Everyday orthopedic surgeons must advise patients about treatment for the various problems presented. Often the question comes up with wrist fractures: can I get by without surgery?
Two hand surgeons from two different medical facilities recently published an article that might offer you some helpful information. They used the case of a 52-year-old woman who fell and broke the radius (bone in the forearm) at the wrist (similar problem to your father but in a younger person).
She was treated in the emergency department with a procedure known as closed reduction. This is the nonoperative approach being suggested as one option for your father. Without an open incision to realign the bones and without pinning the fracture site, the physician would use a special splint to hold the wrist in place.
X-ray findings are key here in making the decision. Is there a shortening of the broken bone? Do the two ends of the broken bone meet in a straight line? If there is a slight buckle making a hump referred to as a dorsal angle that measures 15 degrees or more, then surgery might be needed.
One way to evaluate this patient’s chances for full recovery is to review the published literature. They did this looking for outcomes other patients have had with these kinds of problems (dorsal angulation, radial shortening). There were several studies with large numbers of patients who chose a nonsurgical approach and were then followed for several years to see what happened.
Some of the studies divided patients out by the degree of dorsal angulation (e.g., zero to 10 degrees, zero to 15 degrees, more than 10 degrees, more than 15 degrees). Patients were asked questions several years later about their experience and perceived problems. Some researchers took follow-up X-rays. Others tested their patients for grip strength and other functional skills.
They report that with a small amount of radial shortening (three millimeters or less difference between the radius and the ulna), patients did just fine. Most of them (96 per cent) had good to excellent function and reported little to no pain. With slightly more shortening (three to five millimeters), the results were less impressive. Three-fourths of the patients still reported good results. As the shortening increased (radius bone more than five millimeters shorter), the satisfaction with results decreased.
Likewise, the more deformity was present in the wrist, the more likely the patient would have some measurable loss of motion and function. But overall, the amount of deformity seen on an X-ray in patients who were treated nonoperatively was NOT directly linked with worse function or worse results.
Age of the patient was a predictive factor. Younger, more active adults regained motion and function faster. By the end of six months after the injury, they had gained as much strength and motion back as older adults who took longer (up to a year) to recover. And for older adults who put low demand on their wrist, results were more often considered “satisfactory” compared with younger adults with the same amount of residual deformity or shortening.
One thing to consider is your father’s activity level and specific activities he enjoys (e.g., golf, tennis, cooking, and gardening require more strength and function than typing on a computer, jogging, or singing). In other words, people with low physical activity have different expectations and goals than patients who are physically very active. At age 81, hale and hearty still means something different than for most 51-year old adults.
When talking with the surgeon you can discuss: how the fracture looks on X-rays before reduction, the severity of your father’s symptoms (pain, swelling, function), and his expectations for activity.
All evidence points to good results without surgical treatment when there is minimal damage, deformity, and/or shortening of the bone. With nonsurgical treatment, your father would be followed weekly with serial X-rays for three weeks to make sure everything stays in place.
When the angulation and shortening are small, if the fracture site shifts back (after nonoperative care) to the amount of angulation and/or radial shortening present at the time of the injury, it’s likely that your father would not experience any problems regaining motion, strength, or function. Surgery is always an option at that time if advised.
Hopefully this information along with an additional conversation with the surgeon will aid you in making the best choice for your loved one.