Welcome back to Deep Dive Ortho, where we pull
apart complex orthopedic topics to get to the
core insights. Today, we're zeroing in on the
wrist an absolute engineering marvel, isn't it?
So intricate, allowing incredible precision,
yet incredibly vulnerable to some truly devastating
injuries. Our focus for this deep dive is on
radiocarpal fracture dislocations. These are
far beyond your everyday sprains or simple breaks.
They're uncommon, yes, but when they do occur,
the impact on a patient's life, their function,
their future, Well, it can be profound and long
-lasting. Our mission today is to truly unpack
the intricacies of these severe injuries. We'll
explore everything from the subtle diagnostic
clues that can be missed to the sophisticated
surgical strategies and the long -term realities
for these patients. We're aiming for a comprehensive,
nuanced understanding tailored specifically for
you, our mid -senior medical professionals who
often face these challenging cases. To guide
us through this complex anatomical and clinical
landscape, we're honored to have our expert guest
with us today. Thank you. It's a pleasure to
be here. You've hit the nail on the head. Radiocarpal
fractured dislocations are, without question,
at the more severe end of the wrist injury spectrum.
They almost invariably result from high energy
trauma, and their potential for significant,
even permanent functional impairment means that
a truly deep understanding is absolutely crucial.
It's not just about fixing a bone. It's about
meticulous planning and execution, really, to
preserve a patient's long -term quality of life.
Absolutely. And that meticulous approach begins
right at the foundation. You know when we talk
about such profound disruptions, it always circles
back to the anatomical foundation. This injury
is so devastating because of how perfectly engineered
the wrist is. Could you start us off by reminding
us of its critical components, especially those
that bear the brunt of these forces? Of course.
Yes, to appreciate the scale of disruption in
these injuries, we must first briefly recap the
wrist's intricate architecture. At its core,
we have the radiocurple joint. It's the primary
articulation where the distal end of the radius,
along with its crucial articular disc, meets
three key bones of the proximal carpus. The scaphoid,
the lunate, and the tricotral. Functionally,
it's classified as a synovial ellipsoid joint,
which is what grants the wrist its incredible
range of two -axis movement, flexion extension,
and abduction. It's vital to remember the radius
directly articulates with the scaphoid and lunate,
while its connection to the trichetrol is indirect,
through that biconcave articular disc. And that
disc is actually part of the larger triangular
fibrocartilaginous complex of TFCC. Adjacent
to this, and equally critical, is the distal
radial nar joint, or DRUJ. This is a synovial
pivot joint formed between the ulnar head and
the sigmoid notch of the radius. Now here's a
truly remarkable insight. While bones obviously
provide structure, the osseous components of
the DRU -J contribute only about 20 % to its
overall stability. Only 20%. Yes, only about
20%. The vast majority, a staggering 80%, comes
from its soft tissues, most notably the triangular
fibrocartilaginous complex, or TFCC. This isn't
just a simple disc, it's a sophisticated complex
that acts as a major stabilizer for both the
radiocarpal and ulna -carpal joints. It plays
a critical role in preventing the ulna from impacting
the carpus, a condition known as ulnocarpal abutment,
and critically, it facilitates the complex pronation
and supination movements of the forearm and wrist.
Its key components include the central articular
disc itself, the dorsal and palmar radial gnar
ligaments that tether the radius and ulna, the
ulnomenescal homolog, and the ulnar collateral
and ulnocarpal ligaments. You see, even a seemingly
minor tear here can lead to profound functional
deficits down the line, far beyond what SC's
injury alone might cause. That's a really important
point about the TFCC. It is. Then beyond these
primary articulations, we have the intricate
arrangement of the eight carpal bones organized
into two rows. These bones, along with a dense
network of intrinsic and extrinsic ligaments,
function as both static and dynamic stabilizers,
enabling the wrist's wide range of movements.
From a clinical perspective, in these severe
injuries, the intrinsic ligaments of most concern
are the scaphalunate and lino -trichotral ligaments.
