Acute Phase
Rehabilitation program
Physical therapy
During prehospital care, stabilize the area of the possible fracture at the wrist and elbow because tension on the radius or ulna may further displace fracture fragments. Urgent reduction of the fracture may be necessary if the neurovascular status of the limb has been compromised. Perform the reduction in the prehospital setting if the time of injury is longer than 6 hours from the estimated time of definitive care.
Surgical intervention
Open fractures and joint-capsule injuries require extensive irrigation (2-3 L), administration of antibiotics such as cephalexin and gentamicin (gentamicin is preferred, especially in cases where open fractures occur in locations around farm animals), emergent operative treatment, and hospital admission.
Other treatment
Accurate and timely fracture reduction is essential to obtaining good functional results. Early reduction lessens morbidity and improves patient comfort. Obtain anatomic reduction by manipulation and plaster fixation. [15, 16, 17, 18]
Administer proper anesthesia before performing closed reduction and fixation (1) to reduce or eliminate patient discomfort and (2) to reduce muscle spasm and splitting, which allows easier reduction and stabilization.
Anesthesia can involve local infiltration, hematoma block, or brachial block. For these methods, bupivacaine at 0.5% is ideal because of its low toxicity and long duration of action. Local anesthesia is obtained by performing a hematoma block. Introduce the needle into the fracture hematoma and aspirate the blood. Then, inject bupivacaine (10 mL of 5% solution) into the hematoma site. Inject another 5 mL around the site. Allow 10-15 minutes before attempting manipulation. Although a brachial block provides excellent anesthesia, it is best left to those who are skilled in its use.
Two key procedures to successful reduction of the typical Colles fracture are as follows:
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Recreate the position of injury in the hand and wrist, and then pronate the forearm to correct the supination twist of the distal fractured segment. This reduction can be performed with the aid of the Weinberg finger traction apparatus or by use of an assistant to fix the arm at the elbow. Relax the periosteal ligaments and allow for easier fracture reduction by recreating the mechanism of injury and position of the bony fragments at injury.
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Extend the wrist back to 90° with the elbow fixed and forearm supinated. Pull the distal segment back, up, and out, at approximately 120°. Then, use both thumbs to push the distal fragment into alignment as the arm is pronated. The initial treatment includes the application of a plaster sugar-tong splint, with the fracture held in slight flexion, the ulna held in deviation, and the forearm held in pronation. Obtain postreduction x-ray films, and assess and document the prereduction and postreduction neurovascular status of the extremity. Document function of the median nerve and sensory branch of the radial nerve.
For proper reduction of a Smith fracture, the forearm must be fully supinated while the elbow is fixed by an assistant or with the aid of the Weinberg traction device. The garden-spade deformity of the Smith fracture is the direct opposite of the dinner-fork deformity of the Colles fracture.
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Extend the wrist to 90° and fully supinate the forearm. Recreate the position of the hand at injury to relax the periosteal attachments. Then, hyperflex the hand and reduce the fracture segment with traction at approximately 60° while the thumbs move the fragments into alignment along the volar aspect of the wrist, pushing the fragment upward and backward. Force the wrist into ulnar deviation and dorsiflexion for the reduction. Hold this position until a plaster sugar-tong splint is placed. These fractures are difficult to hold into position, especially if dorsiflexion and ulnar deviation are lost during the application of the plaster.
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Postreduction x-ray films and documentation of the neurovascular status of the extremity are considered part of the standard care. See the images below.
Reduction obtained by volar inversion of hand on forearm and axial traction. Posteroanterior (PA) view of left wrist post-reduction shows interval reduction of the comminuted fracture of the distal radius with probably extension of fracture lines to the articular surface.
Reduction obtained by volar inversion of hand on forearm and axial traction. Lateral view of left wrist post-reduction shows interval reduction of the ulnar subluxation.
For volar dislocations, hyperpronate the hand. For dorsal dislocations, hypersupinate the hand. Apply a sugar-tong plaster splint to hold the reduction. For volar dislocations, splint the hand in the fully pronated position; for dorsal dislocations, splint the hand in supination. There must be an appropriate consultation with an orthopedist within the next 48 hours.
Scaphoid fracture treatment requires consultation with an orthopedic surgeon. However, this does not mean the sports medicine physician can initially ignore this injury, which may lead to avascular necrosis if not properly protected and splinted. Emergency department and sports medicine standards of care require the application of a thumb spica splint for any possible injury to the scaphoid (clinically defined as any pain in the area of the anatomic snuffbox). The splint also protects the ulnar collateral ligament of the thumb from further injury.
Initial treatment of lunate fractures consists of a short-arm spica cast or splint with thumb immobilization.
Initial treatment of capitate fractures consists of plaster splinting in a position of function and consultation with an orthopedic surgeon.
Recovery Phase
Rehabilitation program
Physical therapy
Under Acute Phase, see Other Treatment for specific casting recommendations. The patient may require physical therapy to regain his/her baseline range of motion.
Consultations
Obtain immediate consultations with a hand specialist or orthopedic surgeon for fractures that are open, are unstable, or require fixation. All other fractures require adequate follow-up monitoring by an orthopedist to ensure proper wrist function.
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Total volar displacement of distal radius fracture from patient fall; mechanism consistent with Smith fracture. Posteroanterior (PA) view of left wrist shows complex comminuted fracture deformity of the distal radius with overlap of the fracture fragments and antipalmar angulation of the fracture apex.
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Total volar displacement of distal radius fracture from patient fall; mechanism consistent with Smith fracture. Anteroposterior (AP) external rotation view of left wrist shows complex comminuted fracture deformity of the distal radius with overlap of the fracture fragments and antipalmar angulation of the fracture apex.
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Total volar displacement of distal radius fracture from patient fall; mechanism consistent with Smith fracture. Lateral view of left wrist shows ulnar sided subluxation of the ulna in relation to the distal carpal bones.
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Reduction obtained by volar inversion of hand on forearm and axial traction. Posteroanterior (PA) view of left wrist post-reduction shows interval reduction of the comminuted fracture of the distal radius with probably extension of fracture lines to the articular surface.
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Reduction obtained by volar inversion of hand on forearm and axial traction. Lateral view of left wrist post-reduction shows interval reduction of the ulnar subluxation.
