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 Common descriptive names of distal radius or ulnar fractures include Colles, Smith, and Barton fractures. A Colles fracture describes a break across the ends of both the radius and ulna, which results in a backward and outward position of the hand relative to the wrist (hyperextension injury). Colles fracture is the most common wrist fracture (Hoynak). Of all distal radius fractures, 60% are associated with a fracture of the ulnar styloid process, and approximately 60% of ulnar styloid fractures are accompanied by a fracture of the ulnar neck (Hoynak). A Smith's fracture describes an injury in which the end of the radius heads downward toward the palm (hyperflexion injury). This fracture is sometimes called a reverse Colles. A Barton's fracture involves the upper (dorsal) edge of the radius and the joint surface, and is associated with partial displacement (subluxation) of the wrist with carpal bone displacement. A Hutchinson fracture, sometimes called a "chauffeur's" or backfire fracture, refers to an isolated fracture of the radial styloid process, usually caused by a direct trauma to the radial side of the wrist. Risk: Most wrist fractures occur in older postmenopausal women, with a female to male ratio of 4:1. (Richards). A personal and family history for osteoporosis or fractures also increases the risk. Individuals who smoke have an increased risk of wrist fractures due to the associated low bone mineral density. Among children and adolescents active in sports, an earlier incidence peak of wrist fracture occurs between the ages of 5 and 14 years. With sufficient trauma, any individual can have this fracture. (Richards). Incidence and Prevalence: Distal radius fractures account for one-sixth of all fractures treated in hospital emergency departments (Hoynak). Distal radius and ulna fractures together account for 75% of all wrist injuries (Hoynak) and 15% of all skeletal fractures in adults (Nana).
Source: Medical Disability Advisor

Diagnosis
History: Individuals may relate a history of a fall or other traumatic event. Individuals may complain of pain, swelling, numbness, and deformity of the wrist. Physical exam: All rings and bracelets as soon as possible because of potential swelling. Upon

examination, skin breakdown, swelling, hematoma formation, deformity, and discoloration may be noted over the fracture site. Application of gentle pressure (palpation) to the wrist and forearm may reveal tenderness. Vascular examination and neurological assessment with 2-point discrimination to rule out concomitant injuries of the neurovascular structures in the area are part of the examination. Tendon and muscle function are evaluated via range of motion of the wrist and fingers, although the ability to move the wrist and fingers does not exclude a fracture. Tests: Plain x-rays with multiple angles are necessary to verify alignment, fragment position, and articular surface involvement. X-rays are repeated after realigning the bone in its normal anatomical position (reduction) and again at weekly intervals until stability and healing of the fracture are assured. Complicated fractures may require CT or MRI scans before and after reduction to help decide if surgery would be the optimal treatment. If there is suspicion of nerve or vessel injury, nerve conduction studies and vascular studies may be ordered.
Source: Medical Disability Advisor

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.
Source: Medical Disability Advisor

ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
Distal Forearm Fractures
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence. Source: ACOEM Practice Guidelines

Prognosis
Uncomplicated distal radius and ulna fractures treated conservatively usually have an excellent outcome in about 6 weeks. There may be stiffness and swelling with activity for a few months. Fractures with open wounds, fractures requiring fixation (ORIF or external fixation), or fractures requiring repeat reduction will have a longer recovery and may have poorer outcomes. In very severe cases in which wrist arthroplasty or fusion is performed, recovery is even slower; however, the outcome is much better in these cases than if no joint replacement had been performed.
Source: Medical Disability Advisor

Rehabilitation
Rehabilitation of a fractured radius and/or ulna depends on the type of fracture and length of immobilization. The main focus of rehabilitation should emphasize restoring full range of motion and strength while maintaining independence in as much of their activities of daily living as is possible. Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative). The goal of rehabilitation is to decrease pain and to return the individual to full function with a painless wrist. Rehabilitation may be administered by a physical therapist, occupational therapist, or hand therapist. Hand dominance and the involved extremity will greatly influence the individual's degree of disability during recovery. In order to decrease pain and edema, modalities, including heat and cold, may be beneficial (Braddom). As the therapy focuses on returning the individual to full function, range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture

