|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 58-60
Complications of distal radius fractures
Mukund Madhav Ojha, Alok Chandra Agrawal, Bikram Kesari Kar, Harshal S Sakale
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||26-Jun-2020|
|Date of Decision||18-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||10-Sep-2020|
Mukund Madhav Ojha
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Distal end radius fractures are the most common fracture encountered by orthopedic surgeons, accounting for 17.5% of all adult fractures. Numerous complications arising during the course of management of these fractures are broadly categorized as immediate (nerve injury, compartment syndrome, and skin injury), early (loss of reduction, tendon rupture, stiffness of joints, and infection), and late complications (maluinon, delayed/nonunion, complex regional pain syndrome, and joint arthropathy). It is imperative for a surgeon to have thorough knowledge of these complications and methods required to prevent and manage them.
Keywords: Carpal tunnel syndrome, tendon rupture, complex regional pain syndrome
|How to cite this article:|
Ojha MM, Agrawal AC, Kar BK, Sakale HS. Complications of distal radius fractures. J Orthop Dis Traumatol 2020;3:58-60
|How to cite this URL:|
Ojha MM, Agrawal AC, Kar BK, Sakale HS. Complications of distal radius fractures. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Sep 22];3:58-60. Available from: http://www.jodt.org/text.asp?2020/3/2/58/294730
| Introduction|| |
Fracture of the distal radius is the universal fracture confronted by orthopedic trauma surgeons, contributing for 17.5% of all adult fractures. In older population, low bone mass density and increasing risk of falls are certain risk factors for distal radius fractures. The risk of complications in distal radial fractures is 6%–80% in various literature.
According to the time of appearance, the complications are classified as:
| Immediate Complications|| |
Most frequently involved nerve is median nerve, leading to carpal tunnel syndrome (CTS) (0%–17%). Ulnar nerve is less frequently involved (0.5%–4.2%). Mobility of the ulnar nerve at wrist and in forearm imparts protection from injuries. Etiologically, it can be divided as early and late.
Early CTS is mainly caused by direct nerve contusion, swelling, and hematoma extending into carpal tunnel or deep to fascia at the fracture level, hematoma block, and cotton-loader position of cast. Late CTS is mainly caused by malunion and callus formation. It has a pessimistic impact on functional outcome after distal radius fracture.
Chronologically, the complications can arise from day 1 to 25 years. Its onset can be classified into three types:
- ACUTE – which arises within 1 week of fracture. It is more common in younger age groups, mostly in males, due to high-energy injuries trauma (AO type C) and those undergoing multiple close reduction attempts
- SUBACUTE – which arises 1–12 weeks postfracture
- DELAYED – which arises more than 12 weeks postfracture. Last two are more prevalent in older women with lower-energy injuries and extra-articular fractures.
Mild CTS symptoms usually resolve gradually with active finger movements to reduce swelling. Noncircumferential splint supports the wrist and reduces the swelling. Decompression is promising in severe cases where it should be extended proximal to wrist crease, if involved.
Most of the ulnar nerve injuries are neurapraxias, which heal spontaneously. Exploration is recommended in complete ulnar nerve palsy with open wound or in association with acute CTS.
Compartment syndrome is a limb-threatening condition arising due to increase in osseofascial compartment pressure above a critical value of >30 mmHg, thus limiting the tissue perfusion of the area, leading to necrosis. Common in severe injuries and young males.
Signs and symptoms
- Early – Disproportionate pain which increases with passive extension.
- Late – Neurological changes.
