Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Radius and Ulna, Distal


Related Terms

  • Barton's Fracture
  • Buckle Fracture
  • Colles Fracture
  • Smith's Fracture
  • Transverse Wrist Fracture
  • Wrist Fracture

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

Loss of reduction, infection, aseptic necrosis, ligament injury, and concomitant carpal injury would lengthen treatment and recovery. Other factors that could influence disability include age, type of fracture, whether the dominant or nondominant hand is involved, stability of the fracture, and job requirements. Compliance with rehabilitation may influence outcome. Disability will be longer when the fracture is distal, or at the joint (intra-articular).

Medical Codes

ICD-9-CM:
813.21 - Closed Fracture of Shaft of Radius (Alone)
813.22 - Closed Fracture of Shaft of Ulna (Alone)
813.23 - Closed Fracture of Radius with Ulna
813.30 - Open Fracture of Shaft of Radius or Ulna, Unspecified
813.31 - Open Fracture of Radius (Alone)
813.33 - Open Fracture of Radius with Ulna
813.40 - Closed Fracture of Lower End of Forearm, Unspecified
813.41 - Colles Fracture, Closed; Smiths Fracture
813.42 - Fracture, Distal End of Radius, Other (Alone), Closed
813.43 - Fracture, Distal End of Ulna (Alone), Closed
813.44 - Fracture, Radius with Ulna, Lower End, Closed
813.45 - Torus Fracture of Radius (alone)
813.50 - Fracture, Lower End of Forearm, Unspecified, Open
813.51 - Colles Fracture, Open
813.52 - Open Fracture of Distal End of Radius, Other (Alone)
813.53 - Open Fracture of Distal End of Ulna (Alone)
813.54 - Open Fracture of Radius with Ulna, Lower End
813.80 - Closed Fracture of Forearm, Unspecified Part
813.81 - Closed Fracture of Radius (Alone), Unspecified Part
813.82 - Closed Fracture of Ulna (Alone), Unspecified Part
813.83 - Closed Fracture of Radius with Ulna, Unspecified Part
813.90 - Open Fracture of Forearm, Unspecified Part
813.91 - Open Fracture of Radius (Alone), Unspecified Part
813.92 - Open Fracture of Ulna (Alone), Unspecified Part
813.93 - Open Fracture of Radius with Ulna, Unspecified Part

Overview

A fracture of the distal radius or ulna (wrist fracture) is a break in one or two bones of the distal forearm near where they form part of the wrist joint. The radius is the bone located on the thumb side of the forearm, and the ulna is the bone located on the side of the little finger.

Depending on the force and mechanism of injury, these fractures usually involve not only the bones but also injury to some of the small ligaments in the wrist. These ligament injuries may further decrease stability of the wrist joint and create problems with eventual function of the wrist and hand.

This type of injury most often results from a fall with the hand extended during landing. Fractures of the distal radius and ulna are described by their location and position, such as open or closed, angulated or displaced. An open fracture means that the skin is not intact and that the bone may be exposed. Closed fractures have no exposed bone but may still have significant soft tissue injury (muscle, tendon, nerve, artery, ligament). A displaced fracture is one in which the two bone parts have shifted in position. This may result in bone overlap. An angulated fracture results in abnormal alignment of the two bone parts but the parts are still maintaining some contact. Fractures also may be comminuted (broken into many pieces).

Common descriptive names of distal radius or ulnar fractures include Colles, Smith, Barton and Hutchinson fractures. A Colles fracture describes a break that occurs at the end of the radius. It may also include a fracture of the ulna. The fracture often appears with a backward and outward position of the hand relative to the wrist (hyperextension injury). This appearance is described as a silver-fork deformity because it looks like a fork held upside down. Colles fracture is the most common wrist fracture (Hoynak). Of all distal radius fractures, 60% are associated with a fracture of the ulnar styloid process, and approximately 60% of ulnar styloid fractures are accompanied by a fracture of the ulnar neck (Hoynak). A Smith's fracture describes an injury in which the end of the radius heads anteriorly or toward the palm (hyperflexion injury). This fracture is sometimes called a reverse Colles. A Barton's fracture involves the upper (dorsal) edge of the radius and the joint surface, and is associated with partial displacement (subluxation) of the wrist with carpal bone displacement. A Hutchinson fracture, sometimes called a "chauffeur's" or "backfire" fracture, refers to an isolated fracture of the radial styloid process, usually caused by a direct trauma to the radial side of the wrist.

