Ep 26 - Wrist Trouble? A Deep Dive into Distal Radius Fractures and treatment with a certified hand therapist

Today, we explore the common yet often misunderstood topic of distal radius fractures. Understanding the mechanics of this injury can empower listeners to seek appropriate treatment and foster recovery.

• Definition and causes of distal radius fractures 
• Treatment options: non-displaced vs. displaced fractures 
• The importance of rehabilitation in recovery 

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Chapters

• 0:54 Welcome and Introduction
• 15:19 Understanding Distal Radius Fractures
• 3:48:28 Rehabilitation and Recovery Insights

Transcript

Speaker 1: 0:00

Welcome back to the Hand-to-Shoulder Solution Giving Pain the Middle Finger. I'm your host, carl Petito. I'm an occupational therapist and a board-certified hand therapist. As a hand therapist, I specialize in treating orthopedic conditions from the fingertips through the shoulder. I want to talk to you today about distal radius fractures. Something that's very common is what we call a fall on an outstretched hand, and when you reach down to break your fall, what usually hits first is the distal radius, and we'll talk about that. I want to actually want to show you the anatomy. I want to talk about different ways to treat that.

Speaker 1: 0:38

Now, let's note that this is not treatment advice or treatment direction. This is information sharing so that you can make the best decision for yourself when seeking treatment, and I want you to really understand what is the mechanics of this fracture. What is it exactly? What bone are we talking about? And it's just so common that it's important for everybody to have a general awareness. So let's start with the anatomy. If I overlay this, on my hand, here's the forearm turned palm up. Now, when I turn a palm down and yes, that is a forearm movement the radius turns over the top of the ulna. So when I turn a palm down like this the radius bone crosses over the top of the ulna the ulna is actually the tip of your elbow and that stays stationary. So once again over the top of the ulna, okay, and that's a position falling, falling on outstretched hand, and there's a distal radius right here. This is the radius. The tip of the elbow is right here. That's the ulna bone, okay. So when this strikes the floor and I have a radius right here, let's take that off. When this hits the ground, it usually fractures around this area and this piece moves up. Now a fracture is a break? I'll have patients ask me that question and a fracture is just another word for a break, a broken bone.

Speaker 1: 2:35

Now the fracture can fracture. It could be just a clean line and have it non-displaced, which means it's everything's still aligned, but now there's a crack through it. Also, it could be displaced, which means now it's moved, it's shifted and it has to get realigned so it heals in the correct alignment. Now that realignment can be accomplished by looking at a brief, taking a regular x-ray first and then seeing is it malaligned or is it still lined up the way it's supposed to be, or does that have to be realigned? We can do, the surgeon can do a closed reduction, which means we're not doing any surgery. They're looking at what's called fluoroscopy and they're taking a quick x-ray of it, put it back together manually, palpate it or feel it and feel that it's all aligned, and take another quick shot of it and look at it and say, okay, perfect, now it's lined up and the fracture is simple enough. Where they don't need plates and screws, which is called ORIF open reduction, internal fixation, we'll get to that. Where they don't need plates and screws, which is called ORIF open reduction, internal fixation, we'll get to that. If they don't need plates and screws, then it can be put into a cast and then the cast removed in about six weeks and therapy begun at that time to start to restore range of motion and decrease swelling and restore strength after range of motion has been largely regained.

Speaker 1: 4:07

But now let's go back to the thought of let's say it's so displaced where it's really hard to reduce or to realign, or it's broken in multiple pieces, which is called comminution, that's a comminuted fracture where you have many pieces. And here's an example right here. Ignore the hardware for a minute, but see these lines on the end of the radius bone and it goes across like this, then up like that, then all around. That's a situation where it really does need to be put back together. If it were me speaking for myself and a surgeon told me you really need surgery, you should have plates and screws, I would be eager to have it done, because the benefit of that is now the surgeon is in there, he or she has their hands on it, they're lining it up perfectly. Then they're going to use the perfect hardware to screw it together and it's going to heal beautifully because it's all lined up and it's pressed together properly. So it really mends very nicely.

Speaker 1: 5:21

Another thing is you know, if there's gaps or if it's, if it's offset fracture, healing could be delayed. It could be a lower quality of healing. So in my mind, what's ideal is that the surgeon goes in there, gets eyes and hands on it and just makes it perfect. So let's talk about the implants. So I'll have patients come in who have had the surgery and they're asking where are the plates? And it's a really nice.

Speaker 1: 5:48

Let's go back to the model again. So here's a palmer surface. Let's put it so there's the back of the elbow. Now it's palm up like this and we're going to turn it, palm down so they fall, bang, the end of that radius comes up, or it's fractured in multiple pieces or a combination of the two, and now it has to be fixed. It has to be fixed internally and here's that radius bone palm down. And now let's turn a palm up just so we can see the plate. So the plate would go over the end of the radius and the screws would hold the fracture site together and oftentimes have a compression force so that it really heals and comes together optimally.

Speaker 1: 6:48

Sometimes the fracture line will go into the articular surface. Articular surface means that's the surface that articulates or connects to other bones. That's where the cartilage is. So sometimes that fracture line will go right through the cartilage. And so you can imagine if you're the surgeon and you put plates and screws on just the surface, but now the fracture line extends into the joint surface and this area might fall away.

