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| | [[File:Distal RF Xray.gif|300px|thumb|X-ray wrist AP and Lateral view. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]] |
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| | '''For patient information, click [[Distal radius fracture (patient information)|here]]''' |
| | {{Distal radius fracture}} |
| | {{CMG}}; {{AE}} {{Rohan}} |
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| ==Overview==
| | {{SK}} Wrist fracture; fractured wrist; Colles' fracture; Smith's fracture; Barton's fracture; Chauffeur's fracture |
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| '''Distal radius fractures''' are a very common [[injury]] of the [[radius (bone)|radius]] that occur at the distal end, where the [[wrist]] [[joint]] lies.
| | ==[[Distal radius fracture overview|Overview]]== |
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| ==Definition== | | ==[[Distal radius fracture historical perspective|Historical Perspective]]== |
| A [[fracture (bone)|fracture]] affecting the distal end of the [[radius (bone)|radius]] and often the [[ulna|ulnar styloid]]. Because of its close proximity to the [[wrist|wrist joint]] this injury is often called a '''wrist fracture'''.
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| ==Synonyms== | | ==[[Distal radius fracture classification|Classification]]== |
| Wrist fracture; fractured wrist; [[Colles' fracture]]; [[Smith's fracture]]; [[Barton's fracture]]; [[Chauffeur's fracture]] (so called because the crank used to start old cars often kicked back and broke the chauffeurs' wrists with a particular pattern). Most of these names are applied to specific patterns of distal radius fracture but confusion exists because "Colles' Fracture" is used (for example by the US National Library of Medicine[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=mesh&list_uids=68003100&dopt=Full]) as a generic term for distal radius fracture.
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| ==Incidence== | | ==[[Distal radius fracture pathophysiology|Pathophysiology]]== |
| This is the most commonly occurring fracture in adults. Common fragility fracture in the elderly. Also a common injury in children where it may involve the [[epiphysis|growth plate]]. A similar fracture in children involving the growth plate is called a Salter Harris Fracture. It is less common in young adults but because it requires greater force, the injury is often very severe in this age group.
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| ==Pathogenesis and predisposing factors== | | ==[[Distal radius fracture causes|Causes]]== |
| The most common cause of this type of [[fracture (bone)|fracture]] is when an [[individual]] falls on an outstretched hand (''[[acronym]]'': '''FOOSH''').<ref name="pmid10499710">{{cite journal |author=Vilke GM |title=FOOSH injury with snuff box tenderness |journal=J Emerg Med |volume=17 |issue=5 |pages=899–900 |year=1999 |pmid=10499710 |doi=}}</ref> In young adults it is the result of moderate to severe force. The risk of injury is increased in patients with [[osteoporosis]] and other metabolic bone diseases.
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| ==Clinical features== | | ==[[Distal radius fracture differential diagnosis|Differentiating Distal radius fracture from other Diseases]]== |
| ===History===
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| Patients usually present with a history of an injury and localized [[Pain and nociception|pain]]. They frequently also notice deformity of the wrist and swelling. Numbness of the hand can occur. Inability to use the hand is also common.
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| ===Examination=== | | ==[[Distal radius fracture epidemiology and demographics|Epidemiology and Demographics]]== |
| Deformity, tenderness and loss of wrist motion are normal features on examination of a patient with a distal radius fracture. Swelling is common. Broadening of the wrist can be perceived. Radial styloid and ulnar styloid may be at the same level. Examination should rule out a skin wound which might suggest an open fracture, loss of sensation or loss of circulation to the hand.
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| ===Injuries associated=== | | ==[[Distal radius fracture risk factors|Risk Factors]]== |
| [[Scaphoid_fracture|Scaphoid fracture]]; wrist dislocation. Injuries to the elbow, humerus and shoulder are also common after a FOOSH (fall on out-stretched hand). Swelling and displacement can cause an acute [[carpal tunnel syndrome]]. | |
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| ==Diagnosis== | | ==[[Distal radius fracture screening|Screening]]== |
| Diagnosis may be evident clinically when the distal radius is deformed but should be confirmed by x-ray.<br>
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| '''Differential Diagnosis''' includes scaphoid fracture and wrist dislocation which can also co-exist with a distal radius fracture.
