UL: DISTAL FOREARM AND WRIST #'s & DISLOCATIONS

Question 1

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

MONTEGGIA FRACTURE

Answer 1

• COMMON IN ADULTS- DIRECT BLOW TO ULNA OR FALL
Type 1 =Anterior Monteggia (extension type)-The most common pattern- 90%
Type 2=Posterior Monteggia (flexion type)-10%

MANAGEMENT
• ORIF using a plate, with radial head reduction.
• The elbow is immobilised in an above elbow POP for 3-6/52.
• A sling is applied for a further 2-4/52 and mobilising exercises are commenced during this time.

Question 2

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

GALEAZZI FRACTURE

Answer 2

FRACTURE OF THE DISTAL HALF OF THE SHAFT OF THE RADIUS WITH DISLOCATION OF THE INFERIOR RADIO-ULNAR JOINT.

MANAGEMENT:
ORIF OF THE RADIUS WITH PLATES.
THE ULNA SHOULD RELOCATE SPONTANEOUSLY ONCE THE RADIUS IS FIXED.
MAY USE POP OR PRESSURE BANDAGE.

CONTRA-INDICATIONS AND PRECAUTIONS POST-SURGERY:
 NO FORCED PASSIVE MOVEMENTS.
 AVOID PRO- AND SUPINATION FOR 3/52 TO AVOID STRESSING THE INFERIOR RADIO ULNAR JOINT.
 USUAL CONTRA-INDICATIONS AND PRECAUTIONS FOR A PATIENT IN POP

Question 3

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

COLLES FRACTURE. CAUSE, DEFORMITY, COMPLICATIONS

Answer 3

• COMMON INJURY, ESPECIALLY IN OLDER, OSTEOPOROTIC WOMEN.
• THE DISTAL 2,5 – 3 CM OF THE RADIUS IS FRACTURED.
• THERE IS OFTEN AN ASSOCIATED AVULSION # OF THE ULNAR STYLOID PROCESS OR A TEAR OF THE ULNAR COLLATERAL LIGAMENT.
• THE # OFTEN EXTENDS INTO THE RADIOCARPAL JOINT (ONLY SEEN ON CT SCAN)

CAUSE
• A FALL ONTO AN OUTSTRETCHED HAND.

DEFORMITY
• THE TYPICAL ‘DINNER-FORK’ DEFORMITY:

COMPLICATIONS
• EXCESSIVE SWELLING, OEDEMA AND STIFFNESS OF THE HAND
• MEDIAN NERVE COMPRESSION
• MALUNION
• STIFF SHOULDER
• REFLEX SYMPATHETIC DYSTROPHY
• SPONTANEOUS RUPTURE OF EXTENSOR POLICIS LONGUS TENDON

Question 4

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

COLLES FRACTURE MANAGEMENT AND CONTRAINDICATIONS & PRECAUTIONS

Answer 4

CONSERVATIVE MANAGEMENT
• MANIPULATION UNDER ANAESTHESIA, THEN BELOW ELBOW POP FOR 6/52. THE WRIST WILL BE HELD IN SLIGHT FLEXION, ULNAR DEVIATION AND PRONATION.

CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK.

SURGICAL MANAGEMENT
• ORIF (PLATES/K-WIRES) IF THE FRACTURE EXTENDS VERTICALLY INTO THE RADIOCARPAL JOINT. MAY BE IN A CAST POST SURGERY, FOR EXTRA SUPPORT.

CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK.
• NO FORCED PASSIVE MOVEMENTS

Question 5

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

PHYSIOTHERAPY MANAGEMENT/GUIDELINES

Answer 5

• IN POP- EX’S TO NECK, SCAPULA, SHOULDER, ELBOW & FINGERS
• ISOMETRICS WITHIN PAIN
• FUNCTIONAL ACTIVITIES WITHIN POP & PAIN
• POP REMOVED- ↑SKIN CONDITION, ↑ROM, ↑MP
• HOME PROGRAMME
• SUPINATION & GRIP STRENGTH ++++

Question 6

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

SMITH FRACTURE

Answer 6

• THIS IS AN UNCOMMON INJURY. IT MAY BE CAUSED BY A FALL ONTO THE BACK OF THE HAND OR A FLEXED WRIST.

Fracture of the distal radius. The distal fragment is displaced anteriorly and towards the ulna.

MANAGEMENT
• ABOVE ELBOW POP WITH FOREARM SUPINATED AND ELBOW FLEXED TO 90 FOR 6/52.

Question 7

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

BARTON FRACTURE, management, contraindications and precautions, complications

Answer 7

• FRACTURE OF THE ANTERIOR PORTION OF THE DISTAL RADIUS. THE FRACTURE EXTENDS INTO THE JOINT WITH ANTERIOR SUBLUXATION OF THE CARPUS. A form of Smiths fracture

MANAGEMENT
• ORIF WITH A SMALL PLATE. A BELOW ELBOW POP POSTSURGERY (10 DAYS).

CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK.
• NO FORCED PASSIVE MOVEMENTS.

COMPLICATIONS
• PROLONGED STIFFNESS OF THE WRIST D/T INTRA-ARTICULAR FRACTURE

Question 8

FRACTURES AND DISLOCATIONS OF THE DISTAL FOREARM AND WRIST

Answer 8

FRACTURE OF THE SCAPHOID
• COMMON IN YOUNG ADULTS, IN SPORTS AND D/T FALLS
DEFORMITY

COMPLICATIONS
• DELAYED UNION – MAY TAKE UP TO 12 WEEKS
• NON-UNION
• AVASCULAR NECROSIS – COMMON COMPLICATION
• OSTEOARTHRITIS

MANAGEMENT
• SCAPHOID POP APPLIED, EVEN BEFORE THE FRACTURE IS CONFIRMED ON X-RAY.

CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK.