Category Archive Fracture of Bone A-Z

Collarbone Fracture/Clavicle fracture is one of the most common injuries around the shoulder girdle [rx]. It has been reported that fractures of the clavicle account for approximately 2.6% of all fractures [rx]. Incidence in males is usually highest in the second and third decade which decreases thereafter as per age [rx]. In females, it is usually bimodal, with a peak incidence in young and elderly [rx]. Allman classified clavicle fractures into three groups based on their location along the bone. The middle-third fractures are most common and account for approximately 80–85% all clavicular fractures [rx].

Fractures of the clavicle are common injuries accounting for between 2.6 and 4% of adult fractures and 35% of injuries to the shoulder girdle [rx–rx]. Early reports of clavicle fractures date back to Hippocrates [rx], who noted that “when a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage”.

Anatomy

The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years [rx].

Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concaves laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. The cross-sectional geometry also changes along its course. It progresses from more tubular medially to flat laterally. This change of contour, which is most acute at the junction of the middle and outer thirds, may explain the frequency of fractures seen in this area [rx].

The lateral clavicle is anchored to the coracoid process by the coracoclavicular ligament, composed of the lateral trapezoid and medial conoid parts. The static joint stabilizers are the AC ligaments, controlling the horizontal stability, and the CC ligament controlling the vertical stability. The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migration of the distal clavicle after disruption of the AC and CC ligaments alone [rx].

The deltoid, trapezius and pectoralis major muscles have important attachments to the clavicle. The deltoid muscle inserts onto the anterior surface of the lateral third of the clavicle, and the trapezius muscle onto the posterior aspect. The pectoralis major muscle inserts onto the anterior surface of the medial two thirds.

Mechanism of Injury of Collarbone Fracture

With the exception of the rare pathologic fracture due to metastatic or metabolic disease, clavicle fractures are typically due to trauma [rx]. Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall [rx]. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from the force applied directly to the shoulder. In a study of 122 consecutive patients, 87% clavicle injuries resulted from a fall onto the shoulder, 7% resulted from a direct blow, and 6% resulted from a fall onto an outstretched hand [rx].

Types of Collarbone Fracture

Classification

GROUP I – Middle third fractures (80%)

GROUP II – Distal third fractures (15%)

• Type I – Minimally displaced / interligamentous
• Type II – Displaced fractures, fracture medial to the coracoclavicular ligaments
  • IIA – Both ligaments (conoid and trapezoid) attached to the distal fragment
  • IIB – Conoid tore, trapezoid attached to the distal fragment
• Type III – Fractures involving articular surface
• Type IV – intact coracoclavicular ligaments attached to periosteal sleeve plus proximal fragment displaced
• Type V – Comminuted

GROUP III – Fracture of the proximal third (5%)

• Type I – Minimally displacement
• Type II – Displaced
• Type III – Intra-articular
• Type IV – Epiphyseal separation
• Type V – Comminuted

Classification by Robinson (Edinburgh classification)

ED managementthirdFollow-upMiddle

Causes of Collarbone Fracture

• Clavicle fractures  – are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Collarbone Fracture

• Pain – particularly with arm movement or on the front part of the upper chest
• Often – after the swelling has subsided, the fracture can be felt through the skin.
• Sharp pain – when any movement is made
• Referred pain – dull to extreme ache in and around clavicle area, including surrounding muscles
• Possible nausea – dizziness, and/or spotty vision due to extreme pain
• Bruising –  swelling, or bulging over your collarbone
• Decreased feeling – or a tingling feeling in your arm or fingers
• Swelling – ecchymosis, and tenderness may be noted over the clavicle
• Abrasion – over the clavicle may be noted, suggesting that the fracture was from a direct mechanism
• Crepitus from – the fracture ends rubbing against each other may be noted with gentle manipulation
• Difficulty breathing – or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax
• Palpation of the scapula – and ribs may reveal a concomitant injury
• Tenting and blanching of the skin – at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization
• The shoulder may appear shortened – relative to the opposite side and may droop
• Non-use – of the arm on the affected side is a neonatal presentation
• Associated distal nerve dysfunction indicates a brachial plexus injury
• Decreased pulses may indicate a subclavian artery injury
• Venous stasis discoloration and swelling indicate a subclavian venous injury.
• Pain where the broken bone is
• Having a hard time moving your shoulder or arm, and pain when you do move them
• A shoulder that seems to be sagging
• A cracking or grinding noise when you raise your arm
• The bone that is pushing against or through the skin
• The patient may cradle the injured extremity with the uninjured arm

Diagnosis of Collarbone Fracture

Physical Examination

• In a clavicle fracture, there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
• During the physical examination, a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
• The basic method to check for a clavicle fracture is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.^[rx]

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Collarbone Fracture

Treatment available can be broadly

Medications

Medication can be prescribed to ease the pain. 

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.^[10]

Surgery is considered when one or more of the following conditions present.

