographic evidence of healing is seen (2-3 mo)
• operative
■ displaced: ORIF with headless/countersink compression screw is the mainstay treatment
Scaphoid fracture specific complications
- most common: nonunion/malunion (use bone graft from iliac crest or distal radius with fixation to heal)
- AVN of the proximal fragment
- delayed union (recommend surgical fixation) • scaphoid nonunion advanced collapse (SNAC) – chronic nonunion leading to advanced collapse and arthritis of wrist
Scaphoid fracture prognosis
- proximal fifth fracture: AVN rate 100%; proximal third fracture: AVN rate 33%
- waist fractures have healing rates of 80-90%
- distal third fractures have healing rates close to 100%
The proximal pole of the scaphoid receives as much as 100% of its arterial blood supply from the radial artery that enters at the distal pole. A fracture through the proximal third disrupts this blood supply and results in a high incidence of AVN/nonunion