Each has dorsal, volar, and interosseous fibrocartilaginous
components, and their integrity is paramount
to maintaining carpal alignment. And how do we
check that alignment? You mentioned radiographs
earlier. Yes. For assessing carpal alignment
on standard radiographs, we heavily rely on what
we call the jalula arcs. When we look at a PA
wrist x -ray, we're almost looking for a specific
set of curves. Think of it like a finely tuned
machine. You expect three perfectly smooth concentric
arches formed by the carpal bones. The first
arc outlines the proximal margin of the proximal
carpus, the second outlines its distal margin,
and the third outlines the proximal margin of
the capitate and hamet. If any of those arcs
are broken, jagged, or discontinuous, a loss
of congruency is a huge red flag. It's a simple
visual cue that immediately tells you something
is profoundly out of alignment within the carpus,
often the first hint of a serious injury. Right,
a break in the pattern. Exactly. Now, when we
discuss the extrinsic ligaments, their role in
preventing radiocarpal dislocation is truly paramount.
What's truly eye -opening is the sheer biomechanical
dominance of the Volar Capsular Ligamentus Complex.
This complex includes critical structures like
the radioscapocapitate, the long and short radiolunate
ligaments, and the Palmar capsule. They are not
just supporting players. They are the primary
restraint against radiocarvel dislocation. Research
demonstrates they contribute a substantial 61
% of resistance to dorsal translation and 48
% to Palmar translation of the carpus. 61 % for
dorsal? That's huge! It is. In stark contrast,
the dorsal ligaments contribute a minor 2 % and
6 % respectively under the same conditions. This
isn't just a number. It's a direct roadmap for
our surgical priorities. Robust repair of these
holostructures and any associated radial styloid
fracture isn't an option. It's the absolute non
-negotiable cornerstone for restoring stability.
So the Volar site is really the key player in
preventing dislocation. Absolutely. Finally,
just briefly on innervation and blood supply.
The radiocarpal joint receives its nerve supply
from articular branches of the anterior interosseous
nerve from the median, the posterior interosseous
nerve from the radial, and the deep endorsal
branches of the ulnar nerve. Blood supply is
primarily from branches of the dorsal and palmar
carpal arches. However, for these high energy
injuries, it's a potential for traction neuropraxia
to these nerves due to the severe deformity.
That's the real clinical concern we must vigilantly
monitor. That foundational understanding of the
wrist's intricate design truly highlights how
disruptive a radiocarpal fracture dislocation
can be. It's like a complex machine suddenly
losing its core alignment, especially when you
consider how much stability comes from those
volar ligaments. Knowing that they are the primary
restraints really puts the severity into perspective.
So what does this all mean when we talk about
the injury itself? How does such a severe disruption
occur, and what exactly defines it, beyond just
the general idea of a wrist injury? You're right
to connect the two. The anatomical complexity
makes these injuries particularly challenging.
To define it precisely, a radiocarpal dislocation
or RCD refers to the total loss of contact between
the carpus and the distal radius. This is a key
differentiator from simpler intraarticular shear
or rim fractures of the distal radius, where
a piece of the articular surface may break off.
But the main articular fragment still maintains
contact with the carpus. When we speak of a radiocarpal
fracture dislocation, or RCFD, we're talking
of this total loss of contact along with associated
bony fractures. It's a combined injury of both
the articulation and bone. Okay, total loss of
contact. And how common are these? Well, in terms
of how often we see these, RCFEs are, thankfully,
rare. They account for only about 0 .2 % of all
wrist injuries annually. Tiny fraction. Very
small. Epidemiologically, we tend to see them
more frequently in males than females, and dorsal
dislocations are somewhat more common than volar
dislocations. The most significant demographic
trend, though, is their strong association with
high -energy trauma. These aren't typically simple
slips. They demand significant force. We're talking
about mechanisms like falls from a significant
height, high -speed motor vehicle accidents,
or industrial accidents. Right, serious mechanisms.
Exactly. The typical mechanism of injury involves
a high -energy shear or rotational force applying
to a wrist that is both hyperextended and pronated.
This classic scenario is often described as a
foosh injury, a fall on an outstretched hand.
The sheer force involved in such an event means
that the damage isn't limited to just the bony
structures. It also extends to the crucial ligaments
and can frequently involve vessels and nerves.
