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 join together in this article to discuss that decision. They use the case of a 52-year-old woman who falls and breaks the radius (bone in the forearm) at the wrist.
She is treated in the emergency department with a procedure known as closed reduction — in other words, without an open incision to realign the bones and pin the fracture site, the physician uses a special splint to hold the wrist in place. But a follow-up X-ray a week later shows some problems.
There is a shortening of the broken bone and the two ends of the broken bone don’t meet in a straight line. Instead, there is a slight buckle making a hump referred to as a dorsal angle that measures 15 degrees. She asks the age-old questions: do I really need surgery? Won’t this heal on its own?
Well, yes, it probally will heal but not in good alignment. The surgeon must then help the patient understand the possible risks and results. For example, it’s possible the slight deformity won’t have any negative effect. But it’s also possible that she will lose strength and function in that hand that won’t come back even with rehab without surgery to restore the normal alignment.
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.
Where does all this good feedback and information leave the surgeon in advising this particular patient? Well, the first thing is to address her activity level and specific activities she 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.
Second, when advising this patient, the surgeon can compare four things: how the fracture looked on X-rays before reduction, how the fracture looks at the time of evaluation (in this case, one week later), the patient’s symptoms (pain, swelling, function), and the patient’s expectations for activity.
There is one other bit of information from previous studies that may guide the surgeon in advising this patient. And that is the fact that patients who have poor outcomes are usually the ones who have the worst fracture deformity and least reduction at the time of the accident.
In this patient’s case, there were two millimeters of radial shortening and 15 degrees of angulation before reduction. One week later, X-rays showed only one millimeter of difference and the wrist was in neutral alignment (no dorsal angulation).
All evidence points to good results in cases like this without surgical treatment. With nonsurgical treatment, she will be followed weekly with serial X-rays for three weeks to make sure everything stays in place. The surgeons make note of the fact that even if the fracture site shifts back to the amount of angulation and/or radial shortening present at the time of the injury, it’s likely that she would not experience any problems regaining motion, strength, or function.