stability. When indicated, range of motion and strengthening exercises should be started at the involved wrist and hand, emphasizing both intrinsic and extrinsic hand muscles. Special attention must be paid to regain full supination (palm-up position) and pronation (palm-down position). Exercise intensity and difficulty should be progressed until full function is achieved. Individuals are guided in performing activities of daily living that correspond with the stage of recovery. In addition to undergoing supervised rehabilitation (Watt), the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation (Wakefield). Occupational therapy may be indicated to assist with activities of daily living if necessary. If operatively managed, the treating physician will dictate the protocol of rehabilitation. Bone healing may occur within 6 to 12 weeks; however, the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is Important to inform the individual not to overload the fracture site until the bone has regained its full strength. The treating physician should guide the timing for resumption of heavy work and sports. FREQUENCY OF REHABILITATION VISITS Nonsurgical Fracture, Radius and Specialist Ulna, Distal Physical, Occupational or Hand Up to 20 visits within 8 Therapist weeks Surgical Fracture, Radius and Ulna, Distal Physical, Occupational or Hand Up to 16 visits within 8 Therapist weeks Specialist

Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.
Source: Medical Disability Advisor

Complications
Stiffness of the wrist joint is a frequent complication. Other complications include failure to regain full mobility of the wrist, chronic pain due to ligament injury, post-traumatic arthritis, and median nerve damage or compression leading to carpal tunnel syndrome. There may be

secondary wrist derangements of the ulnocarpal and distal radioulnar joints. Swelling may cause the serious complication of compartment syndrome. Complex regional pain syndrome, or reflex sympathetic dystrophy, is not uncommon after wrist fractures. Tendon rupture, particularly of an extensor tendon, or conversely Volkmann's contracture may be a late complication. The triangular fibrocartilage complex may be disrupted in as many as 40% to 78% of distal radial fractures (Richards).
Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

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.
Source: Medical Disability Advisor

Failure to Recover
If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:

Did individual complain of pain, swelling, numbness, and perhaps deformity of the wrist? Did individual present with symptoms consistent with a fracture of the radius or ulna? Was fracture confirmed with an x-ray? If diagnosis was uncertain, were other conditions with similar symptoms ruled out? Was treatment appropriate for the particular type of fracture? Was surgery required? Were any complications associated with the procedure? Would individual benefit from consultation with a specialist (e.g., orthopedic surgeon, hand surgeon, occupational therapist, physical therapist, vascular surgeon, neurosurgeon, sports medicine specialist, or physiatrist)? Did individual receive rehabilitation therapy, in particular with a therapist specializing in

Regarding treatment:

the treatment of hands?

Was individual active in rehabilitation program? Does individual have any conditions that may inhibit his or her ability to adhere to a rehabilitative exercise program? Has adequate time elapsed for recovery? What is the expected prognosis? Has individual followed prescribed rehabilitative therapy? Did individual have any injury-related complications such as persistent immobility of the wrist, nonunion of the fracture, infection, chronic pain, post-traumatic arthritis, tendon rupture, compartment syndrome, or median nerve damage? If so, were complications addressed in the overall treatment plan? Does individual have any underlying condition such as degenerative arthritis or osteoporosis that may affect recovery?

Regarding prognosis:

a. Definition Fractures of the radius bone, including fracture of the ulna due to involuntary dislikasi proximal or distal radioulnar joint (Galeazzi fracture dislocation and Montegia) * Galeazzi fracture: the fracture of the distal radius with dislocation or subluxation of the distal radioulnar joint. * Monteggia fracture: the fracture of the proximal third of ulna with anterior dislocation of the capitulum radius * Bado Classification: - Fractures 1 / 3 middle / proximal ulna with anterior angulation of the radial head anterior dislocation accompanied - Fractures 1 / 3 middle / proximal ulna with posterior angulation of the radial head posterior dislocation accompanied by fracture of the radial head radii and radii - Fracture of the distal ulna processus coracoideus with lateral radial head dislocation radii - Fracture of the ulna 1 / 3 middle / proximal ulna with anterior dislocation of the radial head fracture radii and 1 / 3 proximal radii below the tuberosity bicipitalis