Speaker 1: 7:17

There's some additional tools that can be added onto this plate, such as this little hook. So you see this little fork that goes around and that's holding, that's going over the watershed line and that's holding that piece of bone inward so it's not going to fall off and it's going to heal instead of being in a perfect position. Now I mentioned the watershed line. If you picture a river flowing down here of water and this is the waterfalls right when it gets up to the edge and goes over the top, that's the watershed line. I think that's such a clever name. Another reason I mentioned the watershed line is think that's such a clever name. Another reason I mentioned the watershed line is because that plate, we don't want that plate to be beyond that watershed line at all, or or even you know, too far up to it, because that could be a relatively sharp edge that causes some friction on the tendons and then sometimes tendons will rupture. Also, sometimes, if one of these screws starts to back out and that it's a friction point on a tendon, the tendons can rupture and then another surgery has to be done to repair the tendon.

Speaker 1: 8:27

Now the medical hardware companies came up with great technology. There's locking screws on these locking plates, that there's special threads in the head of the screw that actually dig into the plate and create thread lines in the plate. So the screw is locked right in there and there's no chance of the screw coming out. So they really thought of everything with these and I actually have a plate that's not on the bone. I work in the office with an orthopedic surgeon who is a fellowship trained hand surgeon specialist, so we have a really great working relationship, wonderful collaboration, so our patients get well in minimal time, and I asked him if he has this stuff so I can show you, and he was gracious enough to let me borrow these.

Speaker 1: 9:28

I want to show you another piece of technology. This collar right here is raised up off of the plate. What that is is a drill guide, so it's very handy what the surgeon will do before they put in any screws. Here's a plate without screws. They'll actually take some wires and push the wires through the holes into the bone and then do another quick fluoroscopy, another quick radiograph or x-ray and see when I drill my holes and put the screws in, is it going to be, are the screws going to be in the perfect position to grab those bone fragments, to hold them where I need to hold them, and that that, I think, is just, it's just fascinating. And then when they look at that and say okay, yes, they'll remove the pins, drill a hole and in this case there's a, a whole guide so that the drill can go through that collar, make a, make a nice pilot hole, and then they can insert the screws.

Speaker 1: 10:28

You know that's a bit of an oversimplification, but I just want you to have a general idea. There's also a, an oval screw hole here which allows the plate to be affixed and then to be adjusted proximal to distal, or south and north, and really put an optimal position, and that helps the surgeon keep that where it is in the best spot. Now if we were to take off the bone on the end so you can look into it this way end view you can see the different angles of the screws. There's so purple screws and then there's a couple of pins just a couple of posts in here too that are holding things in place. Now here's another really good tidbit Dr Zafante explained to me. He said now if you have, for example, an older person with osteoporosis and their bone isn't very dense and there's, you know, a lot of it's more airy, it's not real dense bone they make screws that actually not only lock on the top but there's some reverse threads that will actually help pull the bone fragment upward to give a little bit of a compression force, and I just want you to be aware of that. There's a lot of different tools within this tool to really give the most optimal fixation, and the body doesn't reject these A lot of times. There'll be even a calcification over the top to really secure it. The body will sometimes encapsulate some of this. To what extent I don't fully know, but these usually do really really well. It's a. It's a great choice, especially for a fracture.

Speaker 1: 12:28

When it has to be done. It's one of those things when it has to be done, it just it has to be done and it really aligns everything perfectly. Now what I do as a hand therapist. I will see these all about a week after surgery and I'll remove the post-operative half cast. Then I'll fabricate a custom orthosis and it'll be. It's a gutter over the forearm and it molds over the wrist with a moldable piece over the back of the hand really protecting the fracture site, holding that position and the patient can remove the brace, perform a very specific range of motion to get the radius moving around the ulna.

Speaker 1: 13:15

There's a thick, heavy ligament between the radius and ulna. All the interosseous ligament is very, very thick. Once that starts to shrink it's very hard to get the range of motion back. In the past I've seen patients who were immobilized for a long, long time and they weren't able to turn their hand palm up further than this and even having difficulty turning a palm down, and that, with this surgery, really helps us avoid all that. So the patient can remove the brace, do their exercises three or four times a day and then even start some light, very light stretching, sometimes using the knee as a fulcrum. If they can't turn on their hand all the way palm up, probably use their inside of their knee as a fulcrum to push it back, outside of the knee, to push it toward the palm. Very light, sustained stretch, 20 seconds, pulling sensation, only no pain For the first few weeks. I'm only just having them move without pushing on themselves, just to restore a range of motion and loosen the tissues.

Speaker 1: 14:20

And, by the way, one of the best ways to increase blood flow and the way our bodies really maximize blood flow throughout the body is with movement. It's the movement squashes around fluids and helps the blood flow through the arteries and veins. And the first two weeks is really the inflammatory phase of wound healing. There's going to be swelling. I inform my patients that that's normal and we're happy to see that because that's a really major part of the immune system, where the lymphatic system is sending lymph fluid and it's flowing throughout the lymph vessels and that is carrying away bacteria. So the first couple of weeks I don't want to be really aggressive with reduced swelling. You know, wear a compression glove. No, and I don't even want the force of the compression glove being pulled on because the fracture is pretty fresh at that point.

Speaker 1: 15:14

So initially, first couple of weeks, we're reintroducing range of motion and then we're, after a few weeks, we're starting light self-range of motion. We call it for stretching. At about six weeks we get rid of the splint and then we get a little more aggressive in the range of motion. I could do some light traction, a little more forceful range of motion Again not painful, but just a firmer stretch and then start strengthening. I like to use a hammer which palm up, palm down, which strengthens many muscles at once. But really the best situation for quicker recovery is having the plates and screws, the hardware, the plate, when it's warranted. So thank you for watching. I hope you found that to be interesting. Thank you for subscribing to the channel. Look forward to talking to you more. Thank you.