Fractures about the wrist are very common when people fall with their body weight onto their hands. The most common fracture about the wrist is that of the distal radius, i.e., the larger forearm bone. This fracture must be assessed with proper x-rays to determine a course of treatment. Initial urgent care consists of splinting of the arm and possible closed reduction of the fracture. If this is determined not to be corrective, then open reduction and fixation, i.e., surgery would be warranted. If the patient is casted, typically they would be immobilized for approximately 6 weeks with sequential x-rays taken during that 6 week time to determine the efficacy of the treatment and making sure that the bone is still in good alignment. If there is deterioration of the alignment and/or there is an unstable fracture from the onset, then surgical intervention is warranted.
This type of surgery is done on an ambulatory basis, i.e., outpatient, under regional anesthesia, i.e., anesthesia just for the upper extremity involved. It involves an incision on the palm side of the forearm to obtain access to the radius bone and placement of a plate. This plate is made of titanium alloy as well as the screws that stabilize the plate to the bone are made of titanium alloy as well.
The advantages of the plate are that they allow for the best possible reduction and maintenance of the bone and alignment as well as allow for early mobilization of the wrist and fingers because the patient does not have to be immobilized in a cast for 6 weeks. Postoperatively, however, the patient must keep the arm clean and dry for approximately 2 weeks while the sutures are in still in place. Subsequent to this, then bathing is allowed freely. Typically, therapy is initiated for the wrist and hand one week after surgical intervention with a removable orthosis placed for stabilization of the arm. Therapy can last several months after the surgical procedure in an effort to regain maximal function within the hand and upper extremity. Complications are rare, but one of the problems that can arise usually at a significant time after the surgery, i.e., years, is irritation of the flexor tendons within the arm and hand. If it does become prominent, then consideration for removal of plate can be done at a later date once the fracture is healed. This problem usually arises in less than 5% of patients that have had surgery for a distal radius fracture.
Scaphoid fractures are the most common carpal bone fractures within the wrist. They usually result from a fall on an outstretched hand. The patient presents with pain and swelling within the radial snuffbox of the wrist. Initial x-rays may not be definitive and an MRI often helps in making a diagnosis. This scaphoid is divided up into proximal, mid and distal zones. Proximal means closer to the head. If the fracture is within the proximal to mid zone, then serious consideration for surgical intervention is warranted.
The scaphoid does have a precarious blood supply and in approximately 33% of patients that have a fracture, the proximal portion will go on to develop avascular necrosis, i.e., death of the bone secondary to the damage to the blood supply. If this does happen, it does not preclude healing of the fracture, but can delay it. Fractures that are evaluated acutely and are non-displaced gives the patient 2 options for treatment. If the fracture is in the proximal portion of the scaphoid, then strong recommendation for surgical fixation with an implantable screw is warranted. Even at the level of the mid waist, a strong recommendation for screw fixation is warranted.
The other option is cast immobilization. Cast immobilization, however, usually means immobilization of the thumb, forearm, and wrist for at least 3 months to secure proper healing. This is only indicated in non-displaced fractures. If the fracture is displaced greater than I mm, the surgical intervention is warranted. The advantage of surgery in either non-displaced or displaced fractures is that it affords excellent stabilization of the fracture, compression of the fracture site and greater than a 90% chance of healing. In addition, it allows the patient to begin early mobilization of the wrist approximately I week after the surgical intervention because of excellent stability it affords the fracture. It is not uncommon to see patients present with a non-union of the scaphoid. This represents an old injury that was no appreciated and the scaphoid bone has gone on to fail with regard to the healing process.
The patient often presents with chronic pain and swelling within the wrist. If left unattended, the scaphoid fracture and the subsequent non-union can lead to degenerative changes within the wrist. This would then require more of a radical type of surgical procedure. A scaphoid non-union when recognized should be treated with surgical intervention. This includes the use of a titanium screw as well as bone grafting which is typically obtained from the distal radius within the same surgical field. In addition, a bone stimulator can be used postoperatively in an effort to accelerate healing and increase the incidence of healing. Literature reveals that the incidence of healing after screw immobilization and bone grafting is approximately 90%.