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Workplace Injury of the Week: Wrist Fracture

A fracture of the distal radius or ulna (wrist fracture) is a break in one or two bones of the distal forearm near where they form part of the wrist joint.

The radius is the bone located on the thumb side of the forearm, and the ulna is the bone located on the side of the small finger.

Such fractures usually involve not only the ends of the bone but also injury to the many small ligaments in the wrist. This may further decrease stability of the wrist joint and create problems with functioning of the wrist and hand.

This type of injury most often results from a fall with the hand extended during landing. Fractures of the distal radius and ulna are described by their location and position, for example, angulated or displaced.

A displaced fracture is one in which the bone has shifted its position. An angulated fracture results in abnormal alignment of the hand on the end of the forearm.

Fractures also may be comminuted or broken into many pieces. In cases in which the force of the impact drives the bone fragments through the skin, or in which the skin is torn away from the area exposing the bone and surrounding tissues, the fracture is referred to as an open fracture. If the skin remains intact, the fracture is a closed fracture.

Treatment

Closed fractures that are not displaced may be treated with a short arm cast or splint if the fracture appears stable. Close monitoring is required because the fragments may slip out of position due to the many pulling forces of ligaments and muscles near the wrist.

Closed fractures with fragments out of position will require reduction, either closed with local or regional anesthesia, or during surgery (open reduction). Again, because of the many forces pulling on the wrist, the fragments may slip after reduction.

Turning the palm of the hand up (supination) and down (pronation) rotates the radius and ulna, which also can cause displacement of the fracture; therefore, the elbow is included in any splint or cast that is applied (sugar tong or long arm cast). This locks the elbow and hand, preventing rotation of the radius and possible displacement of the fracture.

If the fracture is unstable, metal hardware, most often plates and screws may be used to hold the fragments in position during healing. This hardware may be inserted directly into the fragments during surgery (open reduction, internal fixation [ORIF]).

Traction fixation may be accomplished with attached long pins passing through the skin into bone from the mid forearm, across the fractured wrist, and into a set of pins in the hand. These devices, called external fixators, maintain reduction of the fracture with traction. Some individuals require use of a sling, but elevation of the wrist and forearm during the early stages of healing is important to prevent complications.

Motion of the fingers and shoulder is encouraged. Medications for pain and swelling will be needed. Ice packs over the cast or splint can be helpful in reducing swelling and pain. Early motion of the wrist helps prevent stiffness and arthritis. Sometimes a removable splint can be used during the late stages of healing to encourage motion exercises.

Referral to a hand therapist can be invaluable, even early in treatment. In very severe cases in which a wrist fracture has not healed after 4 months or when the bones have been so displaced and fragmented that they cannot be repaired, wrist replacement surgery (wrist arthroplasty) or wrist fusion, partial or total, may be indicated.

Return to Work

If the fracture is unstable, the arm should not be used for several weeks except for finger range of motion exercises without resistance. The wrist should not be rotated until the fracture is healed.

Lifting, carrying, pulling, and pushing should be limited. Use of a cast, splint, external fixation, and/or sling will affect dexterity; therefore, if the dominant side is injured, work restrictions may be more extensive (e.g., if an individual is right-handed and must write or perform fine motor skills with the dominant hand, he or she will experience more work limitations than if the nondominant left hand were injured).

In some cases, alternatives to a standard keyboard such as speech recognition software or one-handed keyboards may be appropriate accommodations. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period.

Rest periods for elevation of the hand and forearm may be necessary during the initial stage of recovery. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Find Out More

To read more about wrists fractures, including treatment, rehabilitation, complicating factors, recovery times and return-to-work durations, go to www.mdguidelines.com.


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