• Comminution with separation (bone is broken into multiple pieces)
• Significant foreshortening of the clavicle (indicated by shoulder forward)
• Skin penetration (open fracture)
• Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
• Nonunion after several months (3–6 months, typically)
• Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

• Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
• Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
  Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
• Precontoured locking plates
• Hook plate
• Distal radius plates
• Coracoclavicular screws
• Flexible coracoclavicular fixation
• Arthroscopic treatment
• Intra-medullary fixation
• Tension band fixation

Complications of Collarbone Fracture

There are risks associated with any type of surgery. These include:

• Nonunion (1-5%)
• Infection (~4.8%)
• Pneumothorax
• Adhesive capsulitis
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• Difficulty with bone healing
• Lung injury
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Thoracic outlet syndrome
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration
• Subclavian thrombosis

Rehabilitation of Collarbone Fracture

• A rehabilitation protocol was started after removal of the bandage in group 1 and immediately after plate fixation in group 2. Gentle pendulum exercises of the shoulder in the sling/arm pouch were allowed as per pain tolerance immediately after surgery in the surgically treated group and after 3 weeks in the conservative group.
• At 3 weeks, gentle active range of motion of the shoulder was allowed with abduction limiting to 90°. Subsequently, the active range of motion exercises that are to be performed at home is advised. At four to 6 weeks, active to an active assisted range of motion in all planes were allowed.
• When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to 12 weeks, isometric and isotonic exercises were prescribed to the shoulder girdle muscles with a return to full activities (including sports) at 3 months.
• Regular follow-up was done every fortnight for the initial 6 weeks, then at 06 weeks, 03 and 06 months using the patient’s subjective evaluation, functional outcome, and radiographic assessment. Patients’ subjective evaluation was investigated by direct interview at the follow-up visits. Functional outcome was graded on the standardized clinical evaluation and completion of the Constant and Murley score [rx].

References

Clavicle fracture is one of the most common injuries around the shoulder girdle [rx]. It has been reported that fractures of the clavicle account for approximately 2.6% of all fractures [rx]. Incidence in males is usually highest in the second and third decade which decreases thereafter as per age [rx]. In females, it is usually bimodal, with a peak incidence in young and elderly [rx]. Allman classified clavicle fractures into three groups based on their location along the bone. The middle-third fractures are most common and account for approximately 80–85% all clavicular fractures [rx].

Fractures of the clavicle are common injuries accounting for between 2.6 and 4% of adult fractures and 35% of injuries to the shoulder girdle [rx–rx]. Early reports of clavicle fractures date back to Hippocrates [rx], who noted that “when a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage”.

Anatomy

The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years [rx].

Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concaves laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. The cross-sectional geometry also changes along its course. It progresses from more tubular medially to flat laterally. This change of contour, which is most acute at the junction of the middle and outer thirds, may explain the frequency of fractures seen in this area [rx].

The lateral clavicle is anchored to the coracoid process by the coracoclavicular ligament, composed of the lateral trapezoid and medial conoid parts. The static joint stabilizers are the AC ligaments, controlling the horizontal stability, and the CC ligament controlling the vertical stability. The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migration of the distal clavicle after disruption of the AC and CC ligaments alone [rx].

The deltoid, trapezius and pectoralis major muscles have important attachments to the clavicle. The deltoid muscle inserts onto the anterior surface of the lateral third of the clavicle, and the trapezius muscle onto the posterior aspect. The pectoralis major muscle inserts onto the anterior surface of the medial two thirds.

Mechanism of Injury of Clavicle Fracture

With the exception of the rare pathologic fracture due to metastatic or metabolic disease, clavicle fractures are typically due to trauma [rx]. Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall [rx]. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from the force applied directly to the shoulder. In a study of 122 consecutive patients, 87% clavicle injuries resulted from a fall onto the shoulder, 7% resulted from a direct blow, and 6% resulted from a fall onto an outstretched hand [rx].

Types of Clavicle Fracture

Classification

GROUP I – Middle third fractures (80%)

GROUP II – Distal third fractures (15%)

• Type I – Minimally displaced / interligamentous
• Type II – Displaced fractures, fracture medial to the coracoclavicular ligaments
  • IIA – Both ligaments (conoid and trapezoid) attached to the distal fragment
  • IIB – Conoid tore, trapezoid attached to the distal fragment
• Type III – Fractures involving articular surface
• Type IV – intact coracoclavicular ligaments attached to periosteal sleeve plus proximal fragment displaced
• Type V – Comminuted

GROUP III – Fracture of the proximal third (5%)

• Type I – Minimally displacement
• Type II – Displaced
• Type III – Intra-articular
• Type IV – Epiphyseal separation
• Type V – Comminuted

Classification by Robinson (Edinburgh classification)

ED managementthirdFollow-upMiddle

Causes of Clavicle Fracture

• Clavicle fractures  – are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Clavicle Fracture

• Pain – particularly with arm movement or on the front part of the upper chest
• Often – after the swelling has subsided, the fracture can be felt through the skin.
• Sharp pain – when any movement is made
• Referred pain – dull to extreme ache in and around clavicle area, including surrounding muscles
• Possible nausea – dizziness, and/or spotty vision due to extreme pain
• Bruising –  swelling, or bulging over your collarbone
• Decreased feeling – or a tingling feeling in your arm or fingers
• Swelling – ecchymosis, and tenderness may be noted over the clavicle
• Abrasion – over the clavicle may be noted, suggesting that the fracture was from a direct mechanism
• Crepitus from – the fracture ends rubbing against each other may be noted with gentle manipulation
• Difficulty breathing – or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax
• Palpation of the scapula – and ribs may reveal a concomitant injury
• Tenting and blanching of the skin – at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization
• The shoulder may appear shortened – relative to the opposite side and may droop
• Non-use – of the arm on the affected side is a neonatal presentation
• Associated distal nerve dysfunction indicates a brachial plexus injury
• Decreased pulses may indicate a subclavian artery injury
• Venous stasis discoloration and swelling indicate a subclavian venous injury.
• Pain where the broken bone is
• Having a hard time moving your shoulder or arm, and pain when you do move them
• A shoulder that seems to be sagging
• A cracking or grinding noise when you raise your arm
• The bone that is pushing against or through the skin
• The patient may cradle the injured extremity with the uninjured arm

Diagnosis of Clavicle Fracture

Physical Examination

• In a clavicle fracture, there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
• During the physical examination, a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
• The basic method to check for a clavicle fracture is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.^[rx]

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Clavicle Fracture

Treatment available can be broadly

Medications

Medication can be prescribed to ease the pain. 

