Walsh, Colleen R. DNP, MSN, RN, ONP-C, ACNP-BC
Mrs. C, a 72-year-old White female, was outside walking her dog on a leash when it suddenly lunged toward a squirrel in an attempt to chase it. Mrs. C was pulled forward, tripped on the uneven sidewalk, and began to fall, her right side leaning forward. She instinctively stretched her right arm forward to break her fall and landed on the heel of her hand. She immediately felt severe pain in her right wrist and was unable to get up. A neighbor witnessed the fall and ran to assist her. The neighbor noticed that Mrs. C's wrist looked grossly deformed and called 911. The emergency medical services (EMS) ambulance arrived several minutes later. Mrs. C was alert and oriented to person, time, and place, and her vital signs were: pulse 112 and regular, respirations 22, and BP 156/90. She complained of severe pain and a “pins and needles” sensation in her wrist. The emergency medical technicians noted that she was unable to fully move her fingers and her right radial pulse was diminished when compared to her left. She was placed in a posterior splint with a bandage wrap and transported to her local community hospital.
The physical exam in the ED revealed a thin, anxious, frail, elderly woman with a “dinner fork” deformity of the right wrist. Her range of motion (ROM) of the wrist and fingers was difficult to determine due to pain. Her hand was warm and pink, and the right radial pulse amplitude equaled the left radial pulse. Mrs. C complained of numbness in her palm and middle finger.
Anteroposterior (AP) radiographs revealed a distal radius fracture (see AP wrist fracture) and the lateral (L) radiographs revealed dorsal displacement of the distal fragment (see Lateral view right wrist). After the orthopedic surgeon evaluated her, Mrs. C was diagnosed with a right Colles fracture (see Colles fracture of the wrist and hand). Because her past medical history included hypertension, type 2 diabetes mellitus, and moderate chronic obstructive pulmonary disease due to long-standing asthma, the surgeon attempted a nonsurgical closed reduction of the fracture in the ED. An I.V. intermittent infusion catheter was placed in Mrs. C's left hand without difficulty.
After moderate sedation and analgesia with midazolam and morphine, the surgeon placed Mrs. C's fingers into traps that allowed for longitudinal traction and elevation, and successfully reduced the distal radius fracture. The postreduction radiographs revealed good alignment with approximately 5 degrees of dorsal angulation. Her wrist was placed in a volar splint with elastic wrap, and she was admitted to the general orthopedic unit for observation and pain management.
Mrs. C continued to complain of numbness in her palm, and her pain wasn't well controlled with oral oxycodone/acetaminophen. The nurse obtained orders from the surgeon for morphine sulfate I.V. every 2 hours as needed for pain management. Her pain level decreased from 7/10 to 4/10, but she continued to complain of numbness in her hand. The surgeon evaluated her and told the nurse that he felt the numbness was due to some swelling around the median nerve and that it would resolve once the swelling subsided.
The next morning, the surgeon gave her discharge instructions and ordered a predischarge repeat AP and L radiographs of the right wrist. The radiograph revealed loss of reduction of the fracture and the surgeon decided to proceed with an open reduction with internal fixation (ORIF). Mrs. C was brought into the OR where the anesthesia provider placed a Bier block after the arm was exsanguinated using an elastic bandage. A pneumatic tourniquet was placed around the mid-humeral portion of the right arm. Using a volar incision, the surgeon explored the fracture and carpal tunnel, noting that the median nerve was compressed. A previously undetected nondisplaced ulnar styloid fracture was also noted. He performed a carpal tunnel release and applied a volar plate with screws to the distal radial fracture (DRF) and pinned the ulnar styloid fracture.
The post-ORIF films revealed good reduction and alignment (see Post ORIF AP/lateral view of right wrist), and the posterior splint with elastic bandage wrap was reapplied. Mrs. C was transferred to the postanesthesia care unit. After an uneventful recovery, she was transferred to the orthopedic unit. She complained of wrist pain that was well controlled with a patient-controlled analgesia pump. The palm and middle finger numbness resolved, and after a social service consultation, Mrs. C was discharged home in the care of her sister 3 days after her fall.
Her primary care provider (PCP) was notified of her hospitalization and a dual energy X-ray absorptiometry (DEXA) scan was obtained; it revealed a T score of -2.6, and Mrs. C was diagnosed with osteoporosis. She was started on an oral dose of the bisphosphonate, alendronate once per week. An occupational therapy consult was obtained so that a customized volar splint could be fabricated after the edema in her hand and wrist resolved (see Volar splint). Follow-up radiographs at 4 and 12 weeks revealed no loss of reduction, and the fractures were healed at 6 months. Since the plate wasn't causing her pain, Mrs. C elected not to have her hardware removed. She reported that the wrist fracture hadn't impaired her ability to care for herself, and she remained independent in all activities of daily living.