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| ==Investigation== | | ==[[Distal radius fracture natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| X-ray of the affected wrist is required if a fracture is suspected. CT scan is often performed to investigate the exact anatomy of the fracture, especially if surgery is considered. Investigation of a potential distal radial fracture includes assessment of the ''lateral articular angle'', ''radial length'', and ''articular surface''.
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| ===Lateral articular angle=== | | ==Diagnosis== |
| The lateral articular angle is the angle between the axis of the radius and the articular cup. This angle is measured on x-ray films.
| | [[Distal radius fracture history and symptoms|History and Symptoms]] | [[Distal radius fracture physical examination|Physical Examination]] | [[Distal radius fracture laboratory findings|Laboratory Findings]] | [[Distal radius fracture x ray|X Ray]] | [[Distal radius fracture CT|CT]] | [[Distal radius fracture MRI|MRI]] | [[Distal radius fracture other imaging findings|Other Imaging Findings]] | [[Distal radius fracture other diagnostic studies|Other Diagnostic Studies]] |
| Normally, the angle is turned down toward the [[thumb]] (volar tilt) by 11°.
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| As pressure is applied to the radius, the cup may become aligned differently.
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| Alignment up to 0° is still considered to be functional, and does not require any intervention.
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| However, tilt away from the thumb (dorsal tilt) beyond this point (>11° deviation) requires reduction of the fracture.
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| When dorsal tilt beyond the acceptable threshold occurs, distal radio-ulnar joint motion is altered, and [[forearm]] rotation becomes restricted. The upper limit of an acceptable deformity after reduction of the fracture is 5° of dorsal tilt.
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| ===Radial length=== | | ==Treatment== |
| Radial length is one of the important considerations in a distal radius fracture.
| | [[Distal radius fracture non-operative treatment|Non-Operative Treatment]] | [[Distal radius fracture surgery|Surgery]] | [[Distal radius fracture primary prevention|Primary Prevention]] | [[Distal radius fracture secondary prevention|Secondary Prevention]] | [[Distal radius fracture cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Distal radius fracture future or investigational therapies|Future or Investigational Therapies]] |
| The core question that must be answered is "is it short?"
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| The radius length would be too short if there is greater than neutral variance, especially when compared to the opposite side of the body.
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| If the radial length remains uncorrected, [[ulnar impaction syndrome]] may occur.
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| ===Articular surface=== | | ==Case Studies== |
| Any articular joint surface must be smooth for it to function properly.
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| The surface is not smooth if there is more than 1 [[millimeter|mm]] step deformity, and is associated with posttraumatic [[arthrosis]].
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| Irregularity may result in radiocarpal [[arthritis]], [[Pain and nociception|pain]], and stiffness.
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| If the surface is very irregular, the optimal treatment is fusion.
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| ==Classification==
| | [[Distal radius fracture case study one|Case #1]] |
| In medicine, classifications systems are devised to describe patterns of injury which will behave in predictable ways, to distinguish between conditions which have different outcomes or which need different treatments. Most wrist fracture systems have failed to accomplish any of these goals and there is no consensus about the most useful one.
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| ===OTA system=== | | ==External Links== |
| The [http://www.ota.org/compendium/radius.pdf|Orthopaedic Trauma Association classification] is widely accepted and under constant review. (More details available [[Bone fracture#OTA classification (Orthopaedic Trauma Association)|here]].)
| | * [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=mesh&list_uids=68003100&dopt=Full NLM MeSH entry on Colles' Fracture] |
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| * (21-A) Extra-articular
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| ** (21-A2) Radius only
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| ** (21-A3) Radius and ulna
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| * (21-B) Articular fracture involving articular surface of only one of the two bones
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| ** (21-B2) Radius fractured, ulna intact
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| ** (21-B3) Articular of one bone, extra-articular of other
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| * ((21-C) Articular fracture involving articular surface of two bones
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| ** (21-C2) Simple of one, multifragmentary of other
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| ** (21-C3) Multifragmentary of both
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| Details on further levels of subcoding are available [http://www.ota.org/compendium/radius.pdf here] (warning: PDF).