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.^[10]

Surgery is considered when one or more of the following conditions present.

• Comminution with separation (bone is broken into multiple pieces)
• Significant foreshortening of the clavicle (indicated by shoulder forward)
• Skin penetration (open fracture)
• Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
• Nonunion after several months (3–6 months, typically)
• Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

• Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.

• Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
  Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
• Precontoured locking plates
• Hook plate
• Distal radius plates
• Coracoclavicular screws
• Flexible coracoclavicular fixation
• Arthroscopic treatment
• Intra-medullary fixation
• Tension band fixation

Complications

There are risks associated with any type of surgery. These include:

• Nonunion (1-5%)
• Infection (~4.8%)
• Pneumothorax
• Adhesive capsulitis
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• Difficulty with bone healing
• Lung injury
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Thoracic outlet syndrome
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration
• Subclavian thrombosis

Rehabilitation of Clavicle Fracture

• A rehabilitation protocol was started after removal of the bandage in group 1 and immediately after plate fixation in group 2. Gentle pendulum exercises of the shoulder in the sling/arm pouch were allowed as per pain tolerance immediately after surgery in the surgically treated group and after 3 weeks in the conservative group.
• At 3 weeks, gentle active range of motion of the shoulder was allowed with abduction limiting to 90°. Subsequently, the active range of motion exercises that are to be performed at home is advised. At four to 6 weeks, active to an active assisted range of motion in all planes were allowed.
• When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to 12 weeks, isometric and isotonic exercises were prescribed to the shoulder girdle muscles with a return to full activities (including sports) at 3 months.
• Regular follow-up was done every fortnight for the initial 6 weeks, then at 06 weeks, 03 and 06 months using the patient’s subjective evaluation, functional outcome, and radiographic assessment. Patients’ subjective evaluation was investigated by direct interview at the follow-up visits. Functional outcome was graded on the standardized clinical evaluation and completion of the Constant and Murley score [rx].

References

Fracture Complications/Fracture of Bones is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may be broken into several pieces.^[rx] A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.^[rx]

Types of Fracture of Bones

Mechanism

• Traumatic fracture – This is a fracture due to sustained trauma. e.g., fractures caused by a fall, road traffic accident, fight, etc.
• Pathologic fracture – A fracture through a bone that has been made weak by some underlying disease is called pathological fracture. e.g., a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause of pathological fracture.
• Periprosthetic fracture – This is a fracture at the point of mechanical weakness at the end of an implant

Soft-tissue involvement

• Closed fractures are those in which the overlying skin is intact
• Open/compound fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.
  • Clean fracture
  • Contaminated fracture

Displacement

• Non-displaced
• Displaced
  • Translated, or ad latus, with sideways displacement.^[11]
  • Angulated
  • Rotated
  • Shortened

Fracture Pattern

• Linear fracture – A fracture that is parallel to the bone’s long axis
• Transverse fracture – A fracture that is at a right angle to the bone’s long axis
• Oblique fracture – A fracture that is diagonal to a bone’s long axis (more than 30°)
• Spiral fracture – A fracture where at least one part of the bone has been twisted
• Compression fracture/wedge fracture – usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma)
• Impacted fracture – A fracture caused when bone fragments are driven into each other
• Avulsion fracture – A fracture where a fragment of bone is separated from the main mass

Fragments

• Incomplete fracture – Is a fracture in which the bone fragments are still partially joined, in such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.
• Complete fracture – Is a fracture in which bone fragments separate completely.
• Comminuted fracture – Is a fracture in which the bone has broken into several pieces.

Anatomical Classifications

Fractures Bones is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may be broken into several pieces.^[rx] A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.^[rx]

Types of Fractures Bones

Mechanism

• Traumatic fracture – This is a fracture due to sustained trauma. e.g., fractures caused by a fall, road traffic accident, fight, etc.
• Pathologic fracture – A fracture through a bone that has been made weak by some underlying disease is called pathological fracture. e.g., a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause of pathological fracture.
• Periprosthetic fracture – This is a fracture at the point of mechanical weakness at the end of an implant

Soft-tissue involvement

• Closed fractures are those in which the overlying skin is intact
• Open/compound fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.
  • Clean fracture
  • Contaminated fracture

Displacement

• Non-displaced
• Displaced
  • Translated, or ad latus, with sideways displacement.^[11]
  • Angulated
  • Rotated
  • Shortened

Fracture Pattern

• Linear fracture – A fracture that is parallel to the bone’s long axis
• Transverse fracture – A fracture that is at a right angle to the bone’s long axis
• Oblique fracture – A fracture that is diagonal to a bone’s long axis (more than 30°)
• Spiral fracture – A fracture where at least one part of the bone has been twisted
• Compression fracture/wedge fracture – usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma)
• Impacted fracture – A fracture caused when bone fragments are driven into each other
• Avulsion fracture – A fracture where a fragment of bone is separated from the main mass

Fragments

• Incomplete fracture – Is a fracture in which the bone fragments are still partially joined, in such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.
• Complete fracture – Is a fracture in which bone fragments separate completely.
• Comminuted fracture – Is a fracture in which the bone has broken into several pieces.