Risk factors for wrist fractures
Figure. Post ORIF AP...Image Tools
Figure. Volar splint...Image Tools
The major risk factor for wrist fractures is osteoporosis, and there's mounting evidence that an osteoporotic wrist fracture can be linked to osteoporotic fractures in other sites.1 In children and adolescents, sports injuries and motor vehicle crashes account for the majority of wrist fractures.2
DRFs, which are the most common type of wrist fracture in the United States, are estimated to occur at a rate of 150,000 to 200,000 per year.3 DRFs have a bimodal distribution. Osteoporotic DRFs typically occur in women in their 60s and 70s, and usually result from a fall from a standing height, which is considered a low-energy fracture.4,5 Adolescents and young adults often sustain DRFs while in their teens and 20s, usually as a result of high-energy injuries, such as motor vehicle crashes.6
The most common mechanism of injury for all types of wrist fractures is a fall on an outstretched hand (FOOSH).5 The wrist is hyperextended and the point of impact causes energy forces through the distal radius that result in various fractures.7,8 Patient weight, degree of deviation of the radius and ulna, and the degree of dorsiflexion at the time of impact determine the fracture pattern.9 In a small group of patients, the scaphoid (a carpal bone) may also be fractured at the time of impact.10
Using data from the National Electronic Injury Surveillance System All Injury Program, Orces and Martinez found that the incidence of fall-related wrist and forearm fractures among women increased gradually with age beginning at age 50. In men, the rate of fractures remained low until much later in life.11 This study demonstrates the marked differences between the sexes and suggests that fall prevention programs may benefit at-risk females, especially those with diminished bone mineral density.11
Figure. Bony structu...Image Tools
Structure and function of the wrist
The wrist is composed of eight carpal bones, the distal ends of the radius and ulna, and the proximal portions of the five metacarpal bones (see Bony structures of the wrist and hand). Together, these bones form the wrist, which is considered a gliding joint.12 The wrist has a broad ROM. The radius is shorter than the ulna, and lies on the thumb side of the wrist.13 The radius rotates around the ulna, which gives the hand the ability to rotate and be flexible.13 The articulation of the distal radius and ulna is called the radioulnar joint. It's held together by multiple ligaments, with the primary being the annular, anterior, and posterior radioulnar ligaments; and the oblique cord ligament.14 The interosseous membrane, a thin fibrous tissue, connects the radius and ulna at various points and allows for other ligamentous attachments.14
The eight carpal bones line up in two rows: the proximal carpal bones are the scaphoid, lunate, triquetrum, and the pisiform; and the distal carpal bones consist of the trapezium, trapezoid, capitate, and the hamate.15,16 The carpal bones allow the wrist to move in a wide arc of motion.
No discussion of the wrist is complete without examining the elbow. The proximal radius and ulna also articulate around the elbow, and they both articulate with the distal humerus to form the elbow joint.13 Many wrist fractures occur with such force that fractures and/or dislocations of the elbow may also occur, therefore, the surgeon must evaluate the elbow as well.
Types of wrist fractures
Fractures of the wrist can be classified as fractures of the carpal bones and fractures of the radius and/or ulna.17 The mechanism of injury can assist the surgeon with evaluating fractures of the wrist. There are many different classification systems used to describe various fractures, but those systems are beyond the scope of this article. Carpal bone fractures include the following:
* Scaphoid fracture is the most common carpal bone fracture.17,18 The mechanism of injury is FOOSH, and incorporates bone and ligament integrity, position of the wrist and hand when the fall occurred, the duration of the compression, and the direction of forces defining the fracture pattern.18,19 Hyperextension of the wrist causes the radial styloid to compress the scaphoid, which causes the fracture.18
* Lunate fracture is relatively uncommon and occurs with FOOSH.17
* Triquetrum fracture is a common carpal bone fracture and is the second-most common fracture in sports injuries.20 Hyperextension and ulnar deviation at the time of the fall is the most common mechanism of injury and considered a high-energy force that will often fracture additional carpal bones.17
* Capitate fracture occurs to the largest carpal bone, which has a limited blood supply.17 A direct blow to the dorsum of the wrist along with FOOSH are the major mechanisms of injury.17
* Hamate fracture is uncommon and usually results from the wrist being in a dorsiflexed position with some ulnar deviation. This usually occurs when an individual who's holding a bat, club, or racket swings through an arc of motion and hits a stationary object.17
* Trapezium fracture is uncommon and occurs with forced radial deviation of the thumb.17
* Trapezoid fracture is very uncommon and occurs with axial loading during the FOOSH.17
* Pisiform fracture occurs to the small sesamoid bone that lies within a tendon (similar to the patella). FOOSH is the usual mechanism of injury.17
The carpal bones are also prone to scaphoid–lunate dissociation, and lunate and perilunate dislocations. These result from extreme flexion or extension of the wrist and often result in ligamentous instability or rupture.17,20,21 These are potentially serious injuries that often are missed during initial exam. It's essential that the surgeon carefully considers all possible injuries to the wrist and supporting structures when evaluating wrist injuries.22
Many fractures of the distal radius have formal names, or eponyms, that describe the location of the fracture and the direction of the displacement of the distal fragment.7 These names usually refer to the physicians who originally described these fractures.23 Fractures that occur with certain occupations are also included in the nomenclature of fractures.24 Radius and/or ulna fractures/dislocations include the following:
* Colles: This is a fracture of the distal radius with dorsal angulation and displacement of the distal fragment. This causes the classic “dinner fork” deformity.8,23,24 The wrist is bent upward.
