Complications Following Distal Radius Fractures

clip_image002This week’s guest post is from Trevor Winnegge PT, DPT, MS, OCS, CSCS.  Your may recognize the name, Trevor is a frequent commenter here on this website.  Trevor has been practicing PT for over 8 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.

A Review of Several Complications Following Fracture of the Distal Radius

It is the time of year (at least here in the Northeast United States) where snow starts falling and the ground becomes icy. With these weather conditions comes an increase in the amount of slip and fall injuries seen by doctors and therapists. One of the most common fractures seen, comprising about 13% of all fractures, is the distal radius fracture. Whether these fractures are intra- or extra-articular; non-operative or post-operative, complications following this fracture often arise. These injuries are not always managed by a specialized hand surgeon, so it is important for therapists to be aware of some of the more common complications following this fracture.

Vascular injury and nerve injury can occur, however these are most likely to be picked up by the referring physician before they enter your clinic. Post-traumatic arthritis is common, yet takes longer to set in and may occur after discharge from therapy. I chose to focus this post on the following common forms of chronic pain after distal radius fracture: Scaphoid fractures, TFCC tears, Distal radioulnar joint instability/ulnar impaction syndrome, carpal instability and Extensor Pollicis Longus rupture.

 

Fractures

clip_image003The most common mechanism of injury for a distal radius fracture is a fall on an outstretched hand, or FOOSH injury. This is also the direct mechanism of fracture of the scaphoid carpal bone. This fracture can be sometimes overlooked due to the more pressing displacement of the distal radius. Signs to watch for in an associated scaphoid fracture include tenderness to direct palpation over the anatomic snuff box, swelling, and pain with wrist and thumb movements, as well as with gripping activities. The presence of swelling in the snuff box is variable, as some cases present with no swelling. Chen describes a scaphoid compression test, in which compression through the thumbs longitudinal axis should produce pain in the presence of fracture. Reliability and validity of this test are in question, as different studies have show mixed results, but I think it is a good quick test to add to the rest of your objective findings. Referral for scaphoid view xrays can be helpful. These are taken with clenched fist and wrist in ulnar deviation. If Xrays are negative and fracture is still suspected, an MRI or CT scan will assist in ruling in/out fracture. Failure to recognize a scaphoid fracture can result in non-union and chronic thumb and wrist pain.

 

TFCC Tears

clip_image004The TFCC is comprised of a fibrocartilage disc interposed between the proximal row of carpals on the ulnar side of the hand and the distal ulna. It’s primary function is to enhance joint stability of the distal radioulnar joint and also acts to absorb some of the compressive forces through the hand and wrist. According to Richards et al, Triangular Fibrocartilage Complex, or TFCC, tears occur in 53% of extra-articular distal radius fractures and 35% of intra-articular fractures. Mechanism of injury for TFCC tears is also a FOOSH injury, typically while the forearm is pronated. Symptoms of a TFCC tear are pain just distal to the ulnar styloid process, clicking with pronation or supination which worsens when the wrist is in ulnar deviation and rotating, and pain with wrist/hand and gripping movements. Nonoperative PT care focuses on restoring wrist ROM and strength, as well as stability of the wrist.

 

Distal Radioulnar Joint Instability/Ulnar impaction syndrome

Instability of the distal radioulnar joint following a distal radius fracture occurs in conjunction with a TFCC tear. Other factors suggestive of instability are widening of the joint on x-ray, a positive ulnar variance, and a shortened radius. Neutral ulnar variance is when the borders of the radius and ulna are level across in height. A common complication following fracture of the distal radius is when the radius shortens. This leads to what is know as a positive ulnar variance. Positive ulnar variance is used to describe a forearm where the distal ulna is no longer in line with the distal radius, resulting in the ulnar being longer. The amount of variance is measured on xray and is usually millimeters. (For the record, a negative ulnar variance occurs when the ulna is shorter). In a neutral (normal) variant wrist, the radius absorbs 80% of the weightbearing load, and the ulnar 20%. In a wrist with positive ulnar variance, the ulnar weight bearing load increases to as much as 42%. Over time, this increased load can lead to a condition called ulnar impaction syndrome. This is one of the more common reasons patients have chronic ulnar sided wrist pain following a distal radius fracture. This occurs when the distal end of the ulna with its increased weightbearing load, wear through the TFCC. Symptoms include restricted ROM-particularly with supination/pronation and ulnar deviation. It can also lead to lunate-triquetral instability and carpal chondral lesions. PT management would include strengthening/stability training and restoring rom. However, often times another procedure is indicated. Surgical options include an arthroscopic waffer procedure, osteotomy, or a hemiresection arthroplasty.

clip_image006 clip_image007clip_image008

Figures: Ulnar variance (left), positive ulnar variance – note the radial border of the ulna is elevated (middle), negative ulnar variance – note the radial border of the ulna is depressed (right).

