Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Distal Radius Fractures

Transcript

Distal Radius Fractures · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Did you know that the bone most commonly broken
• 0:02
  in the arm, often leading to a, well, a distinctive
• 0:05
  dinner fork appearance, is actually just an inch
• 0:08
  from your wrist? It's surprisingly common. It
• 0:11
  really is. It's a significant challenge orthopedic
• 0:14
  professionals face daily, yet... It's far more
• 0:17
  nuanced than it might first appear, isn't it?
• 0:19
  Absolutely. There's a lot to consider. So today,
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  we're taking a deep dive into distal radius fractures,
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  those incredibly common wrist breaks that impact,
• 0:27
  well, really everyone from young athletes right
• 0:30
  through to older adults. A very broad spectrum.
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  Exactly. We'll be exploring not just why they
• 0:35
  happen, but how modern practice approaches diagnosis
• 0:38
  and treatment to ensure the best possible outcomes
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  for patients. Joining us to navigate this complex
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  landscape is an accomplished expert in musculoskeletal
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  trauma. Welcome. So let's unpack this. What exactly
• 0:51
  constitutes a distal radius fracture? And given
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  its commonality, what are the sort of underlying
• 0:55
  patterns driving its prevalence? Well, distal
• 0:58
  radius fractures, or DRFs, as we often call them
• 1:00
  in the field, are essentially breaks in the radius
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  bone, specifically very close to the wrist joint
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  itself. OK. The radius is the larger of the two
• 1:08
  bones in your forearm, positioned on the thumb
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  side. Right. Got it. What's truly fascinating
• 1:13
  when we look at the The epidemiology of these
• 1:16
  fractures is a distinct bimodal distribution
• 1:20
  in the patient population. Bimodal. How so? We
• 1:23
  see a significant peak in children and adolescents.
• 1:27
  This is typically as a result of high energy
• 1:29
  trauma, like playground falls, sports injuries,
• 1:33
  that kind of thing. Right. The usual childhood
• 1:35
  scrapes. Exactly. But then there's a second equally
• 1:38
  pronounced peak in adults over 50. And what's
• 1:41
  particularly striking is its prevalence among
• 1:43
  Caucasian women over 65. Oh, that's specific.
• 1:46
  Yes. For this older demographic, even a low energy
• 1:49
  fall, perhaps just a simple trip from a standing
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  position, can lead to a fracture. Wow. And this
• 1:54
  is, crucially, often strongly linked to conditions
• 1:57
  like osteoporosis, which affects a substantial
• 1:59
  portion around your 40 % of postmenopausal women.
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  40 % is huge. It is. And the overall incidence
• 2:07
  of DRFs is actually on an upward trend globally.
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  We think this is due to factors like increasing
• 2:13
  childhood obesity, perhaps leading to more falls,
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  and certainly an aging population living longer,
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  often with multiple comorbidities impacting bone
• 2:21
  health. So it's complex. It really underscores
• 2:24
  that a distal radius fracture isn't just one
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  disease. It's almost two entirely different clinical
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  challenges needing distinct preventative strategies.
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  One focused on trauma prevention in the young,
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  the other on systemic bone health in the elderly.
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  That dual nature is quite a revelation. And it's
• 2:41
  that very common mechanism, the fall on an outstretched
• 2:43
  hand, the fush injury that often dictates how
• 2:46
  these fractures present, isn't it? Precisely,
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  yes. Could you walk us through the different
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  patterns we typically see from a fush injury?
• 2:52
  Absolutely. The fush mechanism is, without doubt,
• 2:55
  the most common cause across all age groups.
• 2:57
  However, the precise pattern of the fracture
• 3:01
  can vary significantly. It depends on how the
• 3:03
  hand is positioned at impact and the exact force
• 3:06
  applied. For instance, a collis fracture, first
• 3:09
  described by the Irish surgeon Abraham Colles
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  way back in 1814, typically results in the discal
• 3:15
  fragment of the radius tilting upwards, dorsally.
• 3:18
  Ah, the dinner fork. That's the one. creating
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  that very characteristic dinner fork or silver
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  fork deformity you mentioned. It's quite unmistakable
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  on an x -ray. Right. Conversely, its opposite,
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  the Smith's fracture, involves a volar or palm
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  -side downward tilt of the fragment, sometimes
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  referred to as a garden spade deformity. Garden
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  spade, okay. Less common, maybe? Less common
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  than collis, yes, but still significant. Then
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  we encounter more complex types, such as Barton's
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  fractures. These are intra -articular rim fractures,
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  meaning they go into the joint and they can also
• 3:50
  involve joint dislocation, which adds another
• 3:53
  layer of complexity. Right. Involving the joint
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  makes it trickier. Definitely. And Chauffeur's
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  fractures, affecting the radial styloid, that
• 4:00
  little bony prominence on the thumb side, often
• 4:03
  from an axial compression force. And what about
• 4:05
  in children? You mentioned they're one peak.