It's truly a domino effect of destruction. A
domino effect. That's a good way to put it. And
this brings us to the profound importance of
identifying concomitant injuries as they are
exceedingly common with RCFDs. From an orthopedic
perspective, we frequently find various types
of distal radius fractures, particularly radial
styloid avulsion fractures. These are highly
significant because they often involve the direct
attachment point of the radioscapocapitate ligament,
a primary stabilizer we just discussed. Oh, back
to that key ligament. Precisely. We also commonly
see volar lunate facet fractures, which are where
the short radiolunate ligament attaches, and
ulnar styloid fractures. Beyond the radius and
ulna, other carpal bone fractures are regrettably
common, including the scaphoid, lunate trapezium,
trichotrol hamate, pisiform, and capitate. It's
a whole cascade. It's also critical to assess
for an irreducible DRUJ, which can occur due
to soft tissue interposition and for intercarpal
injuries, such as capillunate or lunatric control
dissociation, which further complicate the overall
stability and long -term prognosis. And what
about nerves and vessels? You mentioned neuropraxia
earlier. Yes, neurological involvement is also
a significant concern, often presenting with
a patient reporting numbness or weakness. Median
nerve injuries are more frequent than ulnar nerve
injuries in these cases. These are typically
due to a mechanical traction neuropraxia, where
the nerve is stretched or pulled over the deformed
wrist during the injury. It's not necessarily
a direct laceration, but the nerve is functionally
compromised by the extreme distortion of the
anatomy. Additionally, radial and ulnar artery
injuries are not uncommon due to the severe deformity
that occurs, sometimes requiring immediate vascular
assessment and potentially repair. That cascade
of associated injuries you mentioned, it really
drives home how much is at stake. It's not just
a bone break, it's a systemic disruption affecting
bones, ligaments, nerves, vessels. Here's where
it gets really interesting. The sheer force required
and the cascade of associated injuries underscore
the critical need for a meticulous approach.
So when a patient presents with this level of
trauma, how do we as clinicians effectively cut
through the noise and get a definitive diagnosis?
What are your go -to imaging strategies and what
are the critical findings we should be looking
for? Indeed, diagnosis is foundational. and it
starts with the most accessible tools. Conventional
radiography, or X -ray as it's commonly called,
is always the primary radiological investigation
for acute wrist trauma. For suspected wrist fractures,
it's essential to obtain at least three views.
The posterior anterior, or PA view, the lateral
view, and a 45 degree oblique view. For increased
sensitivity, particularly when a scaphoid fracture
is suspected given their high incidence in FUSH
injuries, we'll often place the hand in ulnar
deviation for the PA scaphoid views as this elongates
the scaphoid bone and can unmask subtle fractures.
High quality radiographs with standardized positioning
are key. Poor images can lead to significant
misdiagnoses. Right, good quality views are essential.
What are the signs on x -ray? On the PA view,
crucial radiographic signs of a radiocarpal dislocation
include a total loss of contact between the carpus
and the radius, often with ulnar translation
of the carpus and widening of the inner carpal
spaces. As we discussed, a clear sign is the
disruption of the jalula arcs, those three concentric
arcs that define normal carpal alignment, losing
their coloniality. The broken arcs again. Exactly.
If you see breaks in those smooth curves, it's
an immediate red flag. On the lateral view, we
look for obvious dorsal or volar radiocarpal
wrist dislocation and a loss of collinearity
of the lunate with the articular surface of the
radius. If there's a lunate dislocation, you'll
specifically see what's often referred to as
the spilled teacup sign, where the lunate displaces
vularly, resembling an overturned teacup. Ah,
the spilled teacup. Classic sign. It is. When
evaluating associated disco -radius fractures
on x -ray, we also measure several parameters
that correlate strongly with long -term patient
outcomes. These include radial length, normally
11 to 22 millimeters, radial inclination, normally
13 to 30 degrees, And the volar, or dorsal tilt,
measured on the lateral view, normally ranges
from 4 degrees dorsal to 11 degrees volar tilt.
Significant deviations, for example, a decrease
in radial length by more than 2 mm, a dorsal
tilt greater than 20 degrees, or radial inclination
less than 10 degrees are all associated with
decreased long -term risk function and alert
us to the need for more aggressive intervention.
Subtle clues on initial radiographs, such as
soft tissue swelling or the obliteration of the
pronator quadratus fat stripe, can also hint
at a fracture. However, it's important to remember
a critical limitation. Approximately 30 % of
wrist fractures, especially scaphoid fractures,
can be radiographically occult on initial x -rays.
30 % missed on initial x -ray. That's significant.