Anatomical Classifications

Colles Fracture Causes/Colles’ fracture is an extra-articular distal radius fracture described by Abraham Colles in 1814. Colles’ fracture is a common fracture presentation in the orthopedic emergency department. It commonly affects the elderly female population. There is a direct relationship between osteoporosis and Colles’ fracture. Colles gave a description of a fracture of the distal radius, that is, within 2.5 cm above the wrist joint line, dorsally angulated and displaced, radially angulated and displaced, impacted and supinated, with or without distal radio-ulnar joint disruption [rx]. Fractures of the distal radius were considered uncomplicated injuries in the past. Initially, Abraham Colles treated these fractures when there was no radiography, aseptic surgery, or anesthesia, and the amount of disability following malunion was accepted. Malunion results in pain, mid-carpal instability, and post-traumatic arthritis [rx–rx].

Mechanism of Colles Fracture

Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination, and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.[rx]

The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution. Cancellous impaction of the metaphysis further compromises dorsal stability. Additional shearing forces influence the injury pattern, resulting in articular surface involvement.[rx]

Types of Colles Fracture

Melone classification

The system that comes closest to directing treatment has been devised by Melone. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex.^[rx]

Frykman Classification

Though the Frykman classification system has traditionally been used, there is little value in its use because it does not help direct treatment. This system focuses on articular and ulnar involvement. The classification is as follows:^[rx]

Universal Classification

The Universal classification system is descriptive but also does not direct treatment. Universal codes are:^[rx]

AO/OTA Classification

A widely used system that includes 27 subgroups. Three main groups based on fracture joint involvement (A – extra-articular, B – partial articular, C – complete articular). Classification further defined based on level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury.^[rx]

Fernandez Classification

The simplified system developed in response to AO classification, intended to be based off injury mechanism with more treatment-oriented classifications (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision making on a case-by-case basis)^[rx]

Note: Associated Lesions include carpal ligament injury, nerve injury, tendon damage, and compartment syndrome

Colles Fracture Causes

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken wrist.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis, a disease that weakens your bones
• Eave low muscle mass or poor muscle strength, or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice, or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Colles Fracture

Common symptoms of a Colles fracture include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• Bruising
• Tenderness
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Colles Fracture

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.^[rx]

The classic Colles fracture has the following characteristics:^[rx]

• Transverse fracture of the radius
• 2.5 cm (0.98 inches) proximal to the radio-carpal joint
• dorsal displacement and dorsal angulation, together with radial tilt^[rx]

Other characteristics^[rx][rx]

• Radial shortening
• Loss of ulnar inclination≤
• Radial angulation of the wrist
• Comminution at the fracture site
• Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• Ulnar styloid fracture
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Colles Fracture

Non-Surgical

• Elevate your wrist – on a pillow or the back of a chair above the level of your heart for the first few days. This will ease the pain and swelling.
• Ice the wrist – Do this for 15-20 minutes every two to three hours for two to three days. Be careful to keep the splint or cast dry while icing.
• Take over-the-counter painkillers – Ask your doctor about nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, naproxen, or aspirin(except for children). They can help with pain and swelling. However, these drugs have side effects, such as an increased risk of bleeding and ulcers. They should be used only occasionally unless your doctor specifically says otherwise, as this may delay healing.
• Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Medication of Distal Radius Fractures

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Closed Reduction and Casting

• All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
• Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the elbow. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[rx] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

• Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[rx]
• However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[rx]

Percutaneous Pinning

• Extra-articular fractures of the distal end of the radius with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[rx,rx]

External Fixation

• External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[rx]

Limited Open Reduction

• In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
• The radial styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
• A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[rx]

Open Reduction and Internal Fixation

• One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

Arthroscopic-Assisted Fracture Reduction

• Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the articular components and assessment and repair of ligamentous injury can then be undertaken.[rx,rx,rx] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation by Pho et al^[rx]

Acute Stage (0-8 weeks)

Goals

• Protection with short-arm cast
• Control pain and edema
• Maintain range in digits, elbows, shoulder

Interventions

• AROM and PROM of digits, elbow, shoulder
• Elevation of hand and digits to control edema
• Cast removal between 6-8 weeks

Sub Acute Stage

Goal

• Control pain and edema (TENS, ice)
• Increase ROM
• Increase activities of daily living (ADLs)

Interventions

• AROM and PROM of digits, elbow, shoulder
• AROM wrist flexion/ extension, forearm supination/ pronation
• PROM of low load and prolonged stretch

Settled Stage

Goals

• Regain full ROM
• Begin strengthening
• Return to activity

Interventions

• Continue all ROM exercises
• Progress to the strengthening of all joints^[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

• Control pain and edema (TENS, ice)
• Protect surgical site
• Maintain ROM of digits, elbow, shoulder

Interventions

• Elevation
• AROM of digits, elbow, shoulder
• AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

• Protect fracture site
• Control pain and edema (TENS, ice)
• ROM of involved and uninvolved joints

Interventions

• AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

• Regain full ROM
• Begin strengthening
• Increase tolerance to ADLs

Interventions

• ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
• PROM of low load and prolonged stretching of wrist motions
• Grip strengthening
• ADL training within tolerance^[rx]