Incidence and Prevalence: Distal radius fractures account for one-sixth of all fractures treated in hospital emergency departments (Hoynak). Distal radius and ulna fractures together account for 75% of all wrist injuries (Hoynak) and 15% of all skeletal fractures in adults (Nana).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Most wrist fractures occur in older postmenopausal women, with a female to male ratio of 4:1 (Richards). A personal and family history for osteoporosis or fractures also increases the risk. This type of fracture is described as a "fragility fracture." Fragility fractures are a type of pathologic fracture that occurs as result of normal activities, such as a fall from standing height or less. The disease process is usually due to osteoporosis ("porous bones"). Osteoporosis is due to a reduction in bone mineral density (BMD) which results in deterioration of the bone microarchitecture. Individuals who smoke have an increased risk of wrist fractures due to the associated low bone mineral density. Among children and adolescents active in sports, an earlier incidence peak of wrist fracture occurs between the ages of 5 and 14 years. With sufficient trauma, any individual can have this fracture (Richards). Traumatic fractures occurring in adults are usually a result of significant trauma (such as a fall from height or an MVA) and more commonly have associated increased soft tissue injury (Blakeney; Larsen).

Source: Medical Disability Advisor



Diagnosis

History: Fractures are almost always related to a history of a fall or other traumatic event. Individuals may complain of pain, swelling, numbness, and deformity of the wrist.

Physical exam: All rings and bracelets are removed as soon as possible because of potential swelling. Upon examination, skin breakdown, swelling, hematoma formation, deformity, and discoloration may be present at the fracture site. Vascular examination and neurological assessment with 2-point discrimination to rule out concomitant injuries of the neurovascular structures in the area are an important part of the examination. Vascular or neurological injury requires immediate treatment, while fracture care can sometimes be delayed. Tendon and muscle function are evaluated via range of motion (ROM) of the wrist and fingers, although the ability to move the wrist and fingers does not exclude a fracture. Additionally, ROM may be decreased due to pain and not specific injury to the tendons or muscles.

Tests: Plain x-rays (usually three views minimum) are necessary to verify alignment, fragment position, and articular surface involvement. X-rays are repeated (post-reduction x-rays) after realigning the bone to an improved anatomical position (reduction) and again at weekly intervals until stability and healing of the fracture are assured. Complicated fractures may require CT or MRI scans before and after reduction to help decide if surgery would be the optimal treatment. If there is suspicion of nerve or vessel injury, nerve conduction studies and vascular studies may be ordered.

Source: Medical Disability Advisor



Treatment

Closed fractures that are not displaced may be treated with a short arm cast or splint if the fracture appears stable. Close monitoring is required because the fragments may slip out of position due to the many pulling forces of ligaments and muscles near the wrist.

Closed fractures with fragments out of position will require reduction, either closed with local or regional anesthesia, or with surgery (open reduction). Again, because of the many forces pulling on the wrist, the fragments may slip after reduction. Turning the palm of the hand up (supination) and down (pronation) rotates the radius and ulna, which also can cause displacement of the fracture; therefore, the elbow may be included in any splint or cast that is applied (sugar tong or long arm cast). This limits motion of the elbow and hand, preventing rotation of the radius and possible displacement of the fracture.

For a minimally displaced Colles fracture, functional bracing or splinting that allows movement of the radiocarpal joint while stabilizing the fracture site is encouraged (Hegmann). Minimally displaced distal radius fractures may be immobilized for 3 weeks rather than the more traditional 6 weeks as this may result in improved range of motion (Hegmann).

If the fracture is unstable, metal hardware, most often plates and screws or K-wires may be used to hold the fragments in position during healing. This hardware may be inserted directly into the fragments during surgery (open reduction, internal fixation [ORIF]). External fixation or traction fixation may be accomplished with attached long pins passing through the skin into bone from the mid forearm, across the fractured wrist, and into a set of pins in the hand (metacarpals). These devices, called external fixators, maintain reduction of the fracture with traction. Some individuals require use of a sling, but elevation of the wrist and forearm during the early stages of healing is important to prevent complications.