b. Scope * Fractures of the radius and ulna dialysis * Fracture-dislocation Galeazi * Monteggia fracture-dislocation. c. Clinical examination Pathophysiological The mechanism of trauma to the antebrachii most often falls to the outstreched hand or direct trauma. Style twisting produces a spiral fracture of the bone at a different level. Direct trauma or disruption caused angulation of the transverse fracture at the same level of bone. If one bone is fractured and had a late antebrachii angulation, the bone becomes shorter towards other bones. When the attachment to the wrist joint and the humerus is intact, the others will experience bone dislocation (Galeazzi fracture dislocation / Monteggia) Clinical examination Fracture radius ulna * Deformity in the fracture area: angulation, rotation (pronation or supination) or shorthening * Pain * Swelling * Physical examination should include evaluation of neurovascular and inspection elbow and wrist. And evaluation of the possibility of compartment syndrome Galeazzi fracture Fractures of the distal third of radius with dislocation of distal radioulnar joint. Dorsal angulation of the distal fragment. At the wrist can be palpated distal ulna protrusion tip. Galeazzi fracture dislocation caused by direct trauma to the wrist, particularly on the dorsolateral aspect or a fall with outstreched hand and forearm pronation. Patients with pain in the wrist or forearm midline and exacerbated by the emphasis on the distal radioulnar joint Monteggia Fractures Half of the proximal ulna fracture with dislocation of the proximal radioulnar joint. Patients with Monteggia fracture-dislocation comes with a swollen elbow, deformity and limited ROM because of pain, especially supination and pronation. Radial head can usually be done in palpasi.Harus neurovascular examination carefully because there Bering periper n radial nerve injury or PIN. Classification of Monteggia fracture dislocation by Bado: 1. Fractures 1 / 3 middle / proximal ulna with anterior angulation of the radial head anterior dislocation accompanied 2. Fractures 1 / 3 middle / posterior angulation of the proximal ulna with dislocation

accompanied 3. posterior radial head fracture radial head radii and radii 4. Fractures of the distal ulna with dislocation of the lateral processes coracoideus radio kaput 5. Fracture of the ulna 1 / 3 middle / proximal ulna with anterior dislocation of the radial head fracture radii and 1 / 3 proximal radii below the tuberosity bicipitalis d. Contra indications Operations Poor general condition e. Examination Support X-Ray with two projections Mechanical Handling conservative therapy and surgery Conservative Treatment Methods The principle is to perform and return the traction to the distal hand position changed due to the rotation Hand positions seen in the right direction lies the broken line - 1 / 3 proksinal proximal fragment in a supine position to be collinear supination of the distal fragment - 1 / 3 middle neutral position then the position of the distal radius neutral - 1 / 3 distal radius pronation of the entire forearm pronation position, after it's done with plaster immobilization of the elbow Operative Treatment Methods - Four basic recommended exposure 1. Straight approach to ulnar shaft fracture of the ulna 2. Antecubital volar approach for fractures of the proximal radius 3. Dorsolateral approach to fracture shaft radius, ranging from the capitulum radius of up to of the distal radius shaft 4. Palmar approach for fracture of radius 1 / 3 distal - Position the patient supine on the operating table. Hand table is helpful for easy operation. Tourniquet may be used unless acquired vascular lesions. - Exposure to a fractured bone in accordance with four principles above. - Repositioning of the fracture fragments as optimal as possible

- Place the plate on the side of the tension that is ideally on the dorsolateral surface of the radius and ulna on the dorsal side. At 1 / 3 distal radius plate should be placed on the volar side to avoid the tuberculum Lister and extensor tendons. - Replace the drain, the surgical wound was closed layer by layer f. Complication * Malunion * Compartment syndrome * Cross union * Atrophy sudeck * Trauma N. Median * Rupture extensor tendon wrist joint, pronation, supination, palmar flexion, and extension movements g. Mortality Generally low h. Post-Surgical Care - Wound care in general surgery - Drain removed 24-48 hours post-operative or in accordance with production - Elevation of the arm 10 cm above the heart - Start of active and passive ROM exercises of the fingers, wrist, elbow as soon as possible after surgery i. Follow Up - Active Physiotherapy ROM's hand, wrist and elbow - Create an X-Ray controls 6 weeks and 3 months thereafter - Healing usually after 16-24 weeks, so far avoiding contact sports and lifting weights more than 2 pounds. Listen Read phonetically Rate translation