It is. A negative x -ray, especially with high
clinical suspicion, should never rule out a fracture
definitively. So what's next if the x -ray isn't
clear or you suspect more? This is precisely
where computed tomography, or CT, becomes the
modality of choice for more detailed evaluation.
CT is invaluable for suspected bony injuries,
particularly when radiographs are negative or
indeterminate. It excels at visualizing complex,
comminuted fractures, and, crucially, it allows
us to identify and measure intraarticular step
-offs, especially those greater than 2 millimeters.
We know these strongly correlate with late development
of osteoarthritis and typically warrant open
reduction and internal fixation to restore articular
congruity. CT also provides multiplanar and volumetric
reformations, which are incredibly useful for
comprehensive preoperative planning, allowing
us to virtually reconstruct the injury before
we even enter the operating theater. So CT for
the bone detail and planning. Exactly. It's also
superior for detecting subtle, non -displaced
scaphoid fractures and other associated carpal
injuries that might be missed on conventional
x -rays. Furthermore, CT is the gold standard
for evaluating DRUJ dislocations, with the epicenter
method being the preferred technique for its
instability and guiding reduction. Okay, and
where does MRI fit into this picture? Magnetic
resonance imaging, or MRI, has a more limited
role in the acute phase of fractures and dislocations
due to its availability, time constraints, and
cost. However, its critical role lies in evaluating
soft tissue injuries, such as damage to tendons,
ligaments, and muscles components often severely
compromised in these high -energy traumas. It's
also excellent for detecting truly occult fractures,
particularly trabecular fractures without cortical
breach, which CT you're going to miss. For instance,
a short protocol MRI can be used effectively
in the emergency setting specifically for suspected
occult scaphoid fractures. Optimized parameters
for wrist MRI typically involve an 8 -12 cm field
of view, 3 mm slice thickness, and dedicated
phased array extremity coils. Sequences like
T2 weighted or proton density with fat suppression
are ideal for detecting bone meridima and fracture
lines, while T1 weighted sequences are added
for assessing bony alignment. It truly provides
the missing pieces of the puzzle when the soft
tissue injury is extensive or unclear. That's
a powerful toolkit for diagnosis. It really underscores
the importance of choosing the right imaging
at the right time to get the full picture, especially
when so much can be missed on initial radiographs.
It's not just about seeing a break. It's about
truly understanding the extent of the damage
to both bone and soft tissue. Once we've identified
and fully characterized the injury, how do we
categorize these complex fragments? dislocations.
Are there classification systems that help guide
prognosis and management? That's an excellent
point, as classification helps us both understand
the severity and plan our approach. While we
have several classification systems, it's worth
briefly acknowledging some of the eponymous distal
radius fractures first. For those of you regularly
in clinic, terms like collis fracture or Smith
fracture are second nature. Very familiar names.
Indeed. They describe specific patterns collis
with dorsal displacement. often from a fall on
a dorsiflexed hand, common in older patients
with osteoporosis. Smith's, the reverse, with
voller displacement, often from higher energy
onto a flexed wrist, perhaps in younger individuals.
Then there's Barton's fracture, an intra -articular
shear fracture with carpal displacement, either
voller or dorsal. and the Hutchinson fracture,
or Chauffeur's fracture, involving the radial
styloid, again intraarticular. While these terms
are deeply ingrained in practice, their universal
reproducibility on radiographs or CT scans is
actually quite limited, as studies have shown.
Ah, so maybe less reliable than we think. Potentially.
Therefore, when assessing the severity of radial
fractures in the context of our CFDs, the most
important considerations for us are the precise
displacement of the fracture fragments, the extent
of intraarticular extension, and any step off.
particularly the DRUJ or radiocarpal joint, the
degree of comminution, and critically, the presence
of any associated ulnar, other carpal bone, or
soft tissue injuries. These factors directly
dictate prognosis and the surgical approach,
perhaps more than the epinome itself. Okay, focus
on the specifics of the injury pattern rather
than just the name. What about classification
specifically for the radiocarpal fracture dislocations
themselves? Yes. Moving specifically to radiocarpal
fracture dislocations, there are a couple of
classifications we refer to. The monium classification
divides these injuries based on the presence
of intercarpal involvement. Type 1 injuries are
RCFDs without associated intercarpal dissociation.
