Hand/Upper Extremity

Carpal instability, malunion among complications of distal radius fracture

While volar plating may be advantageous, screw penetration into the joint may occur, surgeon says.

Many complications exist regarding distal radius fractures and the exact rates of these complications remain unknown. Yet, as techniques for distal radius fractures advance, some surgeons hold that they will see a drop in the incidence of these complications.

“I think ultimately, many of the complications related to conservative nonsurgical management of unstable distal radius fractures are going to disappear as techniques evolve to rapidly stabilize and subsequently rehabilitate the wrist and forearm in a more expeditious fashion,” Peter J. Stern, MD, told Orthopedics Today.

Complication types and rates

Distal radius fracture problems can arise from complications related to the soft tissues, bony anatomy, joints and hardware. Major complications of distal radius fractures include carpal instability, distal radioulnar joint injury, complex regional pain syndrome (CRPS), tendon rupture, ulnar-sided wrist pain and malunion.

While children with distal radius fractures can have many of the same complications as adults, surgeons can accept more deformity in younger patients. “The other thing is that with injury to the growth plate in a child, it is important to watch for the potential of partial or complete growth plate arrest,” David M. Kalainov, MD, told Orthopedics Today. “You may need to intervene at some interval to prevent progressive deformity during growth.”

Due in part to a lack of prospective research, the actual complication rates of distal radius fractures in adults and children remain unclear. “We don’t know for sure because the literature is replete with level four studies, some of which look much more closely at complications,” Stern said. For example, literature reports about the incidence of carpal tunnel syndrome after distal radius fracture vary between 0% and 75%, Stern said.

Rates of scapholunate dissociation range from 0% to 60%, according to Kalainov.

Scapholunate dissociation with a wrist fracture
This image shows a scapholunate dissociation with a wrist fracture.

Repaired ulnar styloid and distal radius fractures
Surgeons repaired the ulnar styloid and distal radius fractures, and then reduced and stabilized the scapholunate interval using K-wires.

Images: Kalainov DM

Carpal instability

Carpal instability may be a big problem that some surgeons treating distal radius fractures might miss, Kalainov said. “I think that it is a problem not only with just under-recognizing [them] but also difficulties under-recognizing the complex patterns,” he said. “Scapholunate dissociation is the most frequently reported traumatic instability, although other complex patterns exist that may confuse the issue and the treatments are somewhat varied and can be difficult.”

Surgeons should also be on the lookout for CRPS. “If a patient starts developing excessive pain, swelling and stiffness, as well as vasomotor changes, it ought to raise a red flag and you may be developing complex regional pain syndrome,” Stern said.

Ulnar contraindications

Ulnar-sided wrist pain can also pose problems after distal radius fracture with pain persisting for several months after bone healing. “Ulnar-sided wrist pain is usually due to incongruency of the distal radioulnar joint or ulnar abutment,” Stern said. “And the best way to prevent both of those is to try to obtain more anatomic reductions.”

In addition, triangular fibrocartilage complex (TFCC) injuries are common with these fractures and surgeons can treat pain associated with TFCC tears or ulnar styloid fractures secondarily. “But, for the most part, almost all of us do not treat the ulnar aspect of the wrist acutely unless it is a big piece of broken bone that needs to be fixed or it is an unstable distal radioulnar joint,” Kalainov said.

Volar plating

The field of distal radius fracture treatment has also seen a recent shift as more surgeons are using volar plates to treat malunions. “The beauty of volar plate fixation is that it provides you with the opportunity to get the patient’s wrist, forearm and hand moving much quicker and it accelerates the rehabilitation considerably,” Stern said. However, both Stern and Kalainov noted that surgeons can encounter complications with volar plates including malunion and tendon rupture. “Probably the biggest complication that I’ve seen is penetration of screws into the wrist joint,” Stern said. “That is a real problem and it can be very difficult despite special imaging to make sure that you haven’t put a screw into the joint.”

While volar plating can make treating these injuries easier, Kalainov noted that distal radius fractures still require judicious treatment. “The fact that it is a lot easier should not change a surgeon’s conservative outlook on an approach to these,” he said. “You really need to ascertain whether you manage this nonsurgically and if you can great. If you can’t then these new systems are helpful but it doesn’t translate into surgery being the right way to go all of the time.”

For more information:
  • David M. Kalainov, MD, assistant professor of clinical orthopedic surgery at Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 450, Chicago, IL 60611; 312-943-7850; e-mail: dkalainov@comcast.net. He has no direct financial interest in any products or companies mentioned in this article.
  • Peter J. Stern, MD, professor and chairman of the Department of Orthopedic Surgery at the University of Cincinnati College of Medicine, P.O. Box 670212, Cincinnati, OH 45267-0212; 513-558-4592; e-mail: peter.stern@uc.edu. He has no direct financial interest in any products or companies mentioned in this article.

