Sports Medicine: Just the Facts

CHAPTER 54 • WRIST AND HAND FRACTURES 311

Rettig AC: Wrist and hand overuse syndromes. Clin Sports Med
20:591, 2001.
Rettig AC, Coyle MP, Hunt TR: Hand and wrist problems in the
athlete. Am Orthop Soc Sports Med Instr Course 108:AOSSM
28th Annual Meeting, Orlando, FL, 2002.
Sugawara M, Oginot T, Minami A, et al: Digital ischemia in base-
ball players. Am J Sports Med14:329, 1986.

54 WRIST AND HAND FRACTURES

Baer G, MD

Chhabra AB, MD

EPIDEMIOLOGY

• Wrist and hand injuries account for 25% of athletic
  injuries (Amadio, 1990).


• Gymnasts have the highest level of wrist and hand
  injuries with up to 43% suffering chronic injuries. In
  one series 88% of elite male gymnasts complained
  of wrist pain and 58% required nonsteroidal anti-
  inflammatory drugs (NSAID) therapy to continue
  competing (Mandelbaum et al, 1989).

DISTAL RADIUS FRACTURES

• Distal radius fractures account for 10% of all bony
  injuries, up to 75% of all fractures to the forearm, and
  16% of all fractures treated in the emergency room
  (Alffram and Bauer, 1962; Owen et al, 1982; Jupiter,
  1991).


• Injury often occurs during running or contact sports
  when the hand is planted on the ground, the wrist
  hyperextends and the arm rotates. In addition to a
  fracture of the distal radius, injury to the triangular
  fibrocartilage complex(TFCC) and distal radioulnar
  joint(DRUJ) can result.


• On physical examination, examine for deformity (clas-
  sic silver forkas described by Colles) (Colles, 1814),
  swelling, pain, and limited range of motion. Check the
  DRUJ for tenderness, dislocation or subluxation, and
  examine for any loss of pronation or supination.


• Carpal tunnel symptoms may be present in up to 15%
  of patients but controversy exists concerning acute
  versus delayed (48 to 72 h) release (Ford, 1986;
  Gelberman, Szabo, and Mortenson, 1984).


• Clinical symptoms of DRUJ disruption, including
  pain and instability, have been found in 5 to 15% of
  fractures (Lidstrom, 1959).
  
  
  • The TFCC is the major stabilizer of the DRUJ.
    Disruption of the TFCC and other carpal ligaments
    including the scapholunate ligament has been identi-
    fied at time of arthroscopy in 45 to 70% of cases
    (Mohanti and Kar, 1980; Geissler et al, 1996). Most
    TFCC tears are in the central or radial portion of the
    complex and are treated with debridement (Richards
    and Roth, 1995).
  
  
  • Anatomic reduction of intra-articular distal radius
    fractures is required. Two millimeters of articular
    step-off increases the risk for subsequent degenerative
    arthritis (Knirk and Jupiter, 1986).
  
  
  
  

RADIOGRAPHICEVALUATION

•True posteroanterior(PA) and lateral views required.

Oblique and fossa lateral views, traction views as well

as MRI, CAT scan, bone scan, and fluoroscopy may

provide critical information regarding the nature of

the fracture and associated injuries when planning for

fracture management (Batillas et al, 1981; Bindra

et al,1997; Breitenseher et al, 1997; Doczi et al,

1995).

MANAGEMENT OFDISTALRADIUSFRACTURES

• Most stable fractures can be treated with closed reduc-
  tion and casting while unstable fractures, suggested
  by ( 1 ) excessive fracture comminution, ( 2 ) fracture
  displacement, ( 3 ) radial articular surface angulation
  greater than 20°, ( 4 ) articular surface separation or
  step-off greater than 2 mm, and ( 5 ) comminution of
  both volar and dorsal cortices often require surgical
  intervention.


• Extra-articular fractures:Stable fracture treatment
  generally consists of closed reduction and placement
  of a well-fitted long-arm cast with a good 3-point
  mold and the forearm in neutral or supination to help
  stabilize the DRUJ and improve recovery of supina-
  tion following fracture healing (Moir, Wardlaw, and
  Maffulli, 1999; Sarmiento, Zagorski, and Sinclair,
  1980). Casting should be performed after acute
  swelling subsides. Close radiographic follow-up is
  required every 1 to 2 weeks to assure that loss of
  reduction and shortening does not occur. Unstable
  extra-articular fractures may require percutaneous pin
  fixation in conjunction with cast or external fixation
  for support.


• Noncomminuted intra-articular fractures:Barton’s
  fractures are the result of shear forces across either the
  volar or dorsal lip of the distal radius resulting in two
  large fragments that extend into the joint (Barton,
  1838). Closed reduction is usually obtained by rever-
  sal of the deformity but maintenance of reduction usu-
  ally requires additional stabilization (Jupiter et al,
  1996).