So the dislocation is at the radiocarpal joint,
maybe with a radial styloid fracture, but the
carpus itself remains intact as a unit. Type
2, on the other hand, involves an RCFD with associated
intercarpal dissociation, maybe a carpal bone
fracture or an intercarpal ligament tear. This
means the injury has propagated further into
the carpus. And does that distinction matter
clinically? It does. It's generally accepted
that type 2 injuries are typically more severe
and are associated with worse outcomes, often
necessitating open reduction and more extensive
repair. They demand a heightened level of vigilance.
Right, more complex repair needed. Then there's
the dumontia classification. This classifies
RCFDs into two groups, historically attempting
to guide the surgical approach. Type 1 is a purely
ligamentous RCFD, or one involving only a small
cortical evulsion off the radius. The key here
is primary ligamentous failure. Type 2 refers
to an RCFD associated with a large radial styloid
fracture fragment, involving at least one third
of the scaphoid fossa. The implication is the
crucial ligaments are attached to that displaced
styloid fragment. Historically, this suggested
maybe a volar approach for type 1 and dorsal
for type 2. However, clinical experience has
shown that outcomes varied, and current thinking
often requires a more combined, comprehensive
approach regardless of this classification to
ensure full anatomical restoration. So the Dumontier
type might not dictate the approach as much anymore?
Not rigidly, no. The injury itself dictates the
approach needed for full reduction and fixation.
Finally, it's also important to consider the
Mayfield classification for perilunate instability,
as RCFDs can be part of this progressive spectrum,
especially with high -energy trauma. This describes
a sequential pattern of ligament disruption around
the lunate. Stage 1. Scaffolunate dissociation
widening of that interval. A lesser arc injury.
Stage 2. Perilunate dislocation. The lunate stays
aligned with the radius, but the rest of the
carpus dislocates, usually dorsally. This is
often a greater arc injury. potentially involving
fractures like a transcephoid perilunate dislocation.
Stage 3 adds lunotricatural joint disruption.
Stage 4, complete disruption of radial lunate
ligaments, allowing the lunate itself to displace
volarely that classic spilled teacup sign again.
The whole carpus sort of unravels sequentially.
Precisely. And it's worth noting that transcephoid
perilunate dislocation is actually the most common
pattern of perilunate fracture dislocation we
encounter. These stages highlight the extensive
damage possible beyond just the primary RCFD,
profoundly impacting function if not addressed
comprehensively. So, what does this all mean
for the clinician? These classifications, while
imperfect perhaps, clearly highlight the need
to look beyond the obvious and consider the full
spectrum of injury. It's not just a dislocation,
it's what else has been disrupted and the sequence
of that disruption. Once the injury is thoroughly
assessed and classified, the next critical step
is management. What are the current approaches,
both conservative and operative, and what evidence
guides these often complex decisions? Precisely.
The initial management is immediate and critical,
often in the emergency department. The primary
goal, as soon as the patient presents, is to
perform an immediate reduction of the dislocation.
This is paramount, not just to alleviate pain,
but to prevent further neurovascular injury.
Remember, those nerves and vessels are stretched
and to facilitate subsequent imaging by normalizing
the anatomy somewhat. Immediate reduction can
make a real difference to nerve recovery. Our
overarching objective is meticulous restoration
of wrist anatomy, paying particular attention
to the radial and ulnar styloids, and crucially,
restoring the precise length of the attached
ligaments. This anatomical restoration confers
stability and is directly linked to positive
long -term outcomes. Good results are achievable
with concentric reduction, treatment of intracarpal
injuries, and sound repair of bone and ligament
damage. So immediate reduction first. Is non
-operative management ever an option? Well...
For non -operative management, the indications
are quite specific and, frankly, limited for
true RCFDs. It's typically reserved for patients
not medically stable for surgery, or in those
exceptionally rare cases where a truly stable
radiocarple joint is achieved after a perfect
closed reduction, confirmed by stress imaging.
The technique involves longitudinal axial traction,
then casting for up to six weeks, usually a sugar
tongue or long arm cast, allowing ligamentous
scarring. While historically some purely ligamentous
injuries did okay with this, especially in older,
low -demand patients, it's associated with common
persistent instability, like ulnar translation
and reduced range of motion. So generally not
the first choice for these high -energy injuries?