| | {{Fractures}} |
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| ===Other systems===
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| The images from this system illustrate how varied the injury can be. [http://www.wheelessonline.com/ortho/fractures_of_the_radius Wheeless] details several classification systems, but comments "the classification does not include extent or direction of initial displacement, dorsal comminution, or shortening of the distal fragment; - hence, it is less useful in evaluating the outcome of treatment". These systems include:
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| * [http://www.wheelessonline.com/ortho/frykman_classification_of_distal_radius_frx Frykman]
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| * [http://www.wheelessonline.com/ortho/melone_classification_for_distal_radius_fractures Melone]
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| * [http://www.wheelessonline.com/ortho/universal_classification_of_dorsal_displaced_radius_fractures Universal]. Universal codes include:
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| ** Type I: extra articular, undisplaced;
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| ** Type II: extra articular, displaced;
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| ** Type III intra articular, undisplaced;
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| ** Type IV: intra articular, displaced;
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| ===General features===
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| Although there is no formal scientific classification based on them, there are three features of the fracture that relate to outcome and to each other:
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| * stability of the fracture
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| * displacement (especially of the joint surface)
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| * how severe the injury to the joint is
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| At one extreme a stable, undisplaced extra-articular fracture has an excellent prognosis. On the other an unstable, displaced intra-articular fracture is difficult to treat and has a poor prognosis.
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| ==Natural history/untreated prognosis==
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| [[Nonunion]] is rare; most of these fractures heal. However, if the fracture is unstable the deformity at the fracture site will increase and cause limitation of wrist motion and forearm rotation, [[pronation]] and [[supination]]. If the joint surface is damaged and heals with more than 1-2 mm of unevenness the wrist joint will be prone to post traumatic osteoarthritis.
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| ==Non-operative treatment==
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| Where the fracture is undisplaced and stable, non operative treatment involves splinting the fracture, often in a [[Cast (orthopedic)|cast]]. In displaced fractures, the fracture may be manipulated under regional or general anaesthesia and casted in a position to minimize the risk of re-displacement. The general principle is to reverse the mechanism of injury. A FOOSH will usually cause over-extension of the wrist joint, often with some radial deviation. Therefore, the preferred position for this type of injury, following reduction, is flexion and ulnar deviation. <br>
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| During the period of follow-up, it is common practice to repeat x-rays at about 1 week to make sure the position is still acceptable. Follow-up is also needed to determine when the cast may be removed, when the fracture has healed and when rehabilitation is complete.<br>
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| The length of time in the cast varies with different ages. Children heal more rapidly, but may ignore activity restrictions. Three weeks in a cast and 6 weeks off sports is often appropriate for them. In adults, the risk of stiffness of the joint increases the longer it is immobilised. If [[callus]] is seen on x-ray at 3 weeks, the cast may be replaced by a removable splint. However, many orthopaedic surgeons leave the patients in the cast for up to 6 weeks. <br>
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| Following healing and cast removal a period of [[Physiotherapy|rehabilitation]] for recovery of strength and range of motion is necessary.
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| ==Risks of non-operative treatment==
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| Failure of non-operative treatment is common and is the largest risk of an adverse outcome. Studies have shown [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3182123&query_hl=7] that the fracture often re-displaces to its original position even in a cast. Earnshaw et al[http://www.ejbjs.org/cgi/content/abstract/84/3/354] showed only 27% - 32% of fractures were in acceptable alignment 5 weeks after closed reduction. Long term this increases the risk of [[Joint stiffness|stiffness]] and post traumatic [[osteoarthritis]] leading to wrist pain and loss of function.<br>
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| Other risks specific to cast treatment relate to the potential for compression of the swollen arm causing [[compartment syndrome]] or [[carpal tunnel syndrome]].
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| [[Reflex sympathetic dystrophy]] is a serious complication following injury and is thought to be more common after cast immobilisation than after surgery. The provoking factors for [[Reflex sympathetic dystrophy|Regional Pain Syndromes]], however, are very complex.<br>
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| [[Joint stiffness|Stiffness]] is universal following a prolonged period of immobilization and swelling. In some cases it does not fully recover. Rehabilitation after cast treatment often takes longer to accomplish a return of acceptable function.