Cryotherapy

• Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid^[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of oedema.^[rx]
• To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.^[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.^[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.^[rx]

Electrical Stimulation

• The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.^[rx]
• Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.^[rx]
• The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

• ISOMETRIC EXERCISE
  1. Wrist flexors and extensors
• ACTIVE RANGE OF MOTION EXERCISE
  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature
• INTRINSIC HAND MUSCLE EXERCISE
  • Thumb/digit opposition
  • Repetitive squeezing of theraputty
  • repetitive towel wringing exercise
• STRENGTHENING ROUTINE
  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated
• FUNCTIONAL ACTIVITIES
  • Patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

References

Colles Fracture Treatment/Colles’ fracture is an extra-articular distal radius fracture described by Abraham Colles in 1814. Colles’ fracture is a common fracture presentation in the orthopedic emergency department. It commonly affects the elderly female population. There is a direct relationship between osteoporosis and Colles’ fracture. Colles gave a description of a fracture of the distal radius, that is, within 2.5 cm above the wrist joint line, dorsally angulated and displaced, radially angulated and displaced, impacted and supinated, with or without distal radio-ulnar joint disruption [rx]. Fractures of the distal radius were considered uncomplicated injuries in the past. Initially, Abraham Colles treated these fractures when there was no radiography, aseptic surgery, or anesthesia, and the amount of disability following malunion was accepted. Malunion results in pain, mid-carpal instability, and post-traumatic arthritis [rx–rx].

Mechanism of Wrist Fractures

Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination, and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.[rx]

The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution. Cancellous impaction of the metaphysis further compromises dorsal stability. Additional shearing forces influence the injury pattern, resulting in articular surface involvement.[rx]

Types of Wrist Fractures

Melone classification

The system that comes closest to directing treatment has been devised by Melone. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex.^[rx]

Frykman Classification

Though the Frykman classification system has traditionally been used, there is little value in its use because it does not help direct treatment. This system focuses on articular and ulnar involvement. The classification is as follows:^[rx]

Universal Classification

The Universal classification system is descriptive but also does not direct treatment. Universal codes are:^[rx]

AO/OTA Classification

A widely used system that includes 27 subgroups. Three main groups based on fracture joint involvement (A – extra-articular, B – partial articular, C – complete articular). Classification further defined based on level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury.^[rx]

Fernandez Classification

The simplified system developed in response to AO classification, intended to be based off injury mechanism with more treatment-oriented classifications (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision making on a case-by-case basis)^[rx]

Note: Associated Lesions include carpal ligament injury, nerve injury, tendon damage, and compartment syndrome

Causes of Wrist Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken wrist.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis, a disease that weakens your bones
• Eave low muscle mass or poor muscle strength, or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice, or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Wrist Fractures

Common symptoms of a Colles fracture include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• Bruising
• Tenderness
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Wrist Fractures

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.^[rx]

The classic Colles fracture has the following characteristics:^[rx]

• Transverse fracture of the radius
• 2.5 cm (0.98 inches) proximal to the radio-carpal joint
• dorsal displacement and dorsal angulation, together with radial tilt^[rx]

Other characteristics^[rx][rx]

• Radial shortening
• Loss of ulnar inclination≤
• Radial angulation of the wrist
• Comminution at the fracture site
• Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• Ulnar styloid fracture
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Wrist Fractures

Non-Surgical

• Elevate your wrist – on a pillow or the back of a chair above the level of your heart for the first few days. This will ease the pain and swelling.
• Ice the wrist – Do this for 15-20 minutes every two to three hours for two to three days. Be careful to keep the splint or cast dry while icing.
• Take over-the-counter painkillers – Ask your doctor about nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, naproxen, or aspirin(except for children). They can help with pain and swelling. However, these drugs have side effects, such as an increased risk of bleeding and ulcers. They should be used only occasionally unless your doctor specifically says otherwise, as this may delay healing.
• Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Medication of Distal Radius Fractures

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Closed Reduction and Casting

• All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
• Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the elbow. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[rx] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

• Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[rx]
• However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[rx]

Percutaneous Pinning

• Extra-articular fractures of the distal end of the radius with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[rx,rx]

External Fixation

• External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[rx]

Limited Open Reduction

• In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
• The radial styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
• A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[rx]

Open Reduction and Internal Fixation

• One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

Arthroscopic-Assisted Fracture Reduction

• Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the articular components and assessment and repair of ligamentous injury can then be undertaken.[rx,rx,rx] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation by Pho et al^[rx]

Acute Stage (0-8 weeks)

Goals

• Protection with short-arm cast
• Control pain and edema
• Maintain range in digits, elbows, shoulder

Interventions

• AROM and PROM of digits, elbow, shoulder
• Elevation of hand and digits to control edema
• Cast removal between 6-8 weeks

Sub Acute Stage

Goal

• Control pain and edema (TENS, ice)
• Increase ROM
• Increase activities of daily living (ADLs)

Interventions

• AROM and PROM of digits, elbow, shoulder
• AROM wrist flexion/ extension, forearm supination/ pronation
• PROM of low load and prolonged stretch

Settled Stage

Goals

• Regain full ROM
• Begin strengthening
• Return to activity

Interventions

• Continue all ROM exercises
• Progress to the strengthening of all joints^[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

• Control pain and edema (TENS, ice)
• Protect surgical site
• Maintain ROM of digits, elbow, shoulder