Generally not. For a high -energy RCFD, non -operative
management is almost always considered suboptimal
due to the high risk of chronic instability,
stiffness, and post -traumatic arthritis. Which
leads us to surgery. It's exactly. Operative
management is widely considered the standard
of care for virtually all RCFDs. The main indications
are an irreducible dislocation, We can't get
it back in place closed or an unstable joint
after attempted closed reduction, where it simply
won't stay reduced. The general approach involves
open reduction, internal fixation, or RRF, often
with radiocarpal pinning and meticulous ligament
repair. The goal is stable fixation, allowing
early, protected motion. Okay, let's get on to
the surgical techniques. What approaches do you
typically use? When it comes to surgical approaches,
we often utilize a Voller -Henry approach to
the distal radius. This offers advantages. Nerve
decompression if needed, fasciotomy access, direct
repair of those crucial volar ligaments, and
good access for radial styloid fixation. However,
it's often not sufficient alone. A dorsal approach
may also be necessary, particularly for dorsal
buttress plating, or to elevate impacted articular
fragments. In fact, a combined volar and dorsal
approach is frequently required. Surgeons shouldn't
hesitate to make that second dorsal incision
for adequate exposure and precise reduction of
all fragments. An inadequate approach risks a
poor outcome. Right. Do what's needed for full
visualization and reduction. What about external
fixation? Provisional stability can be achieved
with external fixation. This is incredibly useful
acutely for restoring length, controlling an
unstable limb, protecting repairs, and allowing
early elbow forearm motion while the wrist is
held. It can be provisional before definitive
internal fixation, or sometimes definitive immobilization
for four to six weeks in complex cases or those
with significant soft tissue injury. And the
internal fixation itself. You mentioned three
columns earlier. Yes, a key principle is often
three -column fixation, addressing the radial,
intermediate, and ulnar columns. For the radial
column, radial styloid, robust fixation is crucial
due to that radioscapacitate ligament attachment.
We might use K -wires, compression screws, or
small plates, dorsal, volar, or radial. If it's
a small fragment or ligament avulsion, soft tissue
repair with suture anchors may be needed. Robust
repair here is paramount for stability. The intermediate
column lunity fast fixation typically uses interfragmentary
screws or tension band wires. Again, suture anchors
for ligamentous issues. Anatomical reduction
here is critical. Even a one two millimeter step
off risks significant arthritis. The ulnar column
distal ulnar styloid fixation is more controversial,
but indicated for DRUJ injury or persistent instability.
This might involve fixing an onostyloid fracture,
K -wire screw, tension band, or TSCC repair.
If the DRUJ is dislocated, it needs meticulous
reduction and often pinning in mid -supination
to maintain it while the TSCC heals. The DRUJ
is often the forgotten joint, but instability
there is debilitating. It sounds like addressing
all three columns comprehensively is key. It
often is. And ligament repair itself is a cornerstone,
often needing magnification. For volar extrinsic
ligaments, suture anchors can reattach them.
It's critical not to overtighten, which could
limit extension and cause stiffness. We must
also evaluate and repair other significant ligaments
if disrupted, like this scaffolding, leaving
that unstable leads to poor outcomes despite
good radiocarble repair. For impacted articular
fragments, bone grafting, examined from iliac
crest, might be needed to restore the joint surface.
And you mentioned nerve decompression earlier
too. Absolutely. Neurovascular decompression
is essential if there are neurological signs
pre -op or concern for compartment syndrome.
Typically achieved via the Palmer approach with
flexor retinaculum release. Critical for these
high energy injuries. That's a powerful combination
of techniques. really customizing the approach
to the specific injury. It sounds like the emphasis
is always on restoring that precise anatomical
alignment and stability. However, even with the
most meticulous surgical intervention, the journey
doesn't end there. What are the common complications
we need to anticipate, and what does the post
-treatment rehabilitation look like? It sounds
like it could be a long road. You're absolutely
right. Surgery is often just the beginning, and
vigilant post -treatment care is vital. After
operative repair, patients typically undergo
immobilization, averaging maybe five weeks, range
four to eight weeks, often in a splint or cast,
depending on surgical stability and soft tissue
repair. But even during immobilization, it's
crucial to start immediate, gentle, regular movement
of all uninvolved joints, shoulder, elbow, fingers,
thumb, to reduce swelling and prevent stiffness
elsewhere. Early motion is key. Keeping everything
else moving. Exactly. Once stability allows,
usually after pin removal or early radiographic
union, critical early hand exercises begin. Simple
finger curls, hook fist, tabletop position. For
the wrist itself, gentle, active and assisted
range of motion, flexion, extension, deviation,
pronation, supination introduced as soon as safe,
avoiding severe discomfort. Move to slight stretch,
not pain. Early on, we can begin isometric strengthening
contracting muscles without moving the joint.