 

Carpal Instability

I mentioned lunate-triquetral instability occurring as a result of the ulnar positive variance following a distal radius fracture. In addition, and more commonly, the scapholunate joint often becomes unstable following a distal radius fracture. It is estimated that in 54% of distal radius fractures, there will be an associated scapholunate instability. Symptoms are pain over the joint line with weight bearing activity, clicking, weakness and a positive instability with joint play testing. Treatment includes splinting, stability and strengthening exercises and activity modification. If a patient does not modify their activity that causes pain, it can lead to a scapholunate dissociation over time, where the scaphoid dislocates. This often requires reduction and internal fixation. Symptoms of this are extreme pain and functional loss of strength, and is easily picked up on x-ray.

 

EPL Rupture

clip_image005Lastly, I want to review the extensor pollicis longus (EPL) muscle and tendon. This is unique in that it occurs following a distal radius fracture in up to 3% of all cases, yet it is poorly understood why this occurs. The EPL inserts on the distal phalanx of the thumb, and acts as a joint extender of the thumb. Rupture of the EPL can occur up to 8 weeks after the initial distal radius fracture. Since it has a poor blood supply, it is postulated that chronic tenosynovitis following this injury wears away the tendon sheath, making it vulnerable to rupture. Testing for a rupture is a simple manual muscle test, where you block the IP joint of the thumb and isolate the distal phalanx. You then ask the patient to extend the distal phalanx and if they are unable to or have trouble doing so, rupture of this tendon should be suspected.

In summary, there are numerous possible complications following a distal radius fracture. I highlighted several of the more common ones. Chronic wrist pain can be difficult to treat as a therapist and aggravating for the patient. Being aware of the possible causes of such pain can lead to a quicker proper diagnosis and preservation of hand and wrist function.

References:

  1. Palmer,AK. The Distal Radioulnar Joint. Anatomy, biomechanics, and triangular fibrocartilage complex abnormalities. Hand Clin. 1987 Feb;3(1):31-40.
  2. Chin HW, Visotsky,J. Wrist fractures in the hand in emergency medicine. Emerg Med Clin North Am 1993; 11:703-735.
  3. Perron AD et al. Orthopedic pitfalls in the ED: scaphoid fracture. Am J Emerg med 2001; 19:310-316.
  4. Wadsworth CT. Anatomy of the hand and wrist. In:Manual Examination and treatment of the Spine and Extremeties. Baltimore, Md: Williams & Wilkins; 1988:128-138.
  5. Cheng et al. An Analysis of causes and treatment outcome of chronic wrist pain after distal radius fractures. Hand Surg. 2008;13(1):1-10. 
  6. Rutgers et al. Combined fractures of the distal radius and scaphoid. J Hand Surg Eur Vol. 2008 Aug;33(4):478-83.
  7. Richards et al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radius fractures. J Hand Surg [Am]. 1997 Sep;22(5):772-6.
  8. Forward et al. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg [Am]. 2007 Nov;89(11):2334-40.
  9. Bickel KD. Arthroscopic treatment of ulnar impaction syndrome. J Hand Surg [Am]. 2008 Oct;33(8):1420-3.
  10. Bonatz et al. Rupture of the extensor pollicis longus tendon. Am J Orthop. 1996 Feb;25(2):118-22.
  11. Owers et al. Ultrasound changes in the extensor pollicis longus tendon following fractures of the distal radius-a preliminary report. J Hand Surg Eur Vol. 2007 Aug;32(4):467-71.
  12. Chen, SC. The scaphoid compression test. J Hand Surg 1989; 14: 323-325.
  13. Dutton,M. Orthopedic Examination, Evaluation & Intervention. New York: McGraw-Hill; 2004
  14. www.wheelessonline.com

H. S. Cheng, L. K. Hung, P. C. Ho, J. Wong (2008). AN ANALYSIS OF CAUSES AND TREATMENT OUTCOME OF CHRONIC WRIST PAIN AFTER DISTAL RADIAL FRACTURES Hand Surgery, 13 (01) DOI: 10.1142/S0218810408003748

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19 Responses to “Complications Following Distal Radius Fractures”

  1. Good information Trevor. At Hartford Hospital we have some of the best hand surgeons in the country, and I think even they would be surprised to hear that as much as 88% of distal radius fractures suffer a TFCC tear. Wow…

  2. Trevor…

    Working in a clinic where all the OTs see the “hand” patients, this was a good review for myself.

