Posttraumatic arthritis of the wrist, degeneration of the articular surface before and after resection X-rays of a wrist fusion X-rays of pins across a<unk> : Notice the ulnar styloid base fracture, which has not been fixed. This patient has instability of the DRUJ because the TFCC is not in continuity with the ulna. Correction should be undertaken if the wrist radiology falls outside the acceptable limits: * 2-3mm positive ulnar variance * There should be no carpus malalignment * If carpus is aligned, then the dorsal tilt should be less than 10 degrees * If carpus is aligned, there are no limits for palmar tilt * If carpus is malaligned, wrist tilt should be neutral * Gap or step deformity is less than 2mm Treatment options for<unk> s include nonoperative management, external fixation, and internal fixation. Indications for each depend on a variety of factors such as the patient's age, initial fracture displacement, and metaphyseal and articular alignment, with the ultimate goal to maximize strength and function in the affected upper extremity. Surgeons use these factors combined with radiologic imaging to predict fracture instability, and functional outcome to help decide which approach would be most appropriate. Treatment is often directed to restore normal anatomy to avoid the possibility of malunion, which may cause decreased strength in the hand and wrist. The decision to pursue a specific type of management varies greatly by geography, physician specialty (hand surgeons vs. orthopedic surgeons), and advancements in new technology such as the volar locking plating system.<unk> s are often associated with<unk>  radial ulnar joint (DRUJ) injuries, and the American Academy of Orthopaedic Surgeons recommends that postreduction lateral wrist X-rays should be obtained in all patients with<unk> s in order to preclude DRUJ injuries or dislocations. Most children with these types of fractures do not need surgery. Nonoperative The majority of<unk> s are treated with conservative nonoperative management, which involves immobilization through application of plaster or splint with or without closed reduction. The prevalence of nonoperative approach to<unk> s is around 70%. Nonoperative management is indicated for fractures that are undisplaced, or for displaced fractures that are stable following reduction. Variations in immobilization techniques involve the type of cast, position of immobilization, and the length of time required in the cast. Undisplaced fractures For those with low demand, cast and splint can be applied for two weeks. In those who are young and active, if the fracture is not displaced, the patient can be followed up in one week. If the fracture is still undisplaced, cast and splint can be applied for three weeks. If the fracture is displaced, then manipulative reduction or surgical stabilisation is required. Shorter immobilization is associated with better recovery when compared to prolonged immobilization. 10% of the minimally displaced fractures will become unstable in the first two weeks and cause malunion. Therefore, follow up within the first week of fracture is important. 22% of the minimally displaced fractures will malunite after two weeks. Subsequent follow ups at two to three weeks are therefore also important. There is weak evidence to suggest that some children with a buckle fracture may not require cast immobilization. Where the fracture is undisplaced and stable, nonoperative treatment involves immobilization. Initially, a backslab or a sugar tong splint is applied to allow swelling to expand and subsequently a cast is applied. Depending on the nature of the fracture, the cast may be placed above the elbow to control forearm rotation. However, an above-elbow cast may cause long-term rotational contracture. For torus fractures, a splint may be sufficient and casting may be avoided. The position of the wrist in cast is usually slight flexion and ulnar deviation. However, neutral and dorsiflex position may not affect the stability of the fracture. Displaced fractures In displaced<unk> , in those with low demands, the hand can be cast until the person feels comfortable. If the fracture affects the median nerve, only then is a reduction indicated. If the instability risk is less than 70%, the hand can be manipulated under regional block or general anaesthesia to achieve reduction. If the post reduction radiology of the wrist is acceptable, then the person can come for follow up at one, two, or three weeks to look for any displacement of fractures during this period. If the reduction is maintained, then the cast should continue for 4 to 6 weeks. If the fracture is displaced, surgical management is the proper treatment. If the instability risk of the wrist is more than 70%, then surgical management is required. 