First slit open the casts or bandages till skin is visible. Immediate volar fasciotomy using a comprehensive incision from the distal arm to carpal tunnel is required to decompress flexor compartment in case of high compartment pressure within 15–20 mmHg of diastolic blood pressure, rising pressure trend on monitoring, total limb ischemia of >6 h, and in unequivocal clinical signs. After procedure, muscle bellies bulge out of the incision revealing release in compartment pressure. Closure is usually accomplished after a week using gradual interrupted suture placement or shoe lace suturing technique. Split skin grafting is done if closure is not possible by the above methods. Fasciotomy is contraindicated in cases presented after 24 h and after inception of septicemia. Prognosis of the limb with compartment syndrome after doing the fasciotomy procedure depends on the severity of injury, and most importantly, time elapsed after the inception of compartment syndrome. Henceforth, it is better to do a fasciotomy as early as possible even when diagnosis of compartment syndrome is in doubt.
Skin injury during manipulation
It is common in older age group owing to their thin skin as skin injury is potential for conversion of close fracture to an open fracture. Adequate care should be taken during close reduction to avoid such complications.
| Early Complications|| |
Loss of reduction
Increasing age, dorsal comminution, and degree of dorsal angulations at presentation are the potential risk factors. Loss of reduction is more common after stabilization with two styloid wires than using a single styloid wire with addition of two dorsal Kapandji wires. With percutaneous K-wires, displacement is greatest in older people and fractures with >50% dorsal comminution. With external fixators, an additional pin in the distal radial fragment imparts better stability. In the study done by Khalid and Algarni, about 40% of cases required remanipulation due to loss of reduction after close reduction of the distal radius fractures in the elderly patients, owing to osteopenia and comminution of fracture. Loss of reduction is defined when there is loss of 10° or more in volar tilt on the lateral radiograph, loss of 5° or more in the radial inclination, and loss of 2 mm or more in the radial length on the anterior–posterior radiograph in follow-up.
Stiffness of joints
It is relatively a common complication. Stiffness is caused by joint adherence due to prolonged immobilization after plaster application. The incidence is less after surgical intervention as rehabilitation is started early. Recovery requires rehabilitation by physiotherapy and can take 2 years to attain normal function. Well-molded cast not crossing distal palmar creases will alleviate stiffness.
It is more common if the wires are left in situ for ≥8 weeks. Infection rate with K-wire fixation is 33% or more.
Burying the K-wires beneath the skin reduces the infection risk. Percutaneous K-wires should not be used to supplement internal fixation.
Causes are the repeated attempts during K-wire fixation. Rupture of extensor pollicis longus tendon can occur which cannot be repaired directly and function can be restored by extensor indicis proprius tendon transfer. Tendon ruptures can be early as when damaged by K-wire or usually takes around 7 weeks after any internal hardware placement. Internal fixation of fractures, either by dorsal or volar plating system, is six times more prone to cause tendon rupture than external fixation devices. Volar plating accounts for 16% of tendon complications which is the least rate when compared with other fixation devices. Extensor pollicis longus is the most common tendon to get ruptured through irritation from the dorsal penetrating screws of volar plate. Flexor pollicis longus is usually injured from hardware irritation of distally placed volar plate. Tendon complication can be prevented by the use of interposition flaps of local tissue, accurate selection of screw size to prevent prominence, placement of volar plate proximal to watershed line, and early removal of hardware.
| Late Complications|| |
Nerve complication and complex regional pain syndrome
Complex regional pain syndrome (CRPS) or reflex dystrophy or shoulder hand syndrome is often serious, debilitating, and most common complication after distal radius fracture. Etiology is unknown; pain, swelling, increase in local temperature, discoloration, and joint contracture are common signs and symptoms. They are frequently occurring in elderly, women, and individuals with psychological predisposition.
Two stages associated with CRPS are:
- Hot swollen stage
- Cold stiff stage.
Treatment modalities include physiotherapy involving hand therapy, ROM and isometrics exercise, cryotherapy, and transcutaneous electric nerve stimulations. Pharmacological treatment includes drugs such as Non steroidal anti Inflammatory drugs (NSAIDs), anticonvulsant such as gabapentin, calcium channel blockers such as nifidipine, tricyclic antidepressant (amitriptyline), and selective serotonin reuptake inhibitors. Sympathectomy using phenol, radiofrequency ablation, and surgery is used when patient is not relieved from above modalities.