Interventions

• Elevation
• AROM of digits, elbow, shoulder
• AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

• Protect fracture site
• Control pain and edema (TENS, ice)
• ROM of involved and uninvolved joints

Interventions

• AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

• Regain full ROM
• Begin strengthening
• Increase tolerance to ADLs

Interventions

• ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
• PROM of low load and prolonged stretching of wrist motions
• Grip strengthening
• ADL training within tolerance^[rx]

Cryotherapy

• Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid^[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of oedema.^[rx]
• To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.^[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.^[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.^[rx]

Electrical Stimulation

• The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.^[rx]
• Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.^[rx]
• The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

• ISOMETRIC EXERCISE
  1. Wrist flexors and extensors
• ACTIVE RANGE OF MOTION EXERCISE
  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature
• INTRINSIC HAND MUSCLE EXERCISE
  • Thumb/digit opposition
  • Repetitive squeezing of theraputty
  • repetitive towel wringing exercise
• STRENGTHENING ROUTINE
  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated
• FUNCTIONAL ACTIVITIES
  • Patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

References

Wrist Fractures/Colles’ fracture is an extra-articular distal radius fracture described by Abraham Colles in 1814. Colles’ fracture is a common fracture presentation in the orthopedic emergency department. It commonly affects the elderly female population. There is a direct relationship between osteoporosis and Colles’ fracture. Colles gave a description of a fracture of the distal radius, that is, within 2.5 cm above the wrist joint line, dorsally angulated and displaced, radially angulated and displaced, impacted and supinated, with or without distal radio-ulnar joint disruption [rx]. Fractures of the distal radius were considered uncomplicated injuries in the past. Initially, Abraham Colles treated these fractures when there was no radiography, aseptic surgery, or anesthesia, and the amount of disability following malunion was accepted. Malunion results in pain, mid-carpal instability, and post-traumatic arthritis [rx–rx].

Mechanism of Wrist Fractures

Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination, and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.[rx]

The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution. Cancellous impaction of the metaphysis further compromises dorsal stability. Additional shearing forces influence the injury pattern, resulting in articular surface involvement.[rx]

Types of Wrist Fractures

Melone classification

The system that comes closest to directing treatment has been devised by Melone. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex.^[rx]

[dropshadowbox align=”none” effect=”lifted-both” width=”auto” height=”” background_color=”#ffffff” border_width=”1″ border_color=”#dddddd” ]

Frykman Classification

Though the Frykman classification system has traditionally been used, there is little value in its use because it does not help direct treatment. This system focuses on articular and ulnar involvement. The classification is as follows:^[rx]

Universal Classification

The Universal classification system is descriptive but also does not direct treatment. Universal codes are:^[rx]

[/dropshadowbox]

AO/OTA Classification

A widely used system that includes 27 subgroups. Three main groups based on fracture joint involvement (A – extra-articular, B – partial articular, C – complete articular). Classification further defined based on level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury.^[rx]

Fernandez Classification

The simplified system developed in response to AO classification, intended to be based off injury mechanism with more treatment-oriented classifications (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision making on a case-by-case basis)^[rx]

[dropshadowbox align=”none” effect=”lifted-both” width=”auto” height=”” background_color=”#ffffff” border_width=”1″ border_color=”#dddddd” ]

Note: Associated Lesions include carpal ligament injury, nerve injury, tendon damage, and compartment syndrome

[/dropshadowbox]

Causes of Wrist Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken wrist.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis, a disease that weakens your bones
• Eave low muscle mass or poor muscle strength, or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice, or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Wrist Fractures

Common symptoms of a Colles fracture include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• Bruising
• Tenderness
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Wrist Fractures

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.^[rx]

The classic Colles fracture has the following characteristics:^[rx]

• Transverse fracture of the radius
• 2.5 cm (0.98 inches) proximal to the radio-carpal joint
• dorsal displacement and dorsal angulation, together with radial tilt^[rx]

Other characteristics^[rx][rx]

• Radial shortening
• Loss of ulnar inclination≤
• Radial angulation of the wrist
• Comminution at the fracture site
• Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• Ulnar styloid fracture
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Wrist Fractures

Non-Surgical

• Elevate your wrist – on a pillow or the back of a chair above the level of your heart for the first few days. This will ease the pain and swelling.
• Ice the wrist – Do this for 15-20 minutes every two to three hours for two to three days. Be careful to keep the splint or cast dry while icing.
• Take over-the-counter painkillers – Ask your doctor about nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, naproxen, or aspirin(except for children). They can help with pain and swelling. However, these drugs have side effects, such as an increased risk of bleeding and ulcers. They should be used only occasionally unless your doctor specifically says otherwise, as this may delay healing.
• Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

[dropshadowbox align=”none” effect=”lifted-both” width=”auto” height=”” background_color=”#ffffff” border_width=”1″ border_color=”#dddddd” ]

Medication of Distal Radius Fractures

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

[/dropshadowbox]

Closed Reduction and Casting

• All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
• Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the elbow. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[rx] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

• Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[rx]
• However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[rx]

Percutaneous Pinning

• Extra-articular fractures of the distal end of the radius with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[rx,rx]

External Fixation

• External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[rx]

Limited Open Reduction

• In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
• The radial styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
• A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[rx]

Open Reduction and Internal Fixation

• One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

Arthroscopic-Assisted Fracture Reduction

• Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the articular components and assessment and repair of ligamentous injury can then be undertaken.[rx,rx,rx] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation^[rx]