43% of displaced fractures will be unstable within the first two weeks and 47% of the remaining unstable fractures will become unstable after two weeks. Therefore, periodic reviews are important to prevent malunion of the displaced fractures. Closed reduction of a<unk>  involves first anesthetizing the affected area with a hematoma block, intravenous regional anesthesia (Bier's block), sedation or a general anesthesia. Manipulation generally includes first placing the arm under traction and unlocking the fragments. The deformity is then reduced with appropriate closed manipulative (depending on the type of deformity) reduction, after which a splint or cast is placed and an X-ray is taken to ensure that the reduction was successful. The cast is usually maintained for about 6 weeks. Outcome of nonoperative treatment Failure of nonoperative treatment leading to functional impairment and anatomic deformity is the largest risk associated with conservative management. Prior studies have shown that the fracture often redisplaces to its original position even in a cast. Only 27-32% of fractures are in acceptable alignment 5 weeks after closed reduction. For those less than 60 years in age, there will be a dorsal angulation of 13 degrees, while for those older than 60, the dorsal angulation can reach as high as 18 degrees. In people over 60, functional impairment can last for more than 10 years. Despite these risks with nonoperative treatment, more recent systematic reviews suggest that when indicated, nonsurgical management in the elderly population may lead to similar functional outcomes as surgical approaches. In these studies, no significant differences in pain scores, grip strength, and range of motion in patients' wrists occurred when comparing conservative nonsurgical approaches with surgical management. Although the nonsurgical group exhibited greater anatomic misalignment such as radial deviation, and ulnar variance, these changes did not seem to have significant impact on overall pain and quality of life. Surgery Surgery is generally indicated for displaced or unstable fractures. The techniques of surgical management include open reduction internal fixation (ORIF), external fixation, percutaneous pinning, or some combination of the above. The choice of operative treatment is often determined by the type of fracture, which can be categorized broadly into three groups: partial articular fractures, displaced articular fractures, and metaphyseal unstable extra- or minimal articular fractures. Significant advances have been made in ORIF treatments. Two newer treatments are fragment-specific fixation and fixed-angle volar plating. These attempt fixation rigid enough to allow almost immediate mobility, in an effort to minimize stiffness and improve ultimate function; no improved final outcome from early mobilization (prior to 6 weeks after surgical fixation) has been shown. Although restoration of radiocarpal alignment is thought to be of obvious importance, the exact amount of angulation, shortening, intra-articular gap/step which impact final function are not exactly known. The alignment of the DRUJ is also important, as this can be a source of a pain and loss of rotation after final healing and maximum recovery. An arthroscope can be used at the time of fixation to evaluate for soft-tissue injury and the congruity of the joint surface and may increase the accuracy of joint surface alignment Structures at risk include the triangular fibrocartilage complex and the scapholunate ligament. Scapholunate injuries in radial styloid fractures where the fracture line exits<unk> ly at the scapholunate interval should be considered. TFCC injuries causing obvious DRUJ instability can be addressed at the time of fixation. Prognosis varies depending on dozens of variables. If the anatomy (bony alignment) is not properly restored, function may remain poor even after healing. Restoration of bony alignment is not a guarantee of success, as soft tissue contributes significantly to the healing process. Little joint involvement These fractures are the most common of the three groups mentioned above that require surgical management. A minimal articular fracture involves the joint, but does not require reduction of the joint. Manipulative reduction and immobilization were thought to be appropriate for metaphyseal unstable fractures. However, several studies suggest this approach is largely ineffective in patients with high functional demand, and in this case, more stable fixation techniques should be used. Surgical options have been shown to be successful in patients with unstable extra-articular or minimal articular<unk> s. These options include percutaneous pinning, external fixation, and ORIF using plating. Patients with low functional demand of their wrists can be treated successfully with nonsurgical management; however, in more active and fit patients with fractures that are
Distal radius fracture
Scaphoid fracture
Elbow fracture
Humerus fracture
Ulna fracture
Scapular fracture
Jefferson fracture
Bosworth fracture