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KEY POINTS
INTRODUCTION
Musculoskeletal injuries, such as distal radius
fractures of the wrist, are a common presentation
to an emergency department (ED). In the United
States, these injuries are second only to respiratory illnesses in frequency of ED visits, accounting
for 20% of chief complaints.13 However, despite
the frequency of presentation, education in
musculoskeletal injuries is often considered
deficient in medical education.48 The volume of
orthopedic presentations to an ED prompted
further study of musculoskeletal education in
emergency medicine training.3 Comer and
colleagues3 provided a validated 25-question orthopedic examination published in 1998 by
Freedman and Bernstein to emergency medicine
residents and attendings at all levels of training.
The results found a 61% overall passing rate
(65% for residents and 57% for attendings). As a
result of the frequency of musculoskeletal injuries,
it is important for all practitioners who evaluate or
Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, 111 South 11th St, Philadelphia, PA
19107, USA
* Corresponding author.
E-mail address: padegimase@gmail.com
Orthop Clin N Am 46 (2015) 259270
http://dx.doi.org/10.1016/j.ocl.2014.11.010
0030-5898/15/$ see front matter 2015 Elsevier Inc. All rights reserved.
orthopedic.theclinics.com
Diagnosis of a distal radius fracture can be made readily with plain radiographs and does not
routinely require advanced imaging with computed tomography or MRI.
Findings that may warrant urgent surgical management include an open fracture, vascular injury, or
acute carpal tunnel syndrome.
Indications for emergency department reduction include significant deformity, joint dislocation or
subluxation, and radiographic parameters that include more than 20 degrees of dorsal tilt.
On reduction, casting should be avoided and ace compression wrapping over the splint should be
applied loosely allowing for early and free finger motion.
Outpatient surgical indications are based on a variety of factors including patient demographics,
age, concomitant injuries, fracture alignment, and fracture stability.
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Fig. 1. (A) Typical deformity of a distal radius fracture with dorsal angulation and swelling. Note the associated
distal radius fracture on (B) posteroanterior and (C) lateral views.
RADIOGRAPHIC ANALYSIS
Fig. 3. The median nerve is tested by sensory and motor examination. (A) Sensory distribution of the median
nerve in the hand is noted by the shaded area. (B) Motor examination is best performed by testing thumb abduction stress testing.
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Fig. 4. The risk for median nerve injury is increased with excessive fracture displacement. (A) Note the volar spike
of the radius on the lateral view (circle), and (B) the intraoperative finding of direct median nerve compression
(arrow).
distal ulna fractures, disruption of the distal radioulnar and radiocarpal joints, and intercarpal ligament injuries, such as a scapholunate ligament
tears or perilunate dislocations (Fig. 6).
Advanced imaging is typically not indicated in
the acute setting. However, computed tomography scan may be used for preoperative planning
of comminuted fractures with articular involvement.44,45 MRI can be useful to assess for additional internal derangement of the wrist, such as
a suspected concomitant ligamentous injury.
Fig. 5. Standard radiographic measurements of the distal radius include (A) radial inclination of approximately 23
degrees, (B) radial height of approximately 11 mm, and (C) volar tilt of approximately 10 degrees. (From Bruinsma
W, Peters F, Jupiter J. Distal radius fractures. In: Ilyas A, Rehman S, editors. Contemporary surgical management of
fractures and complications. New Delhi (India): Jaypee Brothers Medical Publishers (P) Ltd; 2013. p. 132; with
permission.)
Fig. 6. Differentiating between (A) dorsally displaced distal radius fracture and (B) dorsally dislocated radiocarpal
fracture-dislocation may be difficult. Note the maintenance of most of the native articular surface with the radiocarpal fracture-dislocation, whereas in the case of the distal radius fracture the articular surface displaces with the
carpus. (From Bruinsma W, Peters F, Jupiter J. Distal radius fractures. In: Ilyas A, Rehman S, editors. Contemporary
surgical management of fractures and complications. New Delhi (India): Jaypee Brothers Medical Publishers (P)
Ltd; 2013. p. 135; with permission.)