Acute Stage (0-8 weeks)

Goals

• Protection with short-arm cast
• Control pain and edema
• Maintain range in digits, elbows, shoulder

Interventions

• AROM and PROM of digits, elbow, shoulder
• Elevation of hand and digits to control edema
• Cast removal between 6-8 weeks

Sub Acute Stage

Goal

• Control pain and edema (TENS, ice)
• Increase ROM
• Increase activities of daily living (ADLs)

Interventions

• AROM and PROM of digits, elbow, shoulder
• AROM wrist flexion/ extension, forearm supination/ pronation
• PROM of low load and prolonged stretch

Settled Stage

Goals

• Regain full ROM
• Begin strengthening
• Return to activity

Interventions

• Continue all ROM exercises
• Progress to the strengthening of all joints^[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

• Control pain and edema (TENS, ice)
• Protect surgical site
• Maintain ROM of digits, elbow, shoulder

Interventions

• Elevation
• AROM of digits, elbow, shoulder
• AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

• Protect fracture site
• Control pain and edema (TENS, ice)
• ROM of involved and uninvolved joints

Interventions

• AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

• Regain full ROM
• Begin strengthening
• Increase tolerance to ADLs

Interventions

• ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
• PROM of low load and prolonged stretching of wrist motions
• Grip strengthening
• ADL training within tolerance^[rx]

Cryotherapy

• Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid^[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of oedema.^[rx]
• To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.^[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.^[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.^[rx]

Electrical Stimulation

• The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.^[rx]
• Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.^[rx]
• The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

• ISOMETRIC EXERCISE
  1. Wrist flexors and extensors
• ACTIVE RANGE OF MOTION EXERCISE
  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature
• INTRINSIC HAND MUSCLE EXERCISE
  • Thumb/digit opposition
  • Repetitive squeezing of theraputty
  • repetitive towel wringing exercise
• STRENGTHENING ROUTINE
  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated
• FUNCTIONAL ACTIVITIES
  • Patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

Complications of Wrist Fracture

Median Nerve Neuropathy (Carpal Tunnel Syndrome)[rx]

• Most frequent neurologic complication
• One percent to 12% of low-energy fractures and up to 30% of high-energy fractures
• Treat with acute carpal tunnel release in progressive paresthesias, weakness in thumb opposition if symptoms do not respond to closed reduction, and if they last greater than 24 to 48 hours

Extensor Pollicus Longus Tendon Rupture[rx][rx]

• Nondisplaced distal radius fractures have a higher rate of spontaneous rupture of the extensor pollicus longus tendon

Radiocarpal Arthrosis

• The reported incidence of up to 30%
• Ninety percent of young adults will develop symptomatic arthrosis if articular step-off is greater than 1 to 2 mm
• May also be asymptomatic
• Malunion and nonunion

Compartment Syndrome

Complex Regional Pain Syndrome

References

Distal Radius Fractures/Colles’ fracture is an extra-articular distal radius fracture described by Abraham Colles in 1814. Colles’ fracture is a common fracture presentation in the orthopedic emergency department. It commonly affects the elderly female population. There is a direct relationship between osteoporosis and Colles’ fracture. Colles gave a description of a fracture of the distal radius, that is, within 2.5 cm above the wrist joint line, dorsally angulated and displaced, radially angulated and displaced, impacted and supinated, with or without distal radio-ulnar joint disruption [rx]. Fractures of the distal radius were considered uncomplicated injuries in the past. Initially, Abraham Colles treated these fractures when there was no radiography, aseptic surgery, or anesthesia, and the amount of disability following malunion was accepted. Malunion results in pain, mid-carpal instability, and post-traumatic arthritis [rx–rx].

Mechanism of Distal Radius Fractures

Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination, and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.[rx]

The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution. Cancellous impaction of the metaphysis further compromises dorsal stability. Additional shearing forces influence the injury pattern, resulting in articular surface involvement.[rx]

Types of Distal Radius Fractures

Melone classification

The system that comes closest to directing treatment has been devised by Melone. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex.^[rx]

Frykman Classification

Though the Frykman classification system has traditionally been used, there is little value in its use because it does not help direct treatment. This system focuses on articular and ulnar involvement. The classification is as follows:^[rx]

Universal Classification

The Universal classification system is descriptive but also does not direct treatment. Universal codes are:^[rx]

AO/OTA Classification

A widely used system that includes 27 subgroups. Three main groups based on fracture joint involvement (A – extra-articular, B – partial articular, C – complete articular). Classification further defined based on level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury.^[rx]

Fernandez Classification

The simplified system developed in response to AO classification, intended to be based off injury mechanism with more treatment-oriented classifications (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision making on a case-by-case basis)^[rx]

Note: Associated Lesions include carpal ligament injury, nerve injury, tendon damage, and compartment syndrome

Causes of Distal Radius Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken wrist.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis, a disease that weakens your bones
• Eave low muscle mass or poor muscle strength, or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice, or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Distal Radius Fractures

Common symptoms of a Colles fracture include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• Bruising
• Tenderness
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Distal Radius Fractures

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.^[rx]

The classic Colles fracture has the following characteristics:^[rx]

• Transverse fracture of the radius
• 2.5 cm (0.98 inches) proximal to the radio-carpal joint
• dorsal displacement and dorsal angulation, together with radial tilt^[rx]

Other characteristics^[rx][rx]