Figure. External fix...Image Tools
* Smith: This is often called a “reverse Colles fracture” since the distal radius assumes a volar displacement. The wrist is bent downward, and it's common among young people with high-velocity trauma.24
* Barton: These are divided into volar and dorsal fractures.
Volar-type Barton is a fracture-dislocation of the volar rim of the radius and is more common.
Dorsal-type Barton is a fracture-dislocation of the dorsal rim of the radius.24
* Chauffeur: This isolated fracture of the radial styloid process, also called a Hutchinson fracture, is often associated with more complex fractures of the wrist.24
* Galeazzi: This fracture involves a radial shaft with an associated dislocation of the distal radioulnar joint. The mechanism of injury is FOOSH, and these fractures usually require surgery to stabilize the wrist.25
* Monteggia: This is a dislocation of the radial head at the elbow with a fracture, usually along the distal third of the ulna. This is an uncommon fracture and accounts for less than 5% of all forearm fractures.26,27
Treatment of wrist fractures
When treating wrist fractures, the goal is to align the fractures anatomically, immobilize the fractures until healing occurs, and maintain and preserve function.4,5,8,28,29 First, these fractures must be diagnosed accurately. Most fractures can be diagnosed with simple AP and L radiographs; some fractures, especially the carpal bones, may require further imaging with computed tomography or magnetic resonance imaging, especially if ligamentous injury is suspected.17
Many fractures can be manually reduced by the surgeon and splinted; others require surgical intervention. The splinting is important as the surgeon must mold and shape the splint so that it provides the proper anatomical support for the fracture during the healing process.20,21 The splints are fabricated to be fracture specific and also individualized for each patient. Surgical treatment of wrist fractures includes plates and screws, percutaneous pins, cannulated screws, and external fixation.1,2,4,5,8,17 (See External fixation of the wrist.)
Scaphoid fractures represent a challenge for the surgeon. Unfortunately, these fractures may go undetected and unreduced, which can lead to nonunion or avascular necrosis of the scaphoid.30–33
Anatomical reduction with possible pin or screw fixation along with splinting is critical for adequate fracture healing. A thumb spica cast or brace is used to immobilize the thumb and wrist while healing is occurring.32
Treating younger patients may represent a challenge, as the epiphysis is a critical structure in the bone development of children and adolescents. The long bones consist of the epiphysis, which consists of the proximal and distal ends of bones; the metaphysis, which lies between the epiphysis and diaphysis at the proximal and distal ends of bones; and diaphysis, or shaft, of a long bone (proximal epiphysis, proximal metaphysis, diaphysis, distal metaphysis, and distal epiphysis).12
The epiphysis consists of spongy bone covered by a thin layer of compact bone. In children, the epiphysis is separated from the metaphysis by a cartilaginous growth plate, also called the epiphyseal plate. Longitudinal bone growth occurs at the growth plate, and the growth plate usually ossifies (hardens) during late puberty. Any injury to the growth plate before it ossifies can adversely affect the bone's ability to achieve maximum length.34 In children and younger adolescents, DRFs often occur in or near the growth plate. It's critical for the surgeon to identify those fractures and provide treatment that will preserve the integrity of the growth plate. Ironically, although the distal radial physis is the most commonly separated physis in children, it rarely causes disturbances in longitudinal growth of the radius.34 It's important for the surgeon to reduce the fracture anatomically, and percutaneous pinning is performed often to allow for early mobility and ROM. These fractures in children can also be treated with a properly molded cast.
Preoperative and perioperative care
Patients undergoing surgical repair of a wrist fracture require routine preoperative assessment and management the same as any other patient; the perioperative nurse should review the Association of periOperative Registered Nurses Perioperative Standards and Recommended Practices, 2012 Edition, for general guidelines for the perioperative patients.35 Special circumstances include the polytrauma patient and those who have sustained open fractures.