III fractures require cefazolin and tobramycin or piperacillin/tazobactam with the addition of intravenous penicillin if the wound is contaminated with
soil (anaerobic coverage) for a minimum of
3 days after wound closure (Table 1).32,48
An orthopedic surgeon should be consulted
immediately for these injuries because these
must be treated urgently with operative wound irrigation and debridement. Historically, the goal has
been 6 hours to initial debridement32; however,
strict adherence to the 6-hour goal does not
seem to be justified by more recent analysis.49
Although early intervention is important, emergent
debridement and exploration is more frequently
reserved for highly contaminated injuries or
concomitant vascular injuries that require emergent management. Specifically for open distal
radius fractures, the risk of deep infection and
fracture nonunion are predicted by GustiloAnderson classification rather than time to operating room.50 In general, the specific operative
intervention in open distal radius fractures is determined by the degree of soft tissue damage.51
Hematoma Block
If a reduction is indicated, it is important for the
practitioner to provide adequate analgesia. This
is critical for patient comfort and to facilitate fracture reduction. The two most commonly used
techniques for analgesia in the ED are sedation
or local anesthesia, in the form of a hematoma
block. A recent double-blind, randomized clinical
trial found conscious sedation to take longer than
hematoma block without a significant difference
in analgesia or loss of reduction after 1 week.52
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Table 1
Gustilo-Anderson classification of open fractures and antibiotic recommendations
Description
Gustilo I
Wound <1 cm
No contamination
Simple fracture
No periosteal stripping
Wound >1 cm
Moderate contamination
Moderate comminution
No periosteal stripping
Gustilo II
Gustilo III
IIIA
IIIB
IIIC
Antibioticsa
Classification Criteria
First-generation
cephalosporin and
aminoglycoside (gramnegative) for 2472 h
after debridement
First-generation
cephalosporin and
aminoglycoside (gramnegative) for 2472 h
after debridement
First-generation
cephalosporin and
aminoglycoside (gramnegative) for 2472 h
after debridement
Fig. 8. Reduction maneuver for a typical dorsally angulated distal radius fractures. (A) Hold patients hand as if
performing a handshake. (B) Axial traction and wrist extension to disengage fracture site. (C) Flex the wrist while
maintaining axial traction. (D) Apply a volarly and ulnarly directed force while in mild pronation.
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SURGICAL INDICATIONS
Even in cases where the practitioner in the ED
initially evaluating and treating the patient for a
distal radius fracture will not be ultimately
providing definitive treatment, it remains valuable
to understand the surgical indications for distal
radius fractures to better communicate with the
patient and facilitate specialty consultation.
Outpatient surgical indications are ultimately
based on a variety of factors including patient demographics, age, concomitant injuries, fracture
alignment, and fracture stability.
Regarding fracture alignment, acceptable parameters following closed reduction include a residual radial inclination greater than or equal to
15 degrees on posteroanterior view, volar tilt less
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SUMMARY
Distal radius fractures are one of the most common fractures seen in the ED. Therefore, appropriate clinical recognition and management by all
practitioners is important. Concomitant traumatic
injuries must be appropriately worked-up. Findings potentially warranting urgent surgical intervention include open fractures, vascular injury,
and acute carpal tunnel syndrome. Indications
for fracture reduction in the ED include excessive
deformity, any joint dislocation or subluxation,
and dorsal tilt greater than 20 degrees. Fractures
should be adequately reduced and diligently
splinted as described before outpatient followup. Ace wrapping should be applied loosely and
the patient should be instructed to loosen the
dressing and/or return to the ED for increased
pain or symptoms of neurovascular compromise.
Finally, outpatient surgical indications are ultimately based on a variety of factors including patient demographics, age, concomitant injuries,
fracture alignment, and fracture stability.
REFERENCES
1. De Lorenzo RA, Mayer D, Geehr EC. Analyzing clinical case distributions to improve an emergency
medicine clerkship. Ann Emerg Med 1990;19(7):
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