Distal radius fracture non-operative treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]
Non-Operative Treatment
Where the fracture is undisplaced and stable, non operative treatment involves splinting the fracture, often in a 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.
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.
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.
Following healing and cast removal a period of rehabilitation for recovery of strength and range of motion is necessary.
Risks of Non-Operative Treatment
Failure of non-operative treatment is common and is the largest risk of an adverse outcome. Studies have shown[1] that the fracture often re-displaces to its original position even in a cast. Earnshaw et al showed only 27% - 32% of fractures were in acceptable alignment 5 weeks after closed reduction. Long term this increases the risk of stiffness and post traumatic osteoarthritis leading to wrist pain and loss of function.
Other risks specific to cast treatment relate to the potential for compression of the swollen arm causing compartment syndrome or carpal tunnel syndrome.
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 regional pain syndromes, however, are very complex.
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.
Prognosis Following Non-Operative Treatment
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.
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.
On the other hand, in younger patients the injury requires greater force and 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.
References
- ↑ "Late displacement of Colles' fractures. [Int Orthop. 1988] - PubMed - NCBI". Retrieved 2013-03-19.