Motion of the fingers, shoulder, and perhaps elbow (depending on fracture pattern) is encouraged Medications for pain and swelling will be needed. Ice packs over the cast or splint can be helpful in reducing swelling and pain. Early motion of the wrist helps prevent stiffness and arthritis. Sometimes a removable splint can be used during the late stages of healing to encourage motion exercises. Referral to a hand therapist can be invaluable, even early in treatment. In very severe cases in which a wrist fracture has not healed after 4 months or when the bones have been so displaced and fragmented that they cannot be repaired, wrist replacement surgery (wrist arthroplasty) or wrist fusion, partial or total, may be indicated.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Distal Forearm Fractures
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Uncomplicated distal radius and ulna fractures treated conservatively usually have a bone healing after 6 weeks, at which time increased physical activities may be allowed. There may be stiffness and swelling with activity for a 6 to 12 months. Fractures with open wounds, fractures requiring fixation (ORIF or external fixation), or fractures requiring repeat reduction will have a longer recovery and may have poorer outcomes. In very severe cases in which wrist arthroplasty or fusion is performed, recovery is even slower. The final outcome is dependent on the original injury, the age of the patient, associated co-morbidities, the motivation of the patient, and the ability/availability for early return to work. For more information, please refer to "Work Ability and Return to Work," pages 177-228.

Source: Medical Disability Advisor



Rehabilitation

Routine referral for formal therapy in cases of a distal radius fracture without functional deficit is not usually necessary; however, patient education and home exercise program instruction may be best accomplished in therapy visits (Hegmann).

Rehabilitation of a fractured distal radius and / or ulna depends on the type of fracture and length of immobilization. The main focus of rehabilitation should emphasize restoring functional range of motion and strength while maintaining independence in as many activities of daily living as possible. Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative). The treating physician will dictate the protocol of rehabilitation.

The goal of rehabilitation is to decrease pain and to return the individual to full function with a painless wrist. Rehabilitation may be administered by a physical therapist, occupational therapist, or hand therapist. Hand dominance and the involved extremity will greatly influence the individual's degree of disability during recovery. In order to decrease pain and edema, modalities, including heat and cold, may be beneficial (Braddom).

As therapy focuses on returning the individual to full function, range of motion exercises for the adjacent joints may be beneficial unless contraindicated, based on fracture stability. When indicated, range of motion and strengthening exercises should be started at the involved wrist and hand, emphasizing both intrinsic and extrinsic hand muscles. Special attention must be paid to regaining full rotation of the forearm into both palm-up (supination) and palm-down (pronation) positions. Exercise intensity and difficulty should be progressed until full function is achieved. Individuals are guided in performing activities of daily living that correspond with the stage of recovery.

For those requiring supervised rehabilitation, the individual should also be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation (Wakefield). Occupational therapy may be indicated to assist with activities of daily living if necessary.

Bone healing may occur within 6 to 12 weeks; however, the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is Important to inform the individual not to overload the fracture site until the bone has regained its full strength. The treating physician should guide the timing for resumption of heavy work and sports.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Radius and Ulna, Distal
Occupational / Hand / Physical TherapistUp to 20 visits within 8 weeks
Surgical
SpecialistFracture, Radius and Ulna, Distal
Occupational / Hand / Physical TherapistUp to 16 visits within 8 weeks
Surgical (minimally displaced radial fractures)
SpecialistFracture, Radius and Ulna, Distal
Occupational / Hand / Physical TherapistUp to 3 visits
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Stiffness of the wrist joint is a frequent residual problem. Other complications include failure to regain full mobility of the wrist, chronic pain due to ligament injury, post-traumatic arthritis, and median nerve damage or compression leading to carpal tunnel syndrome. There may be secondary wrist derangements of the ulnocarpal and distal radioulnar joints. Swelling may cause the serious complication of compartment syndrome. Complex regional pain syndrome, or reflex sympathetic dystrophy, is uncommon after wrist fractures. Tendon rupture, particularly of an extensor tendon (extensor pollicis longus [EPL]), or conversely Volkmann's contracture (flexor muscle loss following a compartment syndrome) may be a late complication. The triangular fibrocartilage complex may be disrupted in as many as 40% to 78% of distal radial fractures (Richards).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If the fracture is unstable, the arm should not be used for several weeks except for finger range of motion exercises without resistance. The wrist should not be rotated until the fracture is healed. Lifting, carrying, pulling, and pushing should be limited. Use of a cast, splint, external fixation, and / or sling will affect dexterity; therefore, if the dominant side is injured, work restrictions may be more extensive (e.g., if an individual is right-handed and must write or perform fine motor skills with the dominant hand, he or she will experience more work limitations than if the nondominant left hand were injured). In some cases, alternatives to a standard keyboard such as speech recognition software or one-handed keyboards may be appropriate accommodations. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. Rest periods for elevation of the hand and forearm may be necessary during the initial stage of recovery. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Symptoms of stiffness may require 12 months for improvement. It is important to understand that the duration guides address return to work but not resolution of symptoms. Depending on the facture and the healing, some individuals may have permanent symptoms. Permanent symptoms do not mean they cannot work, only that they may have symptoms with or without activities.