As strength and comfort improve, typically 8
-12 weeks post -op, progress to isotonic exercises
with light weights or bands, gradually increasing
load. Controlled progressive loading is vital.
Sounds like a carefully staged rehab process.
What about potential pitfalls, complications?
Despite best efforts, complications can arise.
Acute carpal tunnel syndrome is frequent, especially
with delayed presentation or reduction. Persistent
or worsening nerve signs often need urgent carpal
tunnel release. Stiffness is also highly common.
Maybe 30 -40 % loss in wrist motion are reported.
Prolonged immobilization is a risk factor, but
also scarring. Treatment involves intensive hand
therapy, maybe manipulation under anesthesia,
or hardware removal if it's impeding motion.
That's a significant loss of motion potentially.
It can be. Post -traumatic arthritis is a significant
long -term risk, especially with non -anatomic
reduction or chronic instability. That articular
step -off greater than 2 millimeters is strongly
associated with late osteoarthritis. We also
need awareness of late intercarpal disruption
from occult injuries becoming apparent later.
While many neurological deficits resolve after
reduction decompression, some may persist, like
residual numbness. And non -union or osteonecrosis
is a concern for associated scapoid fractures
due to its blood supply and neglected hook of
Hammett fractures. A lot to watch out for long
-term. What's the overall prognosis typically?
Turning to long -term outcomes, the good news
is that with early diagnosis, precise anatomical
repair, stable fixation, and good rehab, good
functional outcomes can generally be expected.
Reviews show promising results. One study reported
mean flexion extension arc of 100 degrees, grip
strength 86 % of the other side. That's excellent
given the injury severity. Many patients resume
prior occupations, even high demand ones. However,
open injuries and dumontia type 2 injuries historically
show less favorable results, often needing more
rehab and having higher complication rates. We
use outcome scores like quick dash, PWRE to assess
function, pain, motion, grip strength. Scores
over 65 often considered satisfactory. Interestingly,
clinical scores and x -ray changes don't always
correlate perfectly with patient -reported function.
Someone might have arthritis on x -ray but feel
fine functionally or vice versa. That's an interesting
point about the disconnect sometimes between
imaging and function. It is. And in some refractory
cases with persistent instability or severe arthritis,
secondary interventions like radial loon fusion
or even total wrist fusion might be needed as
a salvage procedure later on. That's a truly
comprehensive overview, highlighting both the
successes we can aim for and the significant
challenges demanding ongoing vigilance. This
raises an important question. For our listeners
working with these patients, what's the key takeaway
or perhaps a thought to provoke deeper consideration
on this challenging topic? What's the one thing
you'd want them to carry forward? For our colleagues,
I think the critical importance lies in a thorough,
really deep understanding of the wrist anatomy.
A judicious, multimodality imaging approach,
remembering x -rays, are just the start and implementing
tailored, meticulous surgical strategies. While
these injuries are rare and complex, precise
diagnosis and rigorous anatomical restoration
are absolutely paramount to mitigating those
long -term problems like post -traumatic arthritis
and chronic instability. It's about restoring
not just form but critical function and remembering
the long game for the patient. That's a powerful
message, thank you. This deep dive has truly
laid bare the complexities and the critical pathways
for managing these significant wrist injuries.
As we move forward in orthopedic practice, perhaps
the next frontier lies not just in achieving
perfect initial reduction, but in truly understanding
the subtle individual biomechanical responses
to these high -energy traumas, allowing us to
predict and prevent long -term functional impairments
with even greater precision. What more can we
learn from the patient journey beyond the initial
fracture? And how can we leverage emerging technologies
to better understand those long -term adaptations?
If you found this discussion insightful, please
take a moment to rate and share Deep Dive Ortho
with your colleagues. It helps us reach more
dedicated professionals like yourselves. Thank
you again for your invaluable expertise and insights
today. My pleasure entirely. Thank you for having
me. And thank you for joining us on Deep Dive
Ortho. We'll be back soon with another exploration
into the fascinating world of orthopedics.