CLINICIAN’S CORNER

Doc Talk Recap: Dr. Chris Judson on Distal Radial Fractures

By: Bri Boulerice, PT, DPT Physical Therapist at PTSMC Waterbury

Dr. Chris Judson, an orthopedic surgeon of the Orthopedic Associates of Hartford, recently presented at PTSMC Avon. Dr Judson specializes in the treatment of hand, wrist and elbow injuries with a particular interest in fractures. His recent talk focus speci cally on the management of distal radius fractures. Dr. Judson practices in the Plainville, Rocky Hill, Farmington and En eld areas and is happy to collaborate with therapists via email or text message regarding mutual patients.

Distal radius fractures are the most common orthopedic fracture, making up 18% of fractures in adults. These fractures occur more frequently in females, which is related to the higher rates of osteopenia and osteoporosis in this population. The most common mechanism of injury for a distal radius fracture is a fall onto an outstretched hand, more commonly referred to as a “FOOSH” injury, resulting in a Colles fracture. A Colles fracture, which may present as a “dinner fork” deformity involves dorsal displacement of the radius. Associated injuries in addition to a Colles fracture include distal ulnar styloid fracture, scaphoid fracture, and ligamentous injuries to the distal radial ulnar joint (DRUJ), triangular brocartilage complex (TFCC), and scapholunate ligament. TFCC injuries are often not diagnosed as they can only be detected with MRI and may be suspected in cases where a patient has ongoing ulnar sided wrist pain beyond the expected healing time frame.

Some common ways to categorize fractures include displaced vs. non-displaced, intra-articular vs. extra articular, comminution, and any associated dislocation. Many factors drive the decision-making process to opt for surgical or conservative treatment including radiograph alignment, fracture characteristics and stability, medical comorbidities, and the patient’s activity level. Dr. Judson emphasized the importance of the patient’s activity levels and functional goals in his decision-making process. If opting for non-operative treatment, this can include with or without reduction. In the case of a Colles fracture for example, this is often initially treated non-operatively with reduction in the rst two days after the fracture, which can be done in the orthopedic o ce.

If a patient is treated non-operatively, this involves a period of about 5-6 weeks of immobilization. For children, sometimes this can be as short as 3-4 weeks. Initially, the patient is often splinted using a sugar tong splint rst prior to tting them for a cast as this can accommodate for the initial increase in swelling. If patients have been reduced non-operatively, they will receive weekly or bi-weekly radiographs to ensure the reduction has not displaced. In the initial treatment of these patients while they are immobilized in a cast, it is important to assess cast t. Dr. Judson recommends about 1 nger of space on the cast for good t. If you are able to t 2-3 ngers in the cast, this indicates it is too loose and the patient needs to be referred back to the orthopedic o ce for a cast change. Goals during this initial time frame include full elbow and nger range of motion. The cast is removed at approximately 6 weeks, with initiation of active range of motion and gentle passive range of motion. At 8 weeks, passive range of motion can become more aggressive. Strengthening can also be initiated at this time, however with range of motion should be the primary focus until full range is achieved. At around 10 weeks patients are usually cleared to resume full activity if imaging demonstrates full healing. Full strength can take 6 to 9 months to return, and Dr. Judson emphasized the importance of patient education around this timeline.

Operative treatment may be selected for active patients with malalignment of the fracture, unstable fractures, or patients who require quick return to full activity, such as someone with an occupation that requires use of the wrist and hand. The current most common operative treatment is volar plating, which Dr. Judson uses in about 80% of his procedures. Volar plating has been found to be better tolerated than alternative surgeries, such as dorsal plating. The volar plate can be hidden under the pronator muscle, reducing likelihood of future irritation in this area from the plate.

Dr. Judson reports removing approximately 1% of these types of plates. Plates placed on the dorsal side are much more likely to irritate the tendons and require removal approximately 20% of the time, but occasionally are used when the fragments are only present on the dorsal side of the radius and do not extend to the volar aspect. Volar plating requires an incision along the exor carpi radialis tendon, which can be a common site of sensitivity after surgery. Dr. Judson recommends scar massage here to prevent adherence.

Another common method used in surgery is a fragment speci c method, in which a screw is used to stabilize the fracture that may not require plating. This method often requires a smaller incision. Finally, external xation is very uncommon today and has been largely replaced by a technique called bridge plating. With bridge plating, a stabilizing plate is placed under the skin from the radius into the hand to stabilize the fracture, similar to external xation, however this is not visible to the patient and decreases the risk of infection. This may be used in cases of combined fracture and dislocation or ligamentous injury, or comminuted fractures. The bridge plate is then removed after healing has occurred.

Post-operative timelines have signi cant variability depending on the patient. In general, after volar and dorsal plating, initial goals from 0-10 days post-op include full nger range of motion, edema management, and establishing a home exercise program. From 1-5 weeks post-op, patients begin to wean out of the brace and begin working on range of motion. This time frame is the most variable between patients as this depends on many factors including bone quality, complexity of fracture, and comminution. During this phase, the patient may begin “co ee cup weight bearing” where they are only lifting about the weight of a co ee cup. Pending early signs of healing, around 5-10 weeks, the brace will be discontinued and more aggressive stretching can begin. Strength can be initiated around week 8 as well, but there is some variability here too. At 10 weeks and beyond, nal rehabilitation goals include maximizing range of motion and strength, in addition to return to sport and impact activities.

Rehabilitation following bridge plating involves aggressive passive and active range of motion once the plate is removed at about 10 weeks as healing is complete at this time. The patient will likely have signi cant sti ness due to motion restrictions from the length of time the plating was present. One advantage of the bridge plating is the ability to WBAT immediately, which may be necessary in some patients that must use an assistive device.

Common complications include cosmetic deformity where the ulnar styloid is more prominent due to a shortened radius after non-operative management. Additional complications include sti ness, ulnar sided pain, tendon rupture of the extensor pollicis longus and exor pollicis longus, carpal tunnel syndrome, and complex regional pain syndrome. Dr. Judson emphasized the importance of contacting the surgeon if complications arise.

Overall, in the management of distal radius fractures, there are good functional outcomes with both operative and non-operative management. It is important to educate patients and set expectations early to provide successful care. Operative management can often have many variables that impact rehabilitation and patients bene t from open communication between the surgeon and therapist. Lastly, it is important to identify complications early to maximize outcomes for patients.