eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Wrist: Follow-up

Author: Bryan C Hoynak, MD, FACEP, FAAEM, Associate Clinical Professor of Emergency Medicine, University of California at Irvine School of Medicine; Director of Emergency Services, Chairman of Division of Emergency Medicine, Placentia-Linda Hospital
Coauthor(s): Laura Hopson, MD, Staff Physician, Department of Emergency Medicine, University of Michigan
Contributor Information and Disclosures

Updated: Aug 13, 2009

Follow-up

Further Inpatient Care

• Open fracture and/or joint capsule injury require the following treatments:
  • Extensive irrigation (2-3 L)
  • Administration of antibiotics (eg, cephalexin, gentamicin)
  • Emergent operative treatment and hospital admission
• Distal radius fracture: Look for acute carpal tunnel syndrome.

Further Outpatient Care

• Distal radius fracture
  • Once swelling has subsided, uncomplicated fractures require conversion from a splint to a short-arm cast for 6-8 weeks.
  • An orthopedic specialist should provide follow-up to assess for adequate alignment and the need for operative intervention.
  • Patient may require physical therapy to regain baseline range of motion.
• Scaphoid fracture: Treatment in a spica cast for 12 weeks results in healing in 90% of these fractures.
• Lunate fracture: Most heal in a spica cast for 10-12 weeks.

Inpatient & Outpatient Medications

• Oral analgesics should provide sufficient pain relief.
• To reduce pain and edema, apply ice to the injured region for the first 48 hours.

Transfer

• When proper orthopedic care is not available at a site, transfer the patient to a higher-level care facility once neurovascular stability has been addressed adequately.

Deterrence/Prevention

• Since a large number of wrist fractures occur secondary to in-line skating accidents and other sporting activities, encourage wrist protection during these sports.

Complications

• The anatomy of the scaphoid bone makes it vulnerable to secondary injury. It is supplied by a single blood vessel that penetrates the cortex near the waist of the scaphoid. Scaphoid fractures are prone to delayed healing and avascular necrosis. The more proximal the fracture, the more common these complications. Missed diagnosis and lack of appropriate immobilization increase this risk. Missed diagnosis or nonunion predisposes an individual to development of potentially debilitating radiocarpal arthritis.
• Keinböck disease is osteonecrosis and subsequent collapse of the proximal portion of the lunate resulting in pain, loss of function, and carpal bone instability. The exact mechanism for development of this condition is disputed, with theories ranging from repetitive microtrauma to avascular necrosis from a single injury. As the lunate receives its blood supply from a single distal blood vessel in 20% of individuals, these patients may be predisposed to avascular necrosis and nonunions. Younger patients, typically those younger than 16 years, tend to have better functional outcomes from lunate injuries than older patients.
• Complications from a capitate fracture include nonunion and avascular necrosis as, like the scaphoid, it is dependent on a single blood vessel, which enters from its distal aspect. Posttraumatic arthritis is a frequent complication. Fibrosis of surrounding tissues after injury may result in carpal tunnel syndrome.
• Fractures through the base of the hook of the hamate are frequently displaced by the forces of the hook's multiple ligamentous attachment. Nonunion is a frequent complication and may necessitate surgical excision of the hook to relieve pain from grasping activities.
• Acutely, a Colles fracture has several potential complications. These include compression or contusion of the median and/or ulnar nerves. An acute carpal tunnel syndrome may result from swelling. The flexor tendons may be injured by the bony fragments. Excessive swelling can result in compartment syndromes. Comminuted or severely displaced fractures may be unstable, resulting in a loss of reduction and requiring repeated attempts or surgical intervention.
• Long term, the wrist may have radial shortening and angulation deformity, limiting range of motion. Some individuals experience chronic pain, particularly with supination. Adhesions may limit mobility of the flexor tendons. As with all fractures, malunions or nonunions may complicate healing. With comminuted intra-articular fractures, more than two thirds may be complicated by the late development of arthritis.
• Reflex sympathetic dystrophy complicates some 3% of distal radius fractures. This controversial diagnosis is a syndrome of paresthesias, pain, stiffness, and changes in skin temperature and color.
• Smith (reverse Colles) fracture may result in complications similar to those of Colles fracture.
• Radiocarpal fracture-dislocation may cause entrapment of tendons or of the ulnar nerve and/or artery.¹
• Hutchinson fracture may result in scapholunate dislocation, osteoarthritis, or ligament damage.
• Ulnar styloid fracture often results in nonunion.

Prognosis

• Prognosis depends on many variables, including the following:
  • The outcome of injuries to the distal radius and ulna is determined largely by the degree to which normal anatomic relationships can be restored. Shortening of the radius is a key determinant of prognosis. In general, the more complex the fracture pattern, the worse the outcome. This often takes the form of loss of mobility and debilitating early-onset arthritis.
  • Open fractures with large soft-tissue injuries have a much poorer prognosis.
  • Timely and appropriate care can improve the prognosis.
  • Appropriate follow-up and aggressive rehabilitation are extremely important.
  • With appropriate immobilization, 95% of scaphoid fractures heal with casting for 8-12 weeks.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Wrist Injury and Broken Hand.

Miscellaneous

Medicolegal Pitfalls

• Failure to check for neurologic compromise before and after splinting
• Failure to meet standard of care for suspected scaphoid fracture. The ED physician must apply a thumb spica splint to avoid the complication of avascular necrosis.
• Failure to test for pain in the anatomic snuffbox as a sign of a possible scaphoid fracture. If pain is present, splint and refer for specialty consultation, further imaging techniques, or both.

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