Therapy of a broken spoke and wrist

Note

You are here in the subtopic Symptoms of the broken spoke. General information on the subject can be found under Broken Spokes or Spoke Break Duration.

Wrist fracture therapy

Wrist fractures / broken spokes can generally be treated conservatively or surgically. The decision is made on the basis of the X-ray image.

Basically, all unstable fractures must be treated surgically. Signs of an unstable fracture are:

• Comminuted metaphyseal fracture
• Dislocation of the articular surface by more than 20 °
• Avulsion fracture of the elbow pen
• Wrist fractures
• Dislocation between the radius (radius) and ulna (ulna)
• Elbow feed of more than 3mm
• Patient age over 60 years

If three or more of the criteria mentioned are present, an unstable situation can be assumed and the hernia should be operated on. A sufficient fracture device and stabilization in the plaster cast cannot usually be achieved with unstable fractures.

The aim of every therapeutic measure is to restore normal wrist function.

Healing with perspective / prognosis

The forecast of the cure depends crucially on the fracture shape of the Radius fracture, fracture management and follow-up treatment (physical therapy) from.
Good results can only be expected if it is possible to set up the fracture steplessly and to create stable conditions in the fracture area. Otherwise it can lead to false joint formation (insufficient stability) and wrist arthrosis (pre-arthrosis due to joint step).
The consequences would be pain, restricted mobility and loss of function of the wrist with effects on the whole arm.

In principle, extensive wrist injuries exist even with optimal therapy worse prognosis than with uncomplicated distal radius fractures. A uncomplicated spoke breakage usually heal without consequences.

Complications

Complications can occur with both conservative and surgical therapy.

Complications with conservative therapy:

• Slipping of the fracture (secondary dislocation)
• Pressure damage from plaster of paris
• False joint formation (pseudarthrosis)
• Sudeck's disease
  Sudeck's disease, also known as CRPS, is one of the most feared complications of a broken wrist.

Complications with operative therapy:

• Vascular, tendon and nerve injuries
• infection
• (Slipping of the fracture)
• Implant loosening
• False joint formation (pseudarthrosis)
• Sudeck's disease
  Mobus Sudeck or CRPS occurs significantly more frequently after surgical treatment than after plaster therapy.
  In principle, however, it is not possible to differentiate whether the rupture (violence) or the operation triggered the CRPS.

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In order to be able to treat successfully in orthopedics, a thorough examination, diagnosis and a medical history are required.
In our very economic world in particular, there is too little time to thoroughly grasp the complex diseases of orthopedics and thus initiate targeted treatment.
I don't want to join the ranks of "quick knife pullers".
The aim of any treatment is treatment without surgery.

Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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Conservative therapy

At the beginning of every therapy there is the fracture device (reduction), followed by the fracture stabilization. Simple, undisplaced (undisplaced) fractures do not need to be established. This type of fracture can easily be treated in a plaster cast for 6 weeks. Most childhood radius fractures are included (approx. 3 weeks in plaster).

All displaced fractures must first be brought into a correct (physiological) position. This is done by pulling and pulling back on the upper arm and wrist under flexible X-ray control (image converter control). Because the repositioning maneuver is painful for the patient, a local anesthetic is performed beforehand.

Anesthesia

Freedom from pain can be achieved through fracture gap anesthesia, regional anesthesia or central anesthesia.
Further information can also be found under: Anesthesia

• Fracture gap anesthesia: 10 ml of a 1% local anesthetic are instilled into the fracture gap.
  Advantage: light anesthesia that the surgeon can perform independently.
  Disadvantage: Complete freedom from pain is not always achieved.

• Regional anesthesia: 20-40 ml of a 1% local anesthetic is injected into the venous system of the affected arm and drainage is prevented via a blood evacuation cuff.
  Advantage: Safe freedom from pain
  Disadvantage: Complications from draining local anesthetic possible. Anesthetist necessary.

• Circuit anesthesia: 20-40 ml of a 1% local anesthetic are instilled in the area of ​​the nerve gel in the axillary cavity (arm plexus).
  Advantage: Safe freedom from pain
  Disadvantage: anesthesia takes some time. Anesthetist necessary.

