Distal radius fractures: Is surgery necessary?

As a result of icy and brutally cold weather conditions, we are seeing an increasing amount of injuries from FOOSH: Fall on outstretched hand. These injuries have an impact on proper hand and wrist function.

Some of the most common injuries we see this time of year are distal radius fractures (broken bones at the level of the wrist and forearm).

Distal radius fractures (DRF's) are among the most common type of fracture. DRF's have a bimodal distribution, with a peak in younger persons (aged 18-25 years) and a second peak in older persons (aged >65 years).These broken bones occur due to high impact injury in younger patients and can result from a fall from standing in older individuals.

Distal radius fractures were first described by an Irish Surgeon Abraham Colles in 1814. His description was based on clinical observation alone as X ray imaging had not been invented as a diagnostic tool at that time. These injuries were immobilized for a prolonged period of time and it was considered that all fractures would fare the same regardless of their nature.

After the advent of X ray imaging more thorough classifications were invented based on the location of the break(fracture), amount of displacement(shift of the bone from its normal position) etc. Eponyms have also been added to describe the most common type of wrist fractures: Smith, Colles, Barton fractures etc.

Today, the treatment goals have significantly changed. Instead of focusing on the concept of bone immobilization and healing, we now focus on early return to regular activities and regaining normal upper extremity function.

Simple immobilization and waiting for DRF's to heal has not been proven to be beneficial in all cases as we learned more and more about the nature and location of distal radius fractures based on X ray and more advanced CT scan imaging. As a result of this, indications for surgical intervention as opposed to casting or splinting have been expanded. We now look at a myriad of parameters when considering surgical intervention.

Does the break (fracture) go inside the joint? Is there an unevenness of the joint surface as a result of the break (intraarticular step off)? Has the distal radius bone significantly shortened as a result of the break and has its anatomy changed as a result of bone movement (radial length, inclination, volar tilt)?

In the treatment of distal radius fractures (DRFs), the goal is to return the patient to his or her prior level of functioning. The physician's role is to discuss the options with the patient, and the patient's role is to choose the option that best serves his or her needs and wishes.

Surgical intervention is indicated when some of the above parameters are still abnormal after reducing the bone. In some cases, even mild distortion of these parameters can lead to significant disability if left without surgical treatment.

Evaluation by a skilled hand and upper extremity surgeon may be imperative even in cases of "mild" distal radius fractures because so much of hand and wrist range of motion and dexterity is dependent upon proper healing.

Some of the most common side effects from improper bone healing are significant wrist and hand stiffness, pain or inability to flip the hand up and down(loss of pronation, supination), pain with lifting objects, wrist pain at rest and are not limited to these.

After any break, the window of opportunity for proper reduction is several days and surgical intervention is up to 2 weeks. Delay in treatment may lead to significant disability.

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