    I can also comment on a personal note. I suffered from a TFCC tear when working on the rehab unit one day…just simply transferring a patient into his wheelchair. There was an audible “pop” with immediate pain. From that point on, I had many of the symptoms you described: pain with gripping and ulnar deviation. I also had subluxation during lifting activities such as a biceps curl. I underwent OT, cast immobilization and cortizone injections. We knew it would be difficult because I did, indeed, have a natural postitive ulnar variance. I finally opted for surgical intervention. Since my MRI was inconclusive (vibrating MRI versus tiny little wrists=shaky films) we really didn’t know what was wrong until the arthroscopy. I did have a large central flap tear, but also the L-T tear as well. At that time, they just proceeded with scope.

    I did better after surgery…no more subluxing, but still had great difficulty gripping and lifting (by then I was working in med/surg…lotta lifting). Six months later, I opted for the shortening…but rather than the wafer procedure, they opted to shorten the proximal third and fix with hardware…this also sought to tighten up the L-T joint.

    Six years later…doing great…better than my dominant arm (which has a mild positive variance).

    I agree with you that the TFCC is probably a missed diagnosis and is probably often mislabeled as tendonitis. I was very lucky I had some good OTs that got the occupaptional health doctor to send me to the hand specialist. I don’t regret it one bit.

  3. Trevor Winnegge DPT Reply February 16, 2009 at 4:45 pm

    Brian,
    That was one source that stated 88% but I wouldn’t be surprised at all to see the number consistently in the 80percentile. it often goes unnoticed and is mistreated by general orthopedists who may have been on call and inherited the patient for radius surgery. It can be difficult to convince that general orthopedist that there are other problems involved. Don’t want to bite the hand that feeds you, but sometimes hinting at a hand specialist referral works well!

    Christie-
    Great story on TFCC tear in a PT. did you have any say in the matter on Wafer procedure-vs- ORIF/shortening? You might not have been a candidate for the wafer procedure if you had an anatomical positive variance to begin with. The Wafer prcedure is done arthroscopically and is used a lot more for small variances in the ulna. If that positive variance is greater than a few mm, outcomes are much improved with a shortening. Short term, it is more painful and more difficult to rehab, but in the longterm, it is sometimes better to just have the hardware placed! I am lucky in that I see a great deal of general wrist fractures where I work (the more complicated tendon surgeries go to OT). Most of our referrals come from two doctors that do get their patients from the ER/being on call. We also have a hand specialist on board and the docs will send any problem wrists to him. As a PT in our practice, we don’t get to see too many missed diagnoses. I became interested in this topic after having two consecutive distal radius orif patients with ulnar pain and subsequent TFCc tears. Once I started looking into it for their benefit, i decided to write this post up. Thought it would be a good review since we definitely see more shoulders than wrists, so hopefully this helps some people out!

  4. …A wafer procedure wasn’t considered…I think because of the LT tear. The shortening would’ve taken up the extra slap in the carpals…much better than doing a fusion.

  5. wow Christie, bummer, glad to hear it is better.

  6. Thanks for the info. Don’t usually see pts below the elbow, but glad to have the knowledge.

  7. Trevor,

    Excellent article here! Good work. You know, content like this (which you seem skilled at creating) is a perfect fit for Physiopedia, the open-access, evidence-based encyclopedia written for and by physical therapists. http://www.physio-pedia.com. We would love to have you become an author there!

  8. Trevor would be a great fit for physiopedia, it is an amazing project!

  9. i broke my scafoid and am in heavy labour/ concrete construction and work in very dangerous enviroments and my dr, advsed me to change trades as i will be at risk of injury to myself or others. can anyone help me to find cases of future complications/pain or further injuries due to this kind of return to work
    thanks
    gizzard007@gmail.com

  10. hello, I still wonder why apologizing the volar plating when the bone defect is dorsal and epiphyseal bone mainly osteoporotic. so we work on a lateral percutaneous nailing (with a distal thrue locking). Please have a look on : http://nailoflex.com . the purpose is an internal fixator with a long styloid pin-nail. First 55 cases are very promizing
    DR D.Persoons
    Sarrebourg-France

  11. I broke my radius nine weeks ago, ive had my cast off for three weeks now and am still having pain but he pain is on the oposite side of my broken wrist and its swollen, is this normal ,i thought it might be from my cast, that my cast irritated it, it hurts to use my baby finger to type…help

  12. i had ligament repair jan 15 this year i am having severe pain wakes me up at night iced heat with moist toqwel exercises hor water soaks done different bracing nothing helps

  13. Do you have any recommendations for a pt that is 4 months post distal radius ORIF and has regained almost all ROM with the exception of supination which remains limited by 50%? Thanks.