Healed fractures with residual radiocarpal incompatibility leads to higher rate of radiographic arthrosis. A step off of ≥2 mm in the articular surface of distal radius at healing is significant risk factor. Management involves activity modifications, oral analgesics, splintingand surgical options such as partial or complete wrist fusions, and wrist arthroplasty.
No radiographic signs of bridging trabeculae across fracture site at 4 months is defined as delayed union and similar findings if persist after 6 months then labeled as nonunion, although rare but may occur in presence of extensive metaphyseal communition. Comorbid factors such as diabetes, peripheral vascular disease, peripheral neuropathy, alcoholism, and smoking are contributing factors.
Open reduction and plating with bone grafting to which most nonunions are responsive is the management. Arthodesis should be reserved for cases refractory to plating and bone grafting.
It is common but not frequently reported complication. Malunion may lead to weak, deformed, and painful wrist in young active patients, especially children. Patient usually presents with pain frequently on ulnar side, deformity, tenderness over carpal bone and radiocarpal joint, weakness in grip strength, and restricted movement, especially rotation.
Surgical treatment is preferred in case of fit independent patient.
Timing of surgery
Common dictum is to delay the procedure as this allows a vivid picture of residual symptoms and thus prevent unnecessary surgery, but delay leads to increased period of disability and more problems in defining the deformity plane for surgery. Few recent studies recommend early osteotomy in patients with high functional demand and patients presented early with symptoms. Adaptive malunions may benefit from distal radius osteotomy for carpal alignment restoration, while fusion may be beneficial in nonadaptive or fixed carpal deformity.
| Conclusion|| |
Distal radius fracture is frequently encountered by orthopedic surgeons so it is very important for us to be aware of its outcome and prepare ourselves to tackle the nondesireable complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006;37:691-7.
Mathews AL, Chung KC. Management of complications of distal radius fractures. Hand Clin 2015;31:205-15.
Tsuda T. Epidemiology of fragility fractures and fall prevention in the elderly: A systematic review of the literature. Curr Orthop Pract 2017;28:580-5.
Turner RG, Faber KJ, Athwal GS. Complications of distal radius fractures. Hand Clin 2010;26:85-96.
Seigerman D, Lutsky K, Fletcher D, Katt B, Kwok M, Mazur D, et al
. Complications in the management of distal radius fractures: How do we avoid them? Curr Rev Musculoskelet Med 2019;12:204-12.
Pope D, Tang P. Carpal tunnel syndrome and distal radius fractures. Hand Clin 2018;34:27-32.
Denolf F, Roos J, Feyen J. Compartment syndrome after fracture of the distal radius. Acta Orthop Belg 1994;60:339-42.
Chandraprakasam T, Kumar RA. Acute compartment syndrome of forearm and hand. Indian J Plast Surg 2011;44:212-8.
] [Full text]
Jung HW, Hong H, Jung HJ, Kim JS, Park HY, Bae KH, et al
. Redisplacement of distal radius fracture after initial closed reduction: Analysis of prognostic factors. Clin Orthop Surg 2015;7:377-82.
Khalid N, Algarni AD. Loss of position after initial manipulation of distal radius fractures in elderly. Saudi J Sports Med 2017;17:97-101. [Full text]
Kenneth A, Karia EA, Zingman A, Lee S, Nader Paksima DO. Hand stiffness following distal radius fractures. Bull Hosp Jt Dis 2014;72:288-93.
Hays PL, Rozental TD. Rehabilitative strategies following hand fractures. Hand Clin 2013;29:585-600.
Chloros G, Weisler E, Papadonikolakis A, Li Z. In Book – Fractures and Injuries of the distal radius and carpus: The cutting Edge. David Slutsky, A Lee Osterman, Ed; Saunders Elsevier, 2009:247-257.