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| ==Prognosis following non-operative treatment==
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| In children the outcome of distal radius fracture treatment in casts is usually very successful with healing and return to normal function expected. Some residual deformity is common but this often remodels as the child grows.<br>
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| In the elderly, distal radius fractures heal and may result in adequate function following non-operative treatment (reduction and casting). A large proportion of these fractures occur in elderly people with limited expectations and little requirement for strenuous use of their wrists. Some of these patients tolerate severe deformities and minor loss of wrist motion very well and would not have improved their status significantly had they had exact reduction of their fracture.
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| On the other hand, in younger patients the injury requires greater force and is result in a worse fracture pattern involving the joint. Unless accurate reduction of the joint surface is obtained these patients are very likely to have long term symptoms.
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| ==Management==
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| Closed management of a distal radius fracture involves first [[anesthesia|anesthetizing]] the affected area with a [[hematoma block]], regional anesthesia, [[sedation]] or a general anesthetic.
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| Manipulation generally includes first placing the [[arm]] under traction and unlocking the fragments. The deformity is then reduced with appropriate closed manipulations (depending on the type of deformity) [[reduction (orthopedic surgery)|reduction]], after which a splint or cast is placed and an [[X-ray]] is taken to ensure that the [[reduction (orthopedic surgery)|reduction]] was successful. The cast is usually maintained for about 6 weeks.
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| Closed treatment is frequently unsuccessful in maintaining a good position in adults, because there is frequently [[comminution]] of the fracture. Re-displacement and deformity can reoccur with an unacceptable ultimate result.
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| Contemporary surgical options have developed that really have revolutionized treatment of this common injury. Generally, techniques include [[ORIF|Open Reduction Internal Fixation (ORIF)]], [[external fixation]], [[percutaneous pinning]], or some combination of the above. The greatest recent advances have been with operative open reduction and internal fixation [[ORIF]]. A entire market of surgical implants are available to treat this specific fracture. The two most recent and promising developments have been fragment specific fixation and fixed angle volar plating. These attempt fixation rigid enough to allow almost immediate mobility, thus ultimately less stiffness and greater function is possible. Although restoration of radiocarpal alignment is of obvious importance, one must not overlook the alignment of the distal radioulnar joint as this can be a source of a frustrating pronation contracture down the road.
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| Each orthopaedic surgeon will treat the fracture according to what his/her preferences are and what works best for him/her. The surgeon should be open to discussion of the rationality of the decisions that are made.
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| Prognosis varies depending on dozens of variables. If the [[anatomy]] (bony alignment)is not properly restored, function may remain poor even after healing. Restoration of bony alignment is not a guarantee of success, as there are significant soft tissue contributions to the healing process.
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| An arthroscope can be used at the time of fixation to evaluate for soft tissue injury. Structures at risk include the triangular fibrocartilage complex and the scapholunate ligament. Be ware of scapholunate injuries in radial styloid fractures where the fracture line exits distally at the scapholunate interval. TFCC injuries causing obvious DRUJ instability can be addressed at the time of fixation.
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| ==References==
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| {{reflist|2}} | |
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| ==External resources==
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| * [http://www.ota.org/compendium/radius.pdf Orthopaedic Trauma Association Fracture Classification] Radius and Ulna
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| * [http://www.wheelessonline.com/ortho/fractures_of_the_radius Wheeless' Textbook of Orthopaedics] Fractures of the Radius
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| * [http://www.wheelessonline.com/ortho/closed_reduction_of_distal_radius_fractures Wheeless' Textbook of Orthopaedics] Closed Reduction of Distal Radius Fractures - Good account and list of references.
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| * [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=mesh&list_uids=68003100&dopt=Full NLM MeSH entry on Colles' Fracture]
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| * [http://www.aofoundation.org/portals/wps/myportal/surgeryskully Distal radius fractures]
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| * [http://www.davidlnelson.md/distalradius.htm] Patient Education Page
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| * [http://www.davidlnelson.md/Wrist_Fracture.htm] Broken Wrist Page, written for the Patient Education website for the American Academy of Orthopedic Surgeons
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| {{Fractures}}
| | [[Category:Needs content]] |
| [[Category:Primary care]] | | [[Category:Orthopedics]] |
| | [[Category:Orthopedic surgery]] |
| [[Category:Fractures]] | | [[Category:Fractures]] |