Many complications exist regarding distal radius fractures and the exact rates of these complications remain unknown. Yet, as techniques for distal radius fractures advance, some surgeons hold that they will see a drop in the incidence of these complications.

“I think ultimately, many of the complications related to conservative nonsurgical management of unstable distal radius fractures are going to disappear as techniques evolve to rapidly stabilize and subsequently rehabilitate the wrist and forearm in a more expeditious fashion,” Peter J. Stern, MD, told Orthopedics Today.

Complication types and rates

Distal radius fracture problems can arise from complications related to the soft tissues, bony anatomy, joints and hardware. Major complications of distal radius fractures include carpal instability, distal radioulnar joint injury, complex regional pain syndrome (CRPS), tendon rupture, ulnar-sided wrist pain and malunion.

While children with distal radius fractures can have many of the same complications as adults, surgeons can accept more deformity in younger patients. “The other thing is that with injury to the growth plate in a child, it is important to watch for the potential of partial or complete growth plate arrest,” David M. Kalainov, MD, told Orthopedics Today. “You may need to intervene at some interval to prevent progressive deformity during growth.”

Due in part to a lack of prospective research, the actual complication rates of distal radius fractures in adults and children remain unclear. “We don’t know for sure because the literature is replete with level four studies, some of which look much more closely at complications,” Stern said. For example, literature reports about the incidence of carpal tunnel syndrome after distal radius fracture vary between 0% and 75%, Stern said.

Rates of scapholunate dissociation range from 0% to 60%, according to Kalainov.

Scapholunate dissociation with a wrist fracture
This image shows a scapholunate dissociation with a wrist fracture.

Repaired ulnar styloid and distal radius fractures
Surgeons repaired the ulnar styloid and distal radius fractures, and then reduced and stabilized the scapholunate interval using K-wires.

Images: Kalainov DM

Carpal instability

Carpal instability may be a big problem that some surgeons treating distal radius fractures might miss, Kalainov said. “I think that it is a problem not only with just under-recognizing [them] but also difficulties under-recognizing the complex patterns,” he said. “Scapholunate dissociation is the most frequently reported traumatic instability, although other complex patterns exist that may confuse the issue and the treatments are somewhat varied and can be difficult.”

Surgeons should also be on the lookout for CRPS. “If a patient starts developing excessive pain, swelling and stiffness, as well as vasomotor changes, it ought to raise a red flag and you may be developing complex regional pain syndrome,” Stern said.

Ulnar contraindications

Ulnar-sided wrist pain can also pose problems after distal radius fracture with pain persisting for several months after bone healing. “Ulnar-sided wrist pain is usually due to incongruency of the distal radioulnar joint or ulnar abutment,” Stern said. “And the best way to prevent both of those is to try to obtain more anatomic reductions.”

In addition, triangular fibrocartilage complex (TFCC) injuries are common with these fractures and surgeons can treat pain associated with TFCC tears or ulnar styloid fractures secondarily. “But, for the most part, almost all of us do not treat the ulnar aspect of the wrist acutely unless it is a big piece of broken bone that needs to be fixed or it is an unstable distal radioulnar joint,” Kalainov said.

Volar plating

The field of distal radius fracture treatment has also seen a recent shift as more surgeons are using volar plates to treat malunions. “The beauty of volar plate fixation is that it provides you with the opportunity to get the patient’s wrist, forearm and hand moving much quicker and it accelerates the rehabilitation considerably,” Stern said. However, both Stern and Kalainov noted that surgeons can encounter complications with volar plates including malunion and tendon rupture. “Probably the biggest complication that I’ve seen is penetration of screws into the wrist joint,” Stern said. “That is a real problem and it can be very difficult despite special imaging to make sure that you haven’t put a screw into the joint.”

While volar plating can make treating these injuries easier, Kalainov noted that distal radius fractures still require judicious treatment. “The fact that it is a lot easier should not change a surgeon’s conservative outlook on an approach to these,” he said. “You really need to ascertain whether you manage this nonsurgically and if you can great. If you can’t then these new systems are helpful but it doesn’t translate into surgery being the right way to go all of the time.”

For more information:
  • David M. Kalainov, MD, assistant professor of clinical orthopedic surgery at Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 450, Chicago, IL 60611; 312-943-7850; e-mail: dkalainov@comcast.net. He has no direct financial interest in any products or companies mentioned in this article.
  • Peter J. Stern, MD, professor and chairman of the Department of Orthopedic Surgery at the University of Cincinnati College of Medicine, P.O. Box 670212, Cincinnati, OH 45267-0212; 513-558-4592; e-mail: peter.stern@uc.edu. He has no direct financial interest in any products or companies mentioned in this article.