• Radial shortening
• Loss of ulnar inclination≤
• Radial angulation of the wrist
• Comminution at the fracture site
• Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• Ulnar styloid fracture
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Distal Radius Fractures

Non-Surgical

• Elevate your wrist – on a pillow or the back of a chair above the level of your heart for the first few days. This will ease the pain and swelling.
• Ice the wrist – Do this for 15-20 minutes every two to three hours for two to three days. Be careful to keep the splint or cast dry while icing.
• Take over-the-counter painkillers – Ask your doctor about nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, naproxen, or aspirin(except for children). They can help with pain and swelling. However, these drugs have side effects, such as an increased risk of bleeding and ulcers. They should be used only occasionally unless your doctor specifically says otherwise, as this may delay healing.
• Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Medication of Distal Radius Fractures

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Closed Reduction and Casting

• All fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization. Mainly type I and type IIA Melone’s fracture can be managed conservatively. The fracture should be kept under closed observation to look for any re-displacement.
• Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to the elbow. No clear consensus exists as to the best position for immobilizing the wrist in plaster. Sarmiento et al.[rx] advocated immobilization in a position of supination to decrease the deforming force of the brachioradialis, which may cause loss of reduction.

Pins and Plaster Technique

• Placement of pins in the metacarpals and forearm was initially advocated by Bohler in 1923, but it gained popularity after the report by Green, who showed good or excellent results in 86% of his patients.[rx]
• However, he noted a high incidence of minor or major complications, one-third of which were related to pin site only. Other researchers also noted that one-third of the complications were related to pins and 16% of the patients needed reoperation for complications.[rx]

Percutaneous Pinning

• Extra-articular fractures of the distal end of the radius with extensive comminution or the fractures that have no more than two articular fragments, in which anatomical reduction is obtainable, are amenable to percutaneous pinning of the fracture fragments and application of a plaster cast. A single pin placed through the radial styloid as a means of stabilizing the displaced fracture fragment was first suggested by Lambotte in 1908.[rx,rx]

External Fixation

• External fixation is generally accepted as superior to plaster immobilization in the young patients with an intra-articular comminuted fracture of the distal radius. Other indications for external fixation include some unstable extra-articular fractures with significant comminution and failure to maintain reduction after an initial attempt at closed management in a cast, certain situations of multiple trauma, the presence of dysfunctional contralateral limb, severe open fractures with significant soft tissue injury and neurovascular compromise, and bilateral injuries.[rx]

Limited Open Reduction

• In intra-articular fractures that have more than 2 mm of displacement, the radio-carpal joint may be incongruent despite adequate attempts at reduction. The incongruency usually involves the lunate part of the distal end of the radius.
• The radial styloid process and scaphoid facet are more amenable to reduction through ligamentotaxis or by manipulation and reduction.
• A new technique of combining external fixation with open reduction of the displaced lunate fossa through a small, longitudinal incision and elevation of the impacted fragment without direct visualization of the surface of the joint has been described.[rx]

Open Reduction and Internal Fixation

• One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.

Arthroscopic-Assisted Fracture Reduction

• Intra-articular fractures of the radius can be arthroscopically assessed, and reduction of the articular components and assessment and repair of ligamentous injury can then be undertaken.[rx,rx,rx] The ideal timing for arthroscopically assisted distal radius surgery is 3 to 7 days after injury.

Rehabilitation Guideline for Non-Operative/Conservative rehabilitation by Pho et al^[rx]

Acute Stage (0-8 weeks)

Goals

• Protection with short-arm cast
• Control pain and edema
• Maintain range in digits, elbows, shoulder

Interventions

• AROM and PROM of digits, elbow, shoulder
• Elevation of hand and digits to control edema
• Cast removal between 6-8 weeks

Sub Acute Stage

Goal

• Control pain and edema (TENS, ice)
• Increase ROM
• Increase activities of daily living (ADLs)

Interventions

• AROM and PROM of digits, elbow, shoulder
• AROM wrist flexion/ extension, forearm supination/ pronation
• PROM of low load and prolonged stretch

Settled Stage

Goals

• Regain full ROM
• Begin strengthening
• Return to activity

Interventions

• Continue all ROM exercises
• Progress to the strengthening of all joints^[rx]

Rehabilitation Guideline for External Fixation by Pho et al

Acute Stage (1-6 weeks)

Goals

• Control pain and edema (TENS, ice)
• Protect surgical site
• Maintain ROM of digits, elbow, shoulder

Interventions

• Elevation
• AROM of digits, elbow, shoulder
• AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

• Protect fracture site
• Control pain and edema (TENS, ice)
• ROM of involved and uninvolved joints

Interventions

• AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

• Regain full ROM
• Begin strengthening
• Increase tolerance to ADLs

Interventions

• ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
• PROM of low load and prolonged stretching of wrist motions
• Grip strengthening
• ADL training within tolerance^[rx]

Cryotherapy

• Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid^[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of oedema.^[rx]
• To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.^[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.^[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.^[rx]

Electrical Stimulation

• The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.^[rx]
• Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.^[rx]
• The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active rehabilitation program used in Study

• ISOMETRIC EXERCISE
  1. Wrist flexors and extensors
• ACTIVE RANGE OF MOTION EXERCISE
  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature
• INTRINSIC HAND MUSCLE EXERCISE
  • Thumb/digit opposition
  • Repetitive squeezing of theraputty
  • repetitive towel wringing exercise
• STRENGTHENING ROUTINE
  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated
• FUNCTIONAL ACTIVITIES
  • Patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

References