Communication among the team is essential for the planning and execution of a successful procedure. The preoperative assessment and documentation of the neurovascular function of the hand must be noted.36,37 Confirmation of the operative site as outlined by the American Academy of Orthopaedic Surgeons and The Joint Commission is part of the perioperative RN's responsibility as well as other team members.38 The recommended timing of antibiotic surgical prophylaxis is within 60 minutes prior to skin incision to allow for the greatest tissue concentration of drug, and the perioperative RN needs to ensure that the proper antibiotic is available for the anesthesia provider to administer it.39
Surgical repair of a wrist fracture usually requires the use of a pneumatic tourniquet to establish a bloodless surgical field. As pneumatic tourniquet technology improves, the perioperative RN must remain current in knowledge of tourniquet systems and follow the appropriate guidelines for use of the device.40
Anesthesia is usually accomplished via regional blocks, and care must be taken that the extremity is well padded, as well as those other areas subjected to shearing and pressure forces. The careful documentation of the neurovascular bundle exam findings is essential. The median nerve is often entrapped, and the perioperative RN should anticipate that a carpal tunnel release will most likely be performed at the time of surgical fixation of the fracture.41
Complications of wrist fractures
Complications of wrist fractures can be divided into early and late, as well as high, medium, and low probability of occurring.41 Median nerve entrapment is common with Colles fractures, and many surgeons elect to perform carpal tunnel releases at time of ORIF.2,17,21,41
Malunion of fractures occurs early in the course of treatment as does stiffness and pain in the hand and wrist.41 Nonunions of fractures also can occur, especially of the scaphoid due to the limited blood supply.17,18 DRFs rarely experience nonunions due to excellent blood supply. Complex regional pain syndrome (formerly called reflex sympathetic dystrophy), can occur soon after the fracture.41
In elderly patients with osteoporotic wrist fractures, continued morbidity from osteoporosis often occurs.1,3 Patients with one osteoporotic fracture are twice as likely to sustain another site fracture.1 Clinicians managing the care of elderly patients with wrist fractures should obtain a DEXA scan, and institute treatment for any identified osteoporosis.42
Vascular injuries represent a serious complication of wrist fracture. The force of the initial impact can cause comminution of the bony fragments, causing lacerations or compression of the radial or ulnar arteries.17 Rapid recognition of vascular injuries may prevent loss of the injured hand.
Complications from the surgical repair procedure include screws impinging on tendons or ligaments, or pins interfering with the blood supply.43,44 Knowledge of the intricate anatomy of the hand and wrist can help prevent some of these surgical complications.
Case study revisited
Mrs. C was fortunate that a nearby neighbor witnessed her fall and called for help immediately. The elderly often sustain fractures while in their homes and are unable to call for help—they may not be found for several hours or days.45 Quick management of her fracture helped her to have a positive outcome.
Mrs. C's radial artery and median nerve were compromised when she was initially evaluated, but careful splinting and transport by EMS reversed the pressure on the radial artery and helped restore an adequate blood supply to her hand. The median nerve continued to be compromised, and the carpal tunnel release at the time of volar plating prevented permanent median nerve damage.
It's common for a wrist fracture to lose the anatomic reduction after attempts at closed reduction, as was the case with Mrs. C. In her case, the surgical plating and pinning allowed her to have earlier mobility of her hand, preserving more function. Studies have demonstrated that 6 months after an unstable DRF, patients treated with closed reduction and casting had similar functional outcomes as those treated aggressively with ORIF.46 Patients with closed reduction were required to wear casts or splints until healing occurred, while those who had surgery were allowed to begin using the hand sooner. These findings may indicate that more aggressive approaches to DRFs, especially in the elderly, may improve the ability to perform independent activities of daily living in the short term. The occupational therapy consult early in her recovery period was a wise move in terms of splinting and exercises.
Mrs. C's PCP also ordered a DEXA scan and immediately began treatment for her newly diagnosed osteoporosis. Reversing bone loss can help prevent further osteoporotic fractures, which could adversely affect her quality of life. Some studies support waiting for several months after an osteoporotic fracture to begin bisphosphonate therapy.47 Since bisphosphonates inhibit bone formation and reabsorption, theoretically, the use of these drugs immediately after fractures or surgery for fractures could lead to nonunion of the fracture. The PCP must carefully review the risks and benefits of such treatment, and discuss the risk and benefits with the patient.
Wrist fractures represent a challenge for clinicians. The young and the elderly are at the highest risk, and the perioperative RN must be aware of the physiologic differences between these ages when planning and providing care for these patients. Accurate and timely assessment and communication within perioperative, postoperative, and rehabilitative services can help assure patients with these fractures will have positive outcomes.
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