Risk: Risk for injury is dependent on facture stability. Fracture stability is a combination of the original injury and the medical or surgical treatment. For example after ORIF and plate fixation the fracture may be very stable allowing for only a splint for support and an early return to modified work. Alternatively, the fracture may be commutated and despite ORIF require a long arm cast and very limited use of the limb. Therefore the risk of reinjury varies and this is why the treating physician must understand the concepts of risk, capacity, and tolerance (explained in "Work Ability and Return to Work," pages 9-21).

Capacity: Capacity is an issue once the fracture has healed and risk is no longer an issue. Capacity will also be influenced by age and co-morbidities. Capacity may also be influenced by the employer's job requirements. For example, the patient with a cast on may not be able to return to work as a cook, since the cook has to wash his or her hands before preparing food. However, a retail store greeter or a cashier could return to work with a cast on.

Tolerance: Tolerance early after the fracture will also be affected by fracture stability and the treatment method. Pain will be related to the severity of the injury. Motivation and employer willingness to accommodate are key.

Accommodations: Temporary modification of activities, but not total absence of activity, improves fracture healing. Fracture healing requires a certain amount of stress for bone formation. A change in job duties, sharing or alternating tasks, and limiting time can reduce unnecessary disability. For more information, please refer to "Work Ability and Return to Work," pages 177-228.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is typically achieved within 4 to 168 days of fracture of distal radius and or ulna.

Some additional improvement may occur up to 9 to 128 days after fracture.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with symptoms consistent with a fracture of the radius or ulna?
  • Was fracture confirmed with an x-ray?
  • In addition to the bony injury, were there injuries to arteries, nerves, or ligaments?
  • If diagnosis was uncertain, were other conditions with similar symptoms ruled out?
  • Is the fracture healed, or is non-union present?
  • Did the fracture heal in good position, or is mal-union present?

Regarding treatment:

  • Was treatment appropriate for the particular type of fracture?
  • Was surgery required? Were any complications associated with the procedure?
  • Would individual benefit from consultation with a specialist (e.g., orthopedic surgeon, hand surgeon, occupational therapist, physical therapist, vascular surgeon, neurosurgeon, sports medicine specialist, or physiatrist)?
  • Did individual receive rehabilitation therapy, in particular with a therapist specializing in the treatment of hands (certified hand therapist)?
  • Was the individual active in a rehabilitation program?

Regarding prognosis:

  • Does individual have any conditions that may inhibit his or her ability to adhere to a rehabilitative exercise program?
  • Has adequate time elapsed for recovery? What is the expected prognosis?
  • Has individual followed prescribed rehabilitative therapy?
  • Did individual have any injury-related complications such as persistent immobility of the wrist, nonunion of the fracture, infection, chronic pain, post-traumatic arthritis, tendon rupture, compartment syndrome, or median nerve damage? If so, were complications addressed in the overall treatment plan?
  • Does individual have any underlying condition such as degenerative arthritis or osteoporosis that may affect recovery?

Source: Medical Disability Advisor



References

Cited

Blakeney, W. , and L. Webber. "Emergency Department management of Colles-type fractures: a prospective cohort study." Emergency Medicine Australasia 21 (4) (2009): 298-303.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Hegmann, Kurt E., and Matthew A. Hughes. "Chapter 11 - Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines. Ed. Kurt E. Hegmann. 2nd ed. ACOEM, 1-156.

Hoynak, Bryan. "Wrist Fracture in Emergency Medicine ." eMedicine. Ed. Rick Kulkarni. 1 Jun. 2012. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/828746-overview>.

Larsen, C. F. , and J. Lauritsen. "Epidemiology of acute wrist trauma." International Journal of Epidemiology 22 (5) (1993): 911-916.

Nana, Avind D., et al. "Distal-Third Forearm Fractures." eMedicine. Ed. Harris Gellman. 7 Feb. 2012. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/1238513-overview>.

Riego de Dios, Ricardo, et al. "Distal Radial Fracture Imaging ." eMedicine. Ed. Felix S. Chew. 12 Apr. 2011. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/398406-overview>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Wakefield, A. E., and M. M. McQueen. "The Role of Physiotherapy and Clinical Predictors of Outcome after Fracture of the Distal Radius." Journal of Bone and Joint Surgery 82 7 (2000): 972-976. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 11041584>.

Source: Medical Disability Advisor






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