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  Yes. In children, we frequently see incomplete
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  fractures. like green stick, where the bone bends
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  on one side, breaks on the other, or torus fractures,
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  which are like buckles in the bone cortex. Like
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  a dent? Sort of, yes. And critically, growth
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  plate injuries, known as Salter -Harris fractures,
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  are also common in the younger population. These
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  require very careful management to avoid any
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  long -term growth disturbances. That variation
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  in fracture patterns is remarkable. It must make
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  diagnosis incredibly critical. So once a patient
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  presents, you know, with that immediate pain,
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  swelling, maybe even a visible deformity, what's
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  the very first priority for clinicians assessing
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  these? The initial assessment is absolutely paramount,
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  non -negotiable. Clinicians must meticulously
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  document the exact mechanism of injury, how did
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  it happen, and then perform a detailed physical
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  examination. What does that involve? It includes
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  carefully checking the integrity of the skin
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  is in an open fracture, assessing circulation
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  of the hand and fingers, capillary refill, pulses,
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  and critically evaluating sensation to rule out
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  any nerve involvement. Nerve damage is a risk,
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  then? Yes, especially of the median nerve, which
• 5:16
  runs through the carpal tunnel. It can present
• 5:18
  as acute carpal tunnel -like symptoms, numbness,
• 5:23
  tingling, and imaging. For imaging, x -rays remain
• 5:26
  the gold standard. Essential views include posterior
• 5:29
  anterior, lateral, and sometimes oblique projections.
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  These allow us to accurately measure key parameters
• 5:35
  like radial height, radial inclination, volar
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  tilt. These numbers tell us a lot. And CT scans.
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  For more complex cases, yes. Or when we're planning
• 5:45
  surgery, computed tomography CT scans are invaluable.
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  They provide really detailed 3D views of the
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  fracture pattern and crucially, any involvement
• 5:54
  of the joint surface. Seeing that articular step
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  -off or gap is vital. The core decision then
• 6:00
  really revolves around whether to pursue non
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  -surgical or surgical management. You've laid
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  out the diagnostic steps really clearly. What
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  specifically guides that pivotal decision -making
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  process, opting for non -surgical versus surgical
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  intervention? What are those key parameters you
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  mentioned? The primary objective always is to
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  optimize the patient's long -term functional
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  recovery. It's not just about making the x -ray
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  look perfect on paper. Function over form, essentially.
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  In many ways, yes. Function is key. So for stable
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  non -displaced fractures, especially those that
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  are extra -articular, meaning they don't extend
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  into the joint surface non -surgical treatment,
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  is often remarkably effective. And what does
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  that look like? Typically it involves a closed
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  reduction where we realign the bone without making
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  an incision followed by immobilization. Usually
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  first in a splint to allow for the initial swelling
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  to go down and then into a cast. Okay. And are
• 6:52
  there thresholds? Yes. For adults, acceptable
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  parameters for this non -surgical approach generally
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  include less than five millimeters of radial
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  shortening, a change of less than five degrees
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  in radial inclination, and less than five degrees
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  of dorsal angulation or tilt. Those are the numbers
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  to watch. They are. Interestingly, though, for
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  patients aged 65 or older, non -operative treatment
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  can frequently be considered the primary choice
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  for dorsally displaced fractures, even if the
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  deformity looks quite significant radiologically.
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  Really? Even if it looks quite off? Yes, unless
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  there's clear neurovascular compromise or perhaps
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  extreme deformity affecting skin integrity. Multiple
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  studies, good quality studies have actually shown
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  comparable functional outcomes between operative
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  and non -operative approaches in this specific
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  elderly demographic. That's fascinating. It challenges
• 7:43
  some older assumptions, doesn't it? It does.
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  It emphasizes tailoring treatment to the patient's
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  overall health, activity level, and goals, not
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  just the x -ray. That's a critical distinction,
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  particularly for older patients. But what about
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  those borderline cases or situations where non
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  -surgical approaches just aren't sufficient?
