Fracture, Radius and Ulna, Distal

Risk: 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. 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).

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).

History: Individuals may relate 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 as soon as possible because of potential swelling. Upon examination, skin breakdown, swelling, hematoma formation, deformity, and discoloration may be noted over the fracture site. Application of gentle pressure (palpation) to the wrist and forearm may reveal tenderness. Vascular examination and neurological assessment with 2-point discrimination to rule out concomitant injuries of the neurovascular structures in the area are part of the examination. Tendon and muscle function are evaluated via range of motion of the wrist and fingers, although the ability to move the wrist and fingers does not exclude a fracture.

Tests: Plain x-rays with multiple angles are necessary to verify alignment, fragment position, and articular surface involvement. X-rays are repeated after realigning the bone in its normal 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.

Rehabilitation of a fractured radius and/or ulna depends on the type of fracture and length of immobilization. The main focus of rehabilitation should emphasize restoring full range of motion and strength while maintaining independence in as much of their activities of daily living as is 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 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 the therapy focuses on returning the individual to full function, range of motion exercises of 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 regain full supination (palm-up position) and pronation (palm-down position). 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.

In addition to undergoing supervised rehabilitation (Watt), the individual should 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.

If operatively managed, the treating physician will dictate the protocol of rehabilitation.

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.