  14. Was on crutches 3 months from April 2009 due to complex 3rd hip revision/bone graft, may 2009 fell on to my hand heavily rolled on to my fingers bending 2 back, 2 red vains appeared but disappeared quickly, went to A&E had to walk to & from X-Ray with swollen/Bruised hand, doc. checked said tissue damage, left but called back 3wks later, noticed ulner fracture & undisplaced distal radial fracture, asked how was it, said painful not in agony, consultant said if had been in agony would have casted it, but was told to monitor it. Had loads of problems since the fall,MRI shows non-union ulner & united radial, still having lots or wrist pain, had scope Jan 2013 inflammation remouved, might need open reduction of non-union ulner, if my hand had been casted or treatment sought when I fell would this have helped in the early stages since I was using crutches for 3mths, forgot to mention MRI noticed no passage of dye from carpel to distal-ulner & no triangular fibro-cartilage signal, but I remained tender over the ulner base & extensor carpi ulnaris tendon. PS: had a serious RTA in 1979 3 months in hospital had a smiths/Colles fracture to same wrist was casted whilst in hospital. I wrote this just wondering should early treatment have been given from even the recall appointment since the 1st doc. noticed no bony injury?
    Thanks for reading & sorry about abbreviating some of the above.

  15. I had a Colles fracture on Feb. 22nd this year. My radius was crushed at the top and my Ulna had a crack from the top about 2 inches with a pieces of bone at the top floating around. Went thru cast, etc. Now I am experiencing discomfort by the Ulna and stiffness and tinkeling in the tops of my fingers, clicking. It is getting better and the massaging done by the OT person. OT is done and if I over use my hand/wrist I am in pain. What do you recommend for exercises, etc. to get this better? I believe your article that started with “Over time, this increased load can lead to a condition called ulnar impaction syndrome. This is one of the more common reasons patients have chronic ulnar sided wrist pain following a distal radius fracture. This occurs when the distal end of the ulna with its increased weightbearing load, wear through the TFCC. Symptoms include restricted ROM-particularly with supination/pronation and ulnar deviation. It can also lead to lunate-triquetral instability and carpal chondral lesions. PT management would include strengthening/stability training and restoring rom.” What you describe in this passage is basically what I am experiencing. I hope you can shed some light on what I can do going forward to help my wrist pain.

  16. Wow cant believe i finally have some insight of whats going on with my wrists. Last January i had a snowboarding accident and broke both wrists, i had plates put in and they seems to have healed fine but not quite right. I have extreme pain now on my pinky side of my wrist (ulna) when doing things like zipping up a sweater or grabbing a plate. Doctors seem to dismiss me quite fast and say its just tendinitis or act as if im over reacting. Whats the procedure and what do i tell my doctor to get some help?! please help!!

    • Hi Jessy
      If your not already seeing a hand & upper limb specialist, look on the net at some hospitals in about a 50mile radius, check there qualifications & do some research on them, ask to be referred by your doc, or a second opinion by your consultant. Make notes on the areas you get pain & type of pains, what you can & cant do, what brings the pain on etc. Several things can be the cause, you more than likely have a distal fracture & ulner styloid fracture, your ulner may be a non-union & a possible TFCC tear, an X-ray should show the ulner & styloid, but a MRI will show far more, you may need a dye x-ray scan slightly painful as a needle is inserted into your wrist & x-rays taken, your ulna & radial maybe out of position, do let the docs bully you into accepting it pain killers are addictive & not the answer, although it can take 2yrs for pain to subside per-sue your treatment rights & get them to have a look, after all they wouldn’t put up with pain why should you.
      Good Luck
      Pete

  17. Hi,

    I would love your advice. I had my right distal radius crushed in an ATV accident resulting in several screws, a plate, and a pin to be placed as well as a carpal tunnel release done. I’m 3 weeks post op and then pain in my hand is throbbing and unrelenting. No amount of pain medicine works to relieve it. Ice is about the only thing that helps. My surgeon says everything looks great and doesn’t understand why I have so much pain. Movement is improving and so is the numbness. I’m looking to get a second opinion as I can’t sleep, take care of my child, or talk to anyone. What do you think is going on?

    Thank you,

    Megan

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