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  When is surgery definitely indicated and what
• 8:04
  are the main techniques you use? Right. Surgical
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  intervention is generally considered when the
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  fracture is inherently unstable. when it's significantly
• 8:11
  displaced beyond those acceptable parameters
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  we talked about, or if it simply cannot be adequately
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  reduced and held in place non -surgically. We
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  have several surgical approaches available. One
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  is closed reduction and percutaneous pinning,
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  or K -wiring. We insert small metal pins through
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  the skin to hold the bone fragments in place
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  while they heal. Like internal scaffolding? Sort
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  of, yes. It's minimally invasive. OK. This method
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  is still commonly used, particularly in children
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  and for some simpler adult fractures. OK. However,
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  for adults, especially with more complex fractures,
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  open reduction and internal fixation, or IF,
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  is increasingly the standard. Or at IF. OK, what
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  does that involve? This involves making an incision
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  to directly visualize and realign the bone fragments
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  accurately, the open reduction part, and then
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  we stabilize them using plates and screws, the
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  internal fixation part. Plates and screws, where
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  do they usually go? Volar plating, that's when
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  we apply the plate to the volar, or palm side
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  of the wrist is often preferred nowadays. Why
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  volar? It generally offers incredibly robust
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  fixation, which often allows for earlier mobilization
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  and physiotherapy. Though meticulous surgical
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  technique is vital to avoid complications like
• 9:20
  tendon irritation or even rupture, particularly
• 9:22
  of the flexor tendons on that side. Ah, so there
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  are potential downsides. There are risks with
• 9:28
  any surgery. For very severe fractures, open
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  fractures, where the bone breaks the skin, or
• 9:34
  those that are highly comminuted, meaning shattered
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  into multiple pieces, or perhaps in patients
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  who are medically unstable, external fixation
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  might be used. An external frame. Exactly. An
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  external frame that holds the bones in position
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  from outside the body. It's often combined with
• 9:50
  other internal fixation techniques, maybe some
• 9:52
  pins. It's usually a temporary measure or use
• 9:55
  for damage control. Right. And does timing matter?
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  When you decide to operate? The timing of surgery
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  can be quite important, yes. Particularly for
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  intraarticular fractures, those involving the
• 10:06
  joint, or if there's a re -displacement after
• 10:09
  an initial reduction, intervention often needs
• 10:11
  to happen fairly quickly, ideally within about
• 10:13
  72 hours, to achieve the best anatomical restoration
• 10:16
  and functional results. Okay, so prompt action
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  is needed in those cases. It often is. So, we've
• 10:22
  walked through the diagnosis and the treatment
• 10:23
  options, both surgical and non -surgical. But
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  what does this all mean for the patient in the
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  long run? What challenges might they face during
• 10:31
  recovery, and what's the overall prognosis like
• 10:34
  for regaining full function? Well, recovery can
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  be quite varied. It really depends on the fracture
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  type, the treatment used, and, importantly, patient
• 10:43
  -specific factors, age, general health. Motivation
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  for rehab. It's individual. Very much so. While
• 10:50
  simpler fractures generally heal well with minimal
• 10:52
  long -term issues, complex fractures, or those
• 10:55
  with significant initial displacement, naturally
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  carry a higher risk of complications. What sort
• 11:00
  of complications are we talking about? The overall
• 11:02
  complication rate following surgical fixation
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  is reported to be around 11 .7%. Perhaps a bit
• 11:09
  higher in some studies. The most frequent neurological
• 11:12
  complication we see is actually carpal tunnel
• 11:14
  syndrome. It can affect anywhere from 1 % up
• 11:17
  to perhaps 30 % of patients, particularly after
• 11:19
  high energy injuries that cause a lot of swelling.
• 11:22
  30%. That's quite high. It can be, yes. Symptoms
• 11:26
  like numbness or tingling in the fingers can
• 11:28
  be significant and might even necessitate urgent
• 11:31
  surgical release of the carpal tunnel itself.
• 11:35
  Other common issues include mal -reduction, where
• 11:37
  the bone doesn't heal in quite the right position,
• 11:40
  or a subsequent loss of reduction after initial
• 11:42
  treatment. These might require a second procedure
• 11:45
  to correct the alignment. More surgery. Potentially,
• 11:48
  yes. Tendon complications can also occur. Things
• 11:51
  like irritation from plates or screws, or even
• 11:54
  rupture, especially the extensor pollicis longus,
• 11:57
  or EPL, tendon, which helps extend your thumb.
• 12:00
  That's a known, albeit uncommon risk, particularly
• 12:03
  with some older plating techniques or certain
• 12:05
  fracture patterns. And a more serious, though
• 12:08
  thankfully rarer, complication is complex regional
• 12:12
  pain syndrome or CRPS. CRPS. Yes. It's a debilitating
• 12:15
  condition characterized by severe disproportionate
• 12:18
  localized pain, swelling, stiffness, skin changes.