Once the desired reduction result has been achieved, this should be held reliably in order to prevent later slipping (secondary dislocation).

plaster

The fracture immobilization (retention), which is necessary for this, is achieved by a Plaster cast guaranteed. A well-modeled plaster splint, placed on the stretch side and slightly enclosing the fracture area, is sufficient for this. The plaster of paris should reach to the metacarpal head, the wrist in a 20-30 ° extended position. The clasp of fists and elbow flexion should not be hindered by the plaster cast. After the plaster cast, an X-ray position check should be carried out to rule out a secondary dislocation caused by the plaster cast.

Forearm cast

Tips for handling the plaster splint / follow-up treatment:

• The Fracture healing takes an average of (4) -6 weeks. During this time, the wrist must not be strained (no lifting, supporting, etc.)
  
• Shoulder and elbow should be moved (prevents stiffening).
  
• At least in the beginning Elevating the arm (better venous and lymphatic drainage; better healing).
  
• Active training of the closing of the fist. Alternating full extension of the fingers and clenching of fists with emphasis on the fingertips (better venous and lymphatic drainage; better healing).
  
• Have the pressing plaster replaced immediately (risk of necrosis / pressure sore).
  
• At Sensory disturbances (e.g. tingling in the fingers) and circulatory disorders in the fingers, immediately see the doctor again.
  
• Have the loosened plaster replaced (after the swelling has subsided, 3-6 days) (risk of fracture dislocation due to insufficient stabilization).
  
• X-ray controls after 3 days, 1, 2 and 4 weeks (assessment of the fracture position and fracture healing (fracture consolidation)).
  
• After the fracture has healed, there is a physical therapy / Occupational therapy recommended (promotion of wrist mobility / function)

Operative therapy

All unstable fractures and those with accompanying vascular and nerve injuries must be treated surgically. Likewise, fractures for which no satisfactory fracture device is successful.

Before each operation, the patient must be informed about the type of procedure, alternatives, risks and chances of success and give written consent.

The fracture type (classification), the age of the patient, the bone quality and accompanying soft tissue injuries are decisive for the selected surgical procedure (osteosynthesis procedure).

As a rule, the operation is carried out as an emergency on the day of the accident. In the case of severe soft tissue swelling, it may be necessary to wait 3-5 days (in the meantime, elevate the bed, cool, immobilize in the cast) until the operation can be performed.

• Spike wire osteosynthesis: The hernia is closed and stabilized from the inside with wires inserted through the skin. The wires bridge the fracture zone and are attached to the opposite bone wall (cortex). Then the wire ends are shortened below the skin level. After the operation, an extensor (dorsal) plaster splint is also placed, because the wires alone usually do not create a stable situation for exercise. 6 weeks after the operation, the inserted wires can be removed in a small outpatient procedure under local anesthesia.
  Advantage: Small, less stressful surgical procedure
  Disadvantage: No safe exercise stability. Plaster of paris necessary. Follow-up intervention necessary.
  
• Plate osteosynthesis: The best fracture stabilization is achieved by plating the fracture zone. Angle-stable plates, which achieve a very high level of fracture stabilization, are particularly suitable for this. The plates are inserted either on the extensor or flexion side of the wrist.

X-ray of broken wrist

X-ray fracture of the wrist seen from the side.
The left picture shows the fracture, on the right the fracture was treated with a plate.

Operation broken spoke

Plate and screws
A flexion-side application of the plate is preferred because on the extension side this can lead to irritation of the extensor vision, which runs directly over the implanted plate without greater soft tissue protection. Even fractures in poor bone substance, such as the osteoporotic fractures, can be primary stabilized well with angular stable plates. It is not necessary to put on a plaster splint postoperatively.
Physiotherapeutic exercise measures can start right after the operation. The titanium plates do not necessarily have to be removed.
Advantage: Immediate exercise stability. Implant retention possible.
disadvantage: Major intervention.

External bone tensioner (external fixator)
The supply of one Broken spoke with an external fixator is reserved for certain problem cases. It is contemplated for use in open fractures, extensive comminuted fractures, intra-articular fractures, and infected fractures. The principle of therapy is to achieve fracture stabilization after the fracture device has been closed by an external, joint-bridging fixation. For this purpose, screws (Schanz screws) are inserted into the distant spoke bone and the 2nd metacarpal bone and clamped together using jaws and rods.
Advantage: Fracture stabilization possible in difficult soft tissue and bone conditions.
Disadvantage: Mostly process change necessary (wire spike / plate). False joint formations are observed more frequently during treatment in the fixator.