Our physicians at Proliance Hand, Wrist and Elbow Physicians are experts when it comes to treating fractured wrists. In our experience, one bone in particular seems to be affected more than others – that bone is the distal radius. Recently, we took an in depth look at non-surgical management for fractured wrists in our blog here. Our group also addressed distal radius fractures and osteoporosis for the American Society for Surgery of the Hand.
But what about surgical treatment options for distal radius fractures?
Oh no! My doctor is telling me I need surgery to treat my fractured wrist!
Orthopedic surgeons have long been treating distal radius fractures with a variety of methods, from casting to surgery, to correct the bony alignment. As with many things in life, time and opportunity have drastically improved surgical techniques over the years. This has allowed surgeons to better address the wide variety of distal radius fractures with more and more specific hardware. Naturally, our national societies have been instrumental in defining the conversation regarding which patients should undergo surgery and the American Academy of Orthopaedic Surgeons has an in depth discussion which can be found here.
To summarize our current national guidelines as of September 2021: patients may be recommended to have surgery if they have the appropriate radiographic criteria as determined by your surgeon. These include loss of radial height, dorsal displacement, and/or intra-articular displacement which can be easily visualized on x-rays of the wrist.
Most surgeons are happy to show you your wrist x-rays if you are curious about better understanding what criteria they are using to determine your treatment plan. Surgical and clinical experience play a role here and it is possible surgeons may disagree about which technique to use. Regardless, the fundamental goal should be to restore the fractured wrist to its original alignment.
What sort of surgical techniques exist for treating fractured wrists?
Answering this question keeps orthopedic surgeons and the companies that support research very busy. The oldest techniques include external fixation, visually similar to scaffolding outside of a tall building. External fixation uses metal pins placed in the bone and are secured above the skin to each other by a metal fixture. Obviously having hardware outside of the skin can be concerning and so techniques were developed to place metal under the skin. Previously, the hardware was very generic and used plates (a piece of metal that screws can go through) that could be placed anywhere in the body. The latest generation of hardware is now uniquely designed for the distal radius and can treat severe trauma as the plates are now specific to certain areas of the bone. As every distal radius fracture is slightly different, orthopedic surgeons have a plethora of choices to correct the bony alignment and achieve the best clinical results.
What about closed reduction versus surgery for treating fractured wrists?
While this may seem like an obvious question, until relatively recently there were no high-level studies looking into this. (If you are curious about how we define levels of evidence the definitions can be found here). Researchers in the Netherlands set out to answer a number of questions about the treatment of distal radius fractures with or without surgery and found some intriguing results. The first question they sought to answer was what happens to all distal radius fractures that do not meet criteria for surgery and are treated with a splint or cast. Many surgeons are trained to follow distal radius fractures closely for the first few weeks after the original injury as many fractures will look worse during that time. So, it was no surprise to learn that many patients who were started with splint/cast treatment plans were transitioned to surgery as their fractures displaced. The surprising finding was just how many patients failed conservative management, the researchers documented that 40% of patients were eventually treated with some form of surgery. Next the researchers designed a randomized study to compare distal radius fractures that did not involve the joint to see how splinting would compare to surgery. All fractures in this study were treated with a closed reduction, meaning pulling on the wrist to correct the bony alignment, to get acceptable radiographic criteria as we discussed in the last paragraph. One group of patients was continued in the splint alone and this time about 42% of those patients eventually needed surgery. The other group was treated with surgery and patient outcomes were compared between the two groups at various time points up to one year after injury. The surprising finding was that patients treated with surgery had better functional and patient reported outcomes scores at all timeframes. The differences between the two groups were larger in the early postoperative period rather than later which implies that the return to function is much earlier with surgery than without it. Additionally, more patients treated without surgery suffered more complications when compared to the operative group. As a final case in point, the authors then repeated the study design for distal radius fractures that involved the joint and found similar better results with surgery than without.
So what should I do?
You should meet with your surgeon as soon as possible so together, as a team, you can design an individualized treatment plan that is correct for you. Not every fracture is the same and so not every treatment plan is the same. If your surgeon recommends surgery for treatment of your fractured wrist they should be able to cite evidence supporting that decision.
How Can Proliance Hand, Wrist and Elbow Physicians Help?
A consultation with Proliance Hand, Wrist and Elbow Physicians can help determine how your distal radius fracture is best treated. Our highly trained occupational therapists are onsite at our Kirkland and Bellevue offices. This allows you to see both your hand surgeon and therapist in a single visit. Whether it is time for a cast, or a therapy program, or even a surgical correction, our staff can help. Contact us to make an appointment at any of our five convenient Eastside locations.
Samuel E. Galle, M.D. is a board-certified orthopedic surgeon with subspecialty fellowship training in conditions of the hand and upper extremity. He has published numerous peer-reviewed articles and surgical technique videos. He lives in Kirkland, WA with his wife, two kids and one especially spoiled Cavalier King Charles Spaniel.