• 12:22
  It can greatly hinder rehabilitation and long
• 12:24
  -term function. That sounds difficult to manage.
• 12:27
  It can be very challenging. But whilst complications
• 12:29
  are a concern, a key insight from recent research,
• 12:32
  I think, is that early, often quite aggressive,
• 12:37
  Physiotherapy significantly reduces the incidence
• 12:39
  of long -term stiffness. Even for fractures that
• 12:43
  seem relatively minor initially, early movement
• 12:47
  is key. That sounds challenging, but that insight
• 12:49
  about early physiotherapy is absolutely vital
• 12:51
  then. Just how critical is rehabilitation in
• 12:54
  not just preventing these issues, but ensuring
• 12:56
  the best possible recovery for the patient? Rehabilitation
• 13:00
  is absolutely paramount. I can't stress that
• 13:02
  enough. Early mobilization guided by the surgeon
• 13:05
  and therapist, is crucial to prevent joint stiffness
• 13:08
  and promote functional recovery. When does it
• 13:10
  typically start? Physical therapy, or physiotherapy,
• 13:14
  typically begins within days to weeks after surgery,
• 13:17
  or as soon as the cast is removed if treated
• 13:19
  non -operatively, always depending on the fracture
• 13:21
  stability and the specific treatment. Okay. While
• 13:24
  most patients do regain significant function,
• 13:27
  you need to understand that full recovery from
• 13:28
  a distal radius fracture can take up to a year.
• 13:31
  A whole year. Yes, for full strength and endurance
• 13:33
  to return. And some residual stiffness or perhaps
• 13:37
  an ache with certain activities might persist
• 13:40
  for two years or even permanently in some cases,
• 13:42
  particularly after very high energy injuries
• 13:45
  or perhaps in older patients with pre -existing
• 13:47
  conditions like osteoarthritis. So managing expectations
• 13:50
  is important. Hugely important. Patient education
• 13:53
  about realistic recovery timelines is key. And
• 13:57
  finally, something we really need to emphasize
• 13:59
  for older adults. Experiencing a distal radius
• 14:03
  fracture should always trigger a comprehensive
• 14:05
  evaluation for underlying osteoporosis. Back
• 14:08
  to the bone health point. Exactly. It's not just
• 14:10
  a broken wrist in isolation. It's often a vital
• 14:13
  indicator of systemic bone weakness and a significant
• 14:16
  predictor of future fragility fractures, potentially
• 14:19
  much more serious ones like in the hip or spine.
• 14:21
  So it's a warning sign. It's often the first
• 14:23
  major alarm bell for underlying poor bone health.
• 14:26
  Addressing that through investigation and potentially
• 14:28
  treatment for osteoporosis is a crucial part
• 14:31
  of the overall management, looking beyond just
• 14:33
  fixing the fracture itself. This has been incredibly
• 14:35
  insightful. Thank you. For you, our listener,
• 14:38
  the key takeaways seem really clear. Precise
• 14:42
  diagnosis through that thorough clinical exam
• 14:44
  and appropriate imaging is crucial. Yes. Treatment
• 14:47
  needs to be highly individualized based on the
• 14:50
  specific specific fracture, but also very much
• 14:52
  on the patient's needs and age. Absolutely. And
• 14:55
  early tailored rehabilitation is just fundamental
• 14:57
  for optimizing recovery and function. Couldn't
• 14:59
  agree more. And, as we've just heard so clearly,
• 15:02
  for older patients especially, seeing a distal
• 15:04
  radius fracture should serve as an important
• 15:06
  alarm bell for wider bone health, prompting that
• 15:09
  conversation about osteoporosis investigation
• 15:11
  and management. Which really leads us to a broader
• 15:14
  question, I think, for all of us working in healthcare.
• 15:17
  Go on. How do we continually enhance that interdisciplinary
• 15:20
  coordination between the emergency department
• 15:23
  staff, the orthopedic surgeons, the physiotherapists,
• 15:26
  the GPs, maybe geriatricians? How do we make
• 15:30
  sure we're working together seamlessly to ensure
• 15:33
  the best possible outcomes, not just for the
• 15:35
  fracture itself, but for the patient's overall
• 15:38
  long -term well -being and their future bone
• 15:40
  health? That's a powerful thought to consider
• 15:43
  that joined -up care approach. If you found this
• 15:45
  deep dive valuable, please do consider rating
• 15:48
  and sharing it with a colleague. It genuinely
• 15:50
  helps us reach more professionals like you. Thank
• 15:53
  you so much for guiding us through this